Surgery (esophageal cancer)
The survival rate of patients
with esophageal cancer is poor. Surgical treatment of resectable esophageal cancers results in 5-year survival
rates of 5% to 30%, with higher survival rates in patients with early-stage
cancers. Asymptomatic small tumors confined to the
esophageal mucosa or submucosa are detected only by chance. Surgery is the
treatment of choice for these small tumors. Once symptoms are present
(e.g., dysphagia, in most cases), esophageal cancers have usually invaded
the muscularis propria or beyond and may have metastasized to lymph nodes or
In some patients
with partial esophageal obstruction, dysphagia may be relieved by
placement of an expandable metallic stent or by radiation therapy if the
patient has disseminated disease or is not a candidate for surgery.
Alternative methods of relieving dysphagia have been reported, including laser
therapy and electrocoagulation to destroy intraluminal tumor.
In the presence of complete esophageal obstruction without clinical evidence
of systemic metastasis, surgical excision of the tumor with mobilization of the
stomach to replace the esophagus has been the traditional means of relieving
The optimal surgical approach for radical resection of esophageal cancer is not known. One approach
advocates transhiatal esophagectomy with anastomosis of the stomach to the
cervical esophagus. A second approach advocates abdominal mobilization of the
stomach and transthoracic excision of the esophagus with anastomosis of the
stomach to the upper thoracic esophagus or the cervical esophagus. One study concluded that transhiatal esophagectomy was associated with lower morbidity than was transthoracic esophagectomy with extended en bloc lymphadenectomy; however, median overall disease-free and quality-adjusted survival did not differ significantly. Similarly, no differences in long-term quality of life (QOL) using validated QOL instruments have been reported. More recently, minimally invasive approaches that offer potential advantages of smaller incisions, decreased intraoperative blood loss, fewer postoperative complications, and shorter hospital stays have emerged. However, the ability to obtain negative surgical margins, the adequacy of lymph node dissection, and long-term outcomes have not been fully established with this approach.
In the United States, the median age of patients who present
with esophageal cancer is 67 years. The results of a retrospective
review of 505 consecutive patients who were operated on by a single surgical
team over 17 years found no difference in the perioperative mortality, median
survival, or palliative benefit of esophagectomy on dysphagia when the patients older than 70 years were compared with their younger peers.[Levels of
evidence: 3iiA and 3iiB] All of the patients in this series were selected for
surgery on the basis of potential operative risk. Age alone does not determine
therapy for patients with potentially resectable disease.
Surgical treatment of esophageal cancer is associated with an operative mortality rate of less than 10%. In an attempt to avoid perioperative mortality and to relieve dysphagia,
definitive radiation therapy in combination with chemotherapy has been studied.