In Depth review of the Surgical management of esophageal carcinoma including management overview, endoscopic management, Type of surgeries, Open, and minimally invasive, Extent of lymphadenectomy. Literature review of evidence for type of surgery and complications

1. SURGICAL PRINCIPLES
OF CARCINOMA
ESOPHAGUS
Dr. Bhavin Vadodariya

2. OUTLINE
 Endoscopic Management
 Cervical Esophagus
 Thoracic Esophagus cancer surgery
- Mckeown
- Transhiatal
- Minimally Invasive
 Lymph node dissection
 Reconstruction
 Controversies
 Complications

3. INTRODUCTION
 The surgical treatment strategy of esophageal carcinoma is complex
and the long term outcome of surgical therapy is often disappointing.
 A malignancy arising from the esophagus may easily invade these
adjacent organs, which makes the tumor surgically non-resectable.
 Additionally,lymphatic dissemination is an early event and has a
negative influence on survival.
 Lymph node metastases are found in less than 5% of intramucosal
tumors but in as much as 30–40% of submucosal tumors (1).

4. INTRODUCTION(CONTD.)
 Furthermore, the esophageal wall is characterized by an extensive
submucosal lymphatic plexus, which supplies a drainage route for early
dissemination and gives rise to skip metastases (i.e., lymph nodes
adjacent to the primary tumor are not affected, but more distant-located
lymph nodes contain metastases) (2).
 As a result transmural tumors are showing lymph node
involvement in over 80% and the number of involved nodes increases
with increasing volume of the tumor.

5. INTRODUCTION(CONTD.)
 Also adding to the complexity are the tumors of the gastro-esophageal
junction (GEJ) that are classifed by gastric cancer and by some as
esophageal cancer.
 This explains the ongoing controversy as to which strategy to follow
when it comes to surgical approach, surgical techniques and extent of
lymphadenectomy for cancers of the esophagus and GEJ.

6. INTRODUCTION(CONTD.)
• Localized disease : 22 percent of all cases
• Regional disease : 30 percent of patients.
• Goal of surgical management is curative.
• Surgical resection is the traditional mainstay of multidisciplinary
therapy for patients with localized disease
• The clinical spectrum of esophageal cancer has changed over the last
few decades, with an increase in incidence of adenocarcinoma and a
decrease of squamous cell carcinoma
• Surgical management is independent of histology.

8. Management of Early
esophageal carcinoma

9. CAN WE PREDICT THE RISK OF
LYMPH NODE METASTASIS?
Incidence of nodal metastasis
27%
20%
10%
10%
50%
Takubo et al. Histopathology 2007;51:733-742

12. HIGH RISK FACTORS FOR LYMPH NODE
METASTASIS
 Depth of invasion – T1b
Morphology – types 0-I and 0-III
Lymphatic permeation
Poor histological differentiation
Tumor size >2cm
Infiltrative growth pattern
Takubo et al. Histopathology 2007;51:733-742

13. ENDOSCOPIC THERAPY
 Both therapeutic and staging purpose.
The available options are ER and various ablation
methods, including RFA, PDT, and cryotherapy.
Indicated in limited early stage disease .i.e
Tis and T1a,
<2cm
Well or moderately differentiated scc or adeno
Elderely with multiple comorbidities
Patient preference

14. ENDOSCOPIC MUCOSAL RESECTION AS INTERMEDIATE
STAGING STRATEGY
 accurate depth of invasion.
 The pathology result from the endoscopic
resection (particularly the presence or absence
of LVI) can be used to guide the final decision
as to whether endoscopic therapy alone is
sufficient or if surgery should be recommended.

16. EMR
 Haemorrahge,Stricture
 PPI
 Survellance

17.  There is no evidence from clinical trials. In this systematic review,
surgical therapies showed superiority for survival, and endoscopic
therapies showed superiority in the control of mortality related to cancer
with a high rate of disease recurrence; also, for the comorbidity and the
mortality associated with the procedure, endoscopy is superior.
 Prospective, controlled trials with large sample sizes are necessary to
confrm the results of the current analysis

18.  The survival rates after 3 and 5 years were not similar and showed
superiority in the surgical therapies over time.
 The difference in esophageal neoplasia–related death between the two
treatments was signifcant, and the endoscopic therapies were superior
in the analysis of the mortality associated with cancer, excluding the
population selection bias.
 Although the recurrence rate is higher than the endoscopic therapies,
as demonstrated by the analysis of the 5-year disease-free survivals,
apparently disease control can be achieved with monitoring,
identifcation, and effective treatment of these recurrences.

19. ENDOSCOPIC RESECTION VS
ESOPHAGECTOMY
Equivalent long term outcome in HGD and intramucosal
carcinoma.
Lower morbidity(0% vs30%).
Higher recurrence rate 18% at median follow of 43mth (Mayo
clinic).
Majority can be managed by repeat endoscopic treatment.
Similar long term complete response rate(98% vs 100%)
Similar OS and DFS at5yrs.

20. PHOTODYNAMIC THERAPY

21. PDT
 Photodynamic therapy (PDT) is a treatment that uses a
photosensitizing drug that is administered to the patient, localized to a
tumor, and then activated with a laser to induce a photochemical
reaction to destroy the cell.
 PDT using porfimer sodium followed by excimer dye laser irradiation is
approved as a curative treatment for superficial esophageal cancer in
Japan

22. CRITERIA FOR RESECTION
Esophagectomy as first line of therapy
●cT1N0M0 lesions
●cT2N0M0 lesions are candidates in many medical centers
Esophagectomy following NACT/NACRT
●Patients with thoracic esophageal or EGJ tumors and full-thickness (T3) involvement of the
esophagus with/without nodal disease.
●cT4a disease with invasion of local structures (pericardium, pleura, and/or diaphragm only) that can
be resected en bloc, and who are without evidence of metastatic disease to other organs (eg, liver,
colon).

23. RELATIVE
CONTRAINDICATIONS
● Advanced age
● Comorbid illness
Indicators of unresectability —
• Metastatic disease
• Extra-regional LN spread (eg,
paraaortic or mesenteric
lymphadenopathy).
• The regional lymph nodes for all
locations in the esophagus, including the
cervical and EGJ, extend from the
periesophageal cervical nodes to celiac
nodes.
• Celiac nodal metastases and
mediastinal/supraclavicular nodes are
scored as regional nodal disease TNM
staging system, regardless of the
primary tumor location.
• Number rather than location of involved
LN determines the N stage

24. OPERATIVE PROCEDURES

25. CERVICAL ESOPHAGEAL CANCER RESECTION
• CRT : Primary modality
• Surgical resection : Patients who fail CRT, or who opt for a surgical resection.
• Resection usually requires removal of portions of the pharynx, the larynx, the
thyroid gland, and portions of the proximal esophagus.
• Single stage, three-phase operation requires cervical, abdominal, and thoracic
incisions.
• Permanent terminal tracheostomy.
• Bilateral radical neck dissections are generally performed
• Restoration of GIT continuity with a gastric pull-up and anastomosis to the
pharynx.
• Free jejunal interposition graft or a deltopectoral or pectoralis major
myocutaneous flap are alternative reconstructive options.

26. THORACIC CANCER RESECTION
• EAC and SCC involving the middle or lower third of the esophagus (except GEJ cancers), generally requires
total esophagectomy (submucosal skip lesions)
• In selected superficial or early invasive esophageal cancer arising distally in the setting of BE, a more
limited resection can be performed.
• Optimal surgical approach : Unknown
• Choice of surgical approach depends upon many factors:
● Tumor location, length, submucosal extension, and adherence to surrounding
structures
● The type or extent of lymphadenectomy desired
● The conduit to be used to restore GIT
● Postoperative bile reflux
● The preference of the surgeon

28. TRI-INCISIONAL ESOPHAGECTOMY-
MCKEOWN
• Combines the THE and TTE approaches (MIS can be perfomed)
• Transthoracic total esophagectomy with a thoracic lymphadenectomy and cervical
anastomosis.
• Allows a complete 2-field (mediastinal and upper abdominal)
lymphadenectomy under direct vision.

29. ADVANTAGES OF NECK ANASTOMOSIS
• Easier management of a possible leak
• Lower reflux
• More extensive proximal resection margin
• Location outside of radiation ports if administered preoperatively.

30. ONCOLOGICAL PRINCIPLES
1. Thoracotomy
A right posterolateral thoracotomy or a thoracoscopy is performed to assess
resectability and exclude local invasion of contiguous structures.
En bloc resection is performed
2. Laparotomy
Metastatic disease is excluded, and the stomach is mobilized with
construction of conduit.
3. Neck incision
• Left neck exposure preferred.
• Left RLN recurs lower (around the aortic arch) than the right RLN, which recurs
around the subclavian artery and is therefore more likely to be injured from a right
neck approach.

31. IVOR-LEWIS TRANSTHORACIC ESOPHAGECTOMY
• Lower third of the esophagus.
• Not the optimal approach for cancers located in the middle third because of the limited
proximal margin that can be achieved.
• Combines a laparotomy with a right thoracotomy and an intrathoracic anastomosis.
• Direct visualization of the thoracic esophagus & allows a full thoracic lymphadenectomy.
• Minimally invasive Ivor-Lewis approach to a thoracotomy.

32. DISADVANTAGES- IVOR LEWIS
• Disadvantages :
 Limited length of proximal esophagus that can be resected to achieve a R0,
 Intrathoracic anastomosis.
 3 to 20 percent risk of severe bile reflux .
 Higher morbidity (64%) and mortality associated with leak .
 With current technique, mortality rates are substantially lower .

34.  Inferior pulmonary ligament is divided using electrocautery, and the
lung is retracted anteriorly.
 Dissection of the esophagus begins at a point away from tumor and any associated
scarring, and the esophagus is encircled with a Penrose drain. Traction on the Penrose
drain allows for cautery dissection encompassing all adjacent nodes.
 Arterial branches directly off the aorta are clipped or ligated
 The azygos vein is typically divided

36.  At this level, the vagus nerves are identifed.
 Dissection cranial to this level involves the vagus nerves; the vagus nerves are peeled
off and away from the esophagus to avoid injury to the recurrentvagus branches.
 Dissection between the trachea and esophagus must be done with care and with low
cautery dissection to avoid injury to the membranous trachea. Much of the dissection
high in the chest can be done bluntly).
 The cranial aspect of the dissection is complete when one’s fngers reach easily above
the frst rib.

38.  No effort is made to resect the thoracic duct,
although it is sometimes injured.
 often, injury to the thoracic duct is evident when
slightly cloudy or crystallized fluid is seen pooling
in the region of the duct. If an injury to the duct is
seen, it should be closed with a pledgeted fine
suture such as
5-0 Prolene.
 Mass ligature of the duct, as it enters the chest,
is then performed by encompassing all tissue
between the spine and aorta

44.  The careful palpation of the liver and inspection of the serosal surfaces for tumor implants.
 Palpation of the GE junction and proximal stomach should be performed to rule out gastric
spread of tumor.
 Te left lobe of the liver is mobilized and retracted to the right.

45.  The gastroepiploic artery is identifed and palpated
 Staying at least 2 cm away from the gastroepiploic artery, the lesser sac is entered. Dissection
continues cranially on the stomach along the greater curvature. Dissection may be performed by
dividing tissue and ligating with 2-0 silk ties or by using an ultrasonic scalpel.
 The stomach is retracted medially and the omentum laterally. Te artery itself should not be grasped
used for retraction.
 The gastroepiploic arcade ends near the point where the short gastric arteries begin

46.  The gastrohepatic ligament is divided with cautery up to the GE junction.
 The stomach is lifted anteriorly, and thin adhesions between the stomach and pancreas are
divided with cautery.
 The left gastric vessels are approached from behind the stomach
 The vessels are skeletonized, and lymph nodes are swept up onto the specimen.
 The duodenum is then mobilized using a Kocher maneuver, bringing it to the
midline .

47.  A pyloromyotomy or pyloroplasty may be
performed with equivalent efcacy in aiding
gastric emptying.
 If a pyloroplasty is performed, it is best to
close it in a single layer with interrupted (3-0
silk) sutures.

48. ROLE OF PYLOROPLASTY OR
PYLOROMYOTOMY
Meta-analysis:
9 trials and 553 esophagectomy patients
Randomized to pyloromyotomy vs none
Lower risk of GOO for patients with a
pyloromyotomy (p <0.046).
No difference for:
Operative mortality
Anastomotic leaks
Pulmonary morbidity
Fatal pulmonary aspiration.
Urschel JD, et al. Dig Surg. 2002
Prospective study :
N = 242 patients
Group A : No pyloromyotomy (n = 83)
Group B : Pyloromyotomy (n = 159)
Results:
Pyloromyotomy does not reduce the
incidence of symptomatic DGE.
(Group A 9.6% vs Group B 18.2%, p=0.078).
Post-operative GOO can be effectively
managed with endoscopic pyloric dilatation.
Lanuti M, et al. Eur J Cardiothorac Surg. 2007

50.  A neck incision is then made 6 cm in length along the anterior border of the left
sternocleidomastoid muscle starting at the sternal notch.
 Deep to the platysma, dissection proceeds medial to the sternocleidomastoid muscle and
carotid sheath and lateral to the thyroid.
 The omohyoid can be divided with cautery.
 Blunt dissection is then used to approach the vertebral bodies.
 Lying along the vertebral body, the Penrose drain is grasped and brought out into the neck
wound with the encircled esophagus.

52. RECURRENT LARYNGEAL NERVE
IDENTIFICATION
• Injury can occur during cervical or upper thoracic dissection.
• Incidence: 2-17 %
• More common when a cervical approach is utilized.
• Principles
Precise knowledge of cervical esophageal
anatomy.
Plane of dissection should be as close as possible to the
esophagus.
Avoidance of metal or rigid retractors along the TE groove.
Orringer MB, et al. Ann Surg. 2007

54.  Proximally, the esophagus can be gently mobilized.
 The nasogastric tube is removed, and the esophagus
is divided with a GIA 75-mm stapler.
 A 2 silk suture is attached to the proximal margin, and the specimen
is drawn out into the abdomen.
 The cervical end of this tie is fastened to a clamp.

58. HAND-SEWN VERSUS STAPLED
ANASTOMOSIS
• Hand-sewn (single versus double layer) vs Stapled (circular versus side-to-
side linear) vs Hybrid linear stapled technique,
• Surgeon experience : most important determinant at present.
Meta-analysis (12 RCTs with 1407
patients):
(Circular stapled vs hand sewn)
• Similar rate of anastomotic leak.
• More strictures with circular stapler.
A hybrid linear stapled technique (modifiedCollard
technique)
65 % increase in the anastomotic cross-sectional area
Reduced morbidity.
In a review of 274 patients (Hybrid i.e modified Collard
technique vs hand sewn), the pts with hybrid
anastomosis had:
Less cervical wound infections (8 versus 29 percent) .
Similar leak rate
Fewer anastomotic dilatations (4 versus 11%,
mean 2.4 versus 4.1 per patient, respectively).
Honda M, et al. Ann Surg. 2013
Collard JM, et al. Ann Thorac Surg
Ercan S, et al. J Thorac Cardiovasc Surg.
2005

59. CERVICAL VERSUS THORACIC
ANASTOMOSIS
• Equally safe when performed using standardized techniques.
• At present, the choice of anastomotic location remains clinician dependent.
• A cervical anastomosis has a higher leak rate and risk of injury to the RLN.
• However, the anatomic confines of the neck and thoracic inlet limit surrounding tissue
contamination and, thus, limit morbidity.

60. • 4 clinical trials (267 patients) : 132 cervical anastomosis vs thoracic anastomosis
• Cervical anastomosis were associated
• Higher rate of anastomotic leak (18 versus 4 %).
• Significantly higher rate of RLN injury (OR 7.14, 95% CI 1.75-29.14)
• No difference in rate of pulmonary complications, perioperative mortality, benign
stricture formation, or tumor recurrence at the anastomotic site.

61. •The stomach is the preferred organ for esophageal replacement because of
its 1.Blood supply,
2.The resistance of these vessels to atherosclerotic disease,
3.The need for a single anastomosis,
4.The ability of the stomach to reach the neck without diffculty.
•Contraindications
1. Prior gastric surgery,
2. Scarring from peptic ulcer disease
3. Involvement with tumor.

63. •The left colon is preferred over the right colon for several reasons.
1. Its diameter more closely resembles that of the esophagus,
2. Its vascular supply has less variation,
3. Greater length can be obtained.
•Unfortunately, atherosclerotic disease most commonly affects the inferior
mesenteric artery,and the left colon is often more affected by diverticular disease
than the right.
Colon

65. JEJUNUM
•Jejunal interposition may be applied as a free graft, pedicled graft, or Roux-en-Y
replacement.
•Jejunum is often the third choice (after stomach and colon) for esophageal replacement,
because it cannot replace the entire esophagus to the neck, but can be used to replace a
portion of the distal or proximal esophagus.
•Free jejunal grafts are used in limited reconstructions of the cervical esophagus.

66. TRANSHIATAL ESOPHAGECTOMY
• Distal esophagus and EGJ cancers.
• Upper midline laparotomy incision and a left neck incision.
• Blunt dissection of thoracic esophagus.
• Cervical anastomosis with a gastric pull-up.
• Disadvantages: Limited thoracic lymphadenectomy and blind midthoracic dissection.

69. • In the largest prospective database series of 2007 patients, the in-hospital mortality rate decreased
in the 1998 to 2006 cohort (n = 944 patients) compared with the 1976 to 1998 cohort (1 versus 4
percent) [50].
• The anastomotic leak rate was also lower in the 1998 to 2006 cohort (9 versus 14 percent).
• Other postoperative complications included atelectasis and pneumonia (2 percent), and
intrathoracic hemorrhage, RLN paralysis, chylothorax, and tracheal laceration in <1 percent each.
 Orringer MB, et al. Ann Surg. 2007

70. EGJ CANCER
RESECTION
or.
• Surgical management is standard of care includes either
an esophagectomy with partial or extended gastrectomy,
with/out thoracotomy.
• Principles:
• R0 resection,
• 4-cm (distal) gastric margin, 5-cm
esophageal margin, and
• Resection of at least 15 nodes in basins
appropriate for the primary tum
• Solely transabdominal approach without
thoracoabdominal incision or THE is not acceptable for
tumors that involve the distal esophagus.
Siewert JR, et al. Chirurg 1987

71. • Left thoracoabdominal incision (single
incision)
• Gastric pull-up and an
esophagogastric anastomosis in the
left chest .
• Most useful for tumors involving the
GEJ.
• Disadvantages include a high incidence
of complications such as postoperative
reflux and limitation of the proximal
esophageal margin by the aortic arch.
LLLTA- MODIFIED IVOR LEWIS

72. DIVERSITY OF APPROACHES-
CONTROVERSY

73. THE V TTE
 The limited transhiatal esophagectomy (THE) was developed in an attempt to
mainly minimizing postoperative morbidity/mortality by avoiding a formal thoracotomy
but limiting the extent of lymph node dissection achievable.
 On the other hand, the transthoracic approach (TTE) with two-field lymphadenectomy
(posterior mediastinum, upper abdomen) was introduced as to improve completeness of
the resection and to increase locoregional tumor control.
 It is widely accepted that extensive lymphadenectomy provides the benefit of a more
accurate staging, but its effect on improvement of survival, especially in an era of
neoadjuvant treatment followed by surgery is still a matter of debate

74. •There was no difference in postoperative mortality nor in overall
oncologic results,
between both groups (P=0.45), but intraoperative blood loss and short
term outcome were signifcantly better in the THE arm.
•Nevertheless, in a subsequent subgroup analysis of patients with true
esophageal (distal 1/3 or Siewert type 1) cancer, a better long term
survival was achieved in the TTE arm, in particular in those patients with
a limited number of positive nodes (P=0.02)
•RCT published in 2007
•Siewert 1,2-220
patients
•5-year survival was
34% and 36%,
respectively (P 0.71,
per protocol
analysis).

75. •220 patientswith adenocarcinoma of the distalesophagus (type I) or gastric cardia involving the distal
esophagus type II)
•RCT NEJM 2002
•Perioperative morbidity was higher after transthoracic esophagectomy, but there was no
significant difference in in-hospital mortality (P=0.45).
•After a median follow-up of 4.7 years, 142 patients had died — 74 (70 percent) after transhiatal resection
and 68 (60 percent) after transthoracic resection (P= 0.12).
•Although the difference in survival was not statistically significant, there was a trend toward a survival
benefit with the extended approach at five years: disease-free survival was 27 percent in the transhiatale
sophagectomy group, as compared with 39 percent
in the transthoracic-esophagectomy group

76. •Annals of surgery 2012 meta Analysis
•Transthoracic operations took longer and were associated with a significantly longer length of stay.
•There was no difference in blood loss.
•The transthoracic group had significantly more respiratory complications, wound infections, and early
postoperative mortality, whereas anastomotic leak, anastomotic stricture, and recurrent laryngeal
nerve palsy rate was significantly higher in the transhiatal group.

77. • Lymph node retrieval was reported in 4 studies and was significantly greater in the transthoracic
group by on average 8 lymph nodes.
• Analysis of 5-year survival showed no significant difference between the groups and was subject to
significant heterogeneity
 However lymphadenectomy and reported surgical quality was suboptimal in both groups and the
transthoracic group had significantly more advanced cancer.
 The finding of equivalent survival should therefore be viewed with caution

78. JCOG-9502
Compared THE vs extended esophagectomy using a left thoracoabdominal approach (LTA) for patients with
Sievert type II or III adenocarcinoma.
THE group: Received a total gastrectomy plus a D2 lymphadenectomy (including splenectomy) and PALND.
LTAgroup: Underwent thorough mediastinal nodal dissection below the left IPV + D2 abdominal LAD.
The trial closed prematurely when a planned interim analysis concluded that it was unlikely that LTAwould be
significantly better than TH.
• 5 yr OS was lower in the LTAgroup (38 vs 52 %, p>0.05),
• 10 yr OS: 24 versus 37 percent (p>0.05)[89].
• More complications and mortality in LTA gp.
• Conclusion: LTAcould not be recommended for type II/III tumors.

79. OPEN VERSUS MINIMALLY
INVASIVE
Advantages of MIS include :
●Smaller incisions
●Less blood loss
●Fewer postop complications
●Shorter ICU and hospital stay
●Better preservation of
postoperative pulmonary function
Areas of uncertainty include:
●Optimal minimally invasive
procedure
● Adequacy of the esophageal and
gastric surgical margins
● Extent of LN dissection
●Safety of minimally invasive
esophagectomy in patients who have
undergone preoperative radiation
therapy
● Long-term oncologic outcomes

80. SAFETY OF MIS
ESOPHAGECTOMY
• No consensus that MIE is associated with a decrease in 30-day
mortality and overall morbidity, as found in many retrospective and
prospective studies:

81. n=75,502 Esophagectomy
n = 1155 : MIE
• No significant benefits as defined by a decrease in 30-day mortality
and overall morbidity (4.3 versus 4.0 percent and 38.0 versus 39.2
percent, respectively).
• The re-intervention rate was significantly higher for patients
undergoing an MIE compared with an open esophagectomy (21.0
versus 17.6 percent).

82. COMBINED APPROACH
• Thoracoscopic mobilization of the esophagus + node dissection combined with open
laparotomy.
• Most popular MIE technique with the most extensive published experience.
Relative C/I to thoracoscopic surgery
• Inadequate pulmonary function,
• Extensive pleural adhesions,
• Prior pneumonectomy,
• Bulky tumors,
• Locally infiltrative tumors, particularly
those with airway involvement
Santillan AA, et l. J Natl Compr Canc Netw 2008; 6:879
Wang H, et al. J Thorac Cardiovasc Surg 2015; 149:1006.

83. •This prospective randomized controlled trial on 207 patients
compared TTE to hybrid MIE (thoracotomy, laparoscopy).
•Both postoperative morbidity (OR 0.31, 95% CI: 0.18–0.55,
P=0.0001) and pulmonary complications (30.1% vs. 17.7%,
P=0.037) were lower in the hybrid group.

84. 12 studies
N = 672 MIE or hybrid minimally invasive esophagectomy (HMIE) N = 612 open
esophagectomy
No significant difference in
• 30-day mortality.
• Frequency of anastomotic leak

85. A Prospective TIME trial –Annals of Surgery 2017 found that patients undergoing an MIE have a better
perioperative hospital course.N=115
Patients undergoing an MIE had
• Lower rate of in hospital pulmonary infections (12 vs 34%)
• Lower perioperative (within 2 weeks) pulmonary infections (9 vs 29%).
• Similar DFS (36 versus 40 percent) and 3 yr OS (40 versus 51 percent)

86. • Lap THE was associated with
Fewer overall complications (risk ratio 0.64, 95% CI 0.48-0.86)
Fewer serious complications (risk ratio 0.49, 95% CI 0.24-0.99) Shorter hospital
stays (by three days).
However, RCTs are needed to determine the optimal approach to THE.

87. TOTAL MIE APPROACH
• Limited data for oncologic outcomes.
• In the largest series with oncologic outcomes, 70 of 77 attempts to perform a total MIE were
successful.
• 2 yr OS and DFS were 81 and 74 %, respectively.
• Recurrence was documented in 14 patients, 11 of which were distant recurrences.
• No RCTs comparing any form of MIE to an open procedure.
No differences in the rate of margin positivity or the no of LN
retrieved,
No difference in the time to recurrence or median or 3 yr OS
(compared stage for stage).

88. CIRCUMFERENTIAL RESECTION MARGIN
• Unclear prognostic role till recently
• The College of American Pathologists (CAP) defines a positive CRM as the presence
of esophageal cancer at the resection margin.
• The United Kingdom Royal College of Pathologists (RCP) defines a positive CRM as
the presence of esophageal cancer within 1 mm of the resection margin.
• CAP criteria differentiate a higher-risk group of patients with resectable esophageal
cancer than the RCP criteria.
• Meta- analysis (14 cohort studies including 3566 patients)
5 yr mortality rates were higher for patients with a + CRM
Chan DS, et al. Br J Surg. 2013

90. 2 FIELD VS 3 FIELD

91. EXTENT OF LYMPHADENECTOMY
• Debated. Greenstein AJ, et al. Cancer 2008
• The minimum number of LN that should be removed has not been established.
• However, as many LN should be removed as is feasible, since more extensive
lymphadenectomy has been associated with better survival
• In a retrospective review of 972 patients with node-negative esophageal cancer: 5 yr DSS : 55
percent when fewer than 11 nodes were resected,
5 yr DSS : 66 percent for 11 to 17 nodes resected
5 yr DSS : 75 percent for 18 or more nodes resected
The data suggest that the higher number of nodes retrieved correspond to a more extensive
resection.

92. • Many high-volume surgical centers routinely perform en bloc esophagectomy with a
two-field (mediastinal, upper abdomen) LN dissection.
• 3 field lymphadenectomy of the mediastinal, abdominal, and cervical nodes, is
commonly practiced in Asian countries for upper thoracic esophageal cancers.
• In a retrospective review of 1361 patients with SCC of the thoracic esophagus, the
frequency of nodal metastasis was
Neck (9.8 percent)
Upper mediastinum (18.0 percent)
Middle mediastinum (18.9 percent)
Lower mediastinum (11.8 percent)
Upper abdomen (28.4 percent)
Li B, Chen H, et al. J Thorac Cardiovasc Surg.
2012

93. • Atorki et al: 80 patients underwent 3 field LAD.
5 yr OS was 51 % (88 % for node-negative and 33% for node-positive).
• Unsuspected metastases in the RLN or cervical nodes were detected in 36 % of
pts.
• The location of the tumor (upper versus middle to lower-third) may have an
influence on the frequency of finding cervical nodal metastases.
Altorki N, et al Ann Surg
2002

96. •Overall5-year and disease-free survival after R0 resection of
41.9% and 46.3%, respectively, may indicate a real survival
benefit.
•A 5-year survival of 27.2% in patients with positive cervical
nodes in middle third carcinomas indicates that these nodes
should be considered as regional (N1) rather than distant
metastasis (M1b) in middle third carcinomas.
•These patients seem to benefit from a 3-field lymphadenectomy.
•The role of 3-field lymphadenectomy in distal third
adenocarcinoma remains investigational

97. • At least two randomized trials have compared different extents of
lymphadenectomy during esophageal cancer surgery.
Neither provided a conclusive result as to the benefit of 3 field LAD.
• In the US, en bloc resection of the mediastinal and upper abdominal lymph nodes is
considered a standard component of transthoracic esophagectomy.
Hulscher JB, et al. N Engl J Med. 2002 Nishihira T, et al. Am J Surg. 1998

98. STANDARD VS EXTENDED 2
FIELD

100. •Extended lymphadenectomy increased the number of resected lymph nodes
and improved the healthy/invaded lymph node ratio.
•It allowed to detect skip nodal metastasis in 36.4% of the NC patients.
•Morbidity was higher following extended lymphadenectomy, with respect to
pulmonary complications, and blood transfusions requirement (PZ0.04).
•However, operative mortality was similar in both groups (9 vs. 11%).
•Overall disease-free survival was 28% at 5 years. Median of survival was higher
in N0 than in NC patients (55 months vs. 20 months; PZ0.02).

101. •Extended lymphadenectomy was associated with an improving of disease-free survival
when compared to standard lymphadenectomy (41 vs. 10% at 5 years; P!0.05), especially
in the subgroup of patients with a N0 disease (median of survival 44 months vs. 17 months;
PZ0.001).
•Based on multivariable analyses, predictive factors of recurrence affecting disease free-
survival were the pT status (PZ0.02), standard lymphadenectomy (PZ0.05) and
extracapsular lymph node involvement (0.04)

102. •25% of all patients, and in more than 35% of the N+ patients, standard 2-feld
lymphadenectomy would have led to inadequate staging and, in turn, incomplete
resection.
•These results indicate that extended 2-field lymphadenectomy is an important
component of the surgical treatment of patients with adenocarcinoma of the
oesophagus.
•It increases the likelihood of proper staging and affects patient outcome, while it
does not enhance the operative mortality.
•However, extended lymphadenectomy increases non-fatal morbidity, especially
the incidence of pulmonary complications and the need for blood transfusion

103. RLN LYMPH NODE

105. •To tailor the use of three-field lymphadenectomy as to avoid unnecessary complications, one can
use the possible ‘sentinel’ role of recurrent nerve chain lymph nodes.
•Indeed, in a group of patients systematically treated with three-field lymph node dissection, the
incidence of cervical lymph node involvement was signifcantly higher in recurrent nerve-positive
(51.6%) as compared to recurrent node-negative patients (11.6%) in patients with middle or
lower esophageal cancer .
• Negative preoperative frozen section of recurrent nerve lymph nodes can preclude the need of a
formal three-feld lymph node dissection except for proximal esophageal cancer or in patients with
clinical suspicion of lymph node involvement in the neck.
RLN NODE

106. The sensitivities of the preoperative evaluations of RLN LN
metastasis by EBUS, EUS and CT were 67.6%, 32.4% and
29.4%, respectively.

107. PCR- WHAT TO DO
• Surgical resection is recommended.
• cPR seen in 20-25% of patients.
• However, it is not possible to reliably identify these patients either by EUS or
repeat PET scan.
• The recommendation is to proceed with resection if the patient is fit for surgery
and has not progressed during chemoradiotherapy

108. SURGERY AFTER NACRT
• The impact of NACT/NACRT on perioperative morbidity and mortality was
addressed in a meta-analysis of 23 randomized trials comparing neoadjuvant
therapy versus surgery alone or NACT versus CRT .
• Neither NACT/NACRT increased the risk of total postoperative mortality
or morbidity.
• However, subgroup analysis suggested that patients undergoing NACRT for
SCC might be at an elevated risk for postoperative mortality relative to those
treated by surgery alone (risk ratio 1.95, 95% CI 1.06-3.6).

109.  One hundred sixty-one patients underwent surgery alone, and 159
patients received multimodality treatment.
 The median (interquartile range) number of resected nodes was 18 (12–27) and 14 (9–
21), with 2 (1–6) and 0 (0–1) resected positive nodes, respectively.
 Persistent lymph node positivity after nCRT had a greater negative prognostic impact on
survival as compared with lymph node positivity after surgery alone.
 The total number of resected nodes was significantly associated with survival for patients
in the surgery alone arm (hazard ratio per 10 additionally resected nodes, 0.76; P = 0.007),
but not in the multimodality arm (hazard ratio 1.00; P = 0.98)

110.  In this study, total number of resected lymph nodes was signifcantly lower in patients
undergoing neoadjuvant treatment followed by surgery than compared with patients
treated by surgery alone.
 Furthermore, after surgery alone, total number of resected nodes had a positive
correlation with survival (HR per 10 additionally resected nodes, 0.76; P=0.007), but this
was no longer the case after neoadjuvant treatment (HR 1.00; P=0.98), suggesting a
probably relevant role of extensive lymph node dissection
in patients undergoing primary surgery but not in patients undergoing surgery after
neoadjuvant treatment

111. COMPLICATIONS OF EXTENSIVE
LYMPHADENECTOMY

112. WECC GROUP- MINIMUM LN
 T1-10
T2-20
 T3-30

113.  606 patients- prospective cohort – JAMA 2016
 The extent of lymphadenectomy was not statistically significantly associated with
all-cause or disease-specific mortality, independent of the categorization of
lymphadenectomy or stratification for T category, calendar period, or chemotherapy.
 Patients in the fourth quartile of the number of removed nodes (21-52 nodes) did
not demonstrate a statistically significant reduction in all-cause 5-year mortality
compared with those in the lowest quartile (0-10 nodes) (HR, 0.86; 95% CI, 0.63-
1.17), particularly not in the most recent calendar period (HR, 0.98; 95% CI, 0.57-
1.66 for years 2007-2012

114.  A recent nationwide, population-based cohort
study in Sweden has
shown that a more extensive lymph node
dissection neither increased postoperative
mortality nor negatively influence patient’s
short-term or long term health-related quality o
life which could lead to a more liberal use of
more extended lymph node dissection so as to
maximize the possible improved survival
brought by more extensive lymph node
dissection

115. JEJUNAL FEEDING TUBE PLACEMENT
• A feeding jejunostomy tube is inserted at the time of the surgical resection for all patients
undergoing an esophagectomy and for select patients who require nutritional support during
induction chemotherapy and/or radiation therapy.
• The jejunostomy tube is inserted 40 cm distal to the ligament of Treitz, using either a
laparoscopic approach if technically feasible or through a small laparotomy incision.

116. POSTOPERATIVE MANAGEMENT
• Enteral feedings are started on POD 2 and slowly advanced.
• OGS is performed on POD 7 to evaluate for leak and emptying of the conduit.
• The NG tube generally remains in place until OGS is performed and demonstrates no
leak.
• Minimal liquid diet for approximately 2 weeks.

117. Postoperative thromboprophylaxis : Controversial
High risk procedure :Postoperative thromboprophylaxis is recommended
(The American College of Chest Physicians Guidelines on the Prevention
of VTE)
High risk of bleeding : Especially in the setting of blunt mediastinal dissection,
and thus argue for less aggressive prophylaxis.
Frequent use of neuraxial anesthesia, which further limits the use of
perioperative anticoagulants for thromboprophylaxis .
Unfortunately, a paucity of data exists to help clarify these issues, and,
therefore, clinical practice varies.

118. MORBIDITY AND MORTALITY
• The overall incidence of postoperative complications varies widely between 20 and
80 percent
• Includes systemic complications (eg, pneumonia, myocardial infarction) and
complications specific to the surgical procedure (eg, anastomotic leaks, recurrent
laryngeal nerve injury).
• Pulmonary complications : mc (16 – 67%), mc of mortality.
• Anastomotic leak is the most dreaded (0-40%)
• The overall in-hospital mortality rates range from 0 to 22 percent.
• The overall 30-day mortality rates (excluding in-hospital deaths) is <1 to 6 percent.

119. Anastomotic leak — 5-40 %,
Mortality a/w with leaks: 2-12 %.
Factors affecting leaks:
• Anastomotic technique
• Location (neck vs chest)
• Type of conduit (stomach vs colon vs small bowel)
• Location of the conduit (orthotopic vs heterotopic)
Other Risk Factors:
• Conduit ischemia
• Neoadjuvant therapy
• Comorbid conditions like heart failure, hypertension, renal insufficiency.
• Type of procedure
M/M
Neck leaks : Wound m/m
Thoracic leaks: Re-exploration,
Endoscopic stenting or clips,
transluminal vacuum therapy

120. Systemic complaints
• Pulmonary MC (16 to 67%) ,60% of mortality
• Cardiac AF: 20%,MI: 1.1-3.8%
Chylothorax — 0 to 8% .
• 18% mortality rates and 85% major 30-day complication.
• Diagnosis : High chest tube output (milky),TGs >110, chylomicrons
Mx:
• Parenteral nutrition +octreotide + fluid resuscitation.
• Early surgical intervention (within 14 days from diagnosis) is favored if it persists
(>10 mL/kg for 5 days)
• If the site of the leak is not identified, ligation of all tissue between the spine and the
aorta is performed as caudal as possible in the right hemithorax.

121. Conduit ischemia — 9%
• Minor leak to, rarely, complete loss of the conduit.
• Rate of ischemia similar for gastric pull-up & colonic interposition graft (10.4 vs
7.4 %).
• Total conduit ischemia: Rapidly deteriorating course with septic shock.
• Mandates aggressive resuscitation, surgical removal, drainage and proximal
esophageal diversion, broad-spectrum antibiotic coverage.

122. RLN injury —
• Hoarseness, dyspnea, and/or aspiration pneumonia.
• Laryngoscopy and esophageal swallow evaluation.
• More common in cervical anastomosis and 3-field lymphadenectomy.
• Management of a laterally paralyzed cord requires vocal cord injection or temporary vocal
cord medialization.
Anastomotic stricture : 9 to 40 %
Linked to conduit malperfusion/ischemia or surgical technique. Endoscopic dilatation.

123. QUALITY OF
LIFE
• Temporary and long-term detrimental impacts on HR-QOL.
• Recovery seems to occur within 12 to 24 months.
• Long-term survivors still report residual problems with eating, breathlessness, diarrhea, reflux,
fatigue, and odynophagia even after 3-4 years.
• Recovery of HR-QOL may be to the occurrence of postoperative complications.
• Patients who sustained a major postoperative complication (eg,pneumonia, anastomotic leak)
had significant more dyspnea, fatigue and eating restrictions.
Derogar M,et al. Influence of major postoperative complications on health-related quality of life among long-term survivors of esophageal
cancer surgery. J Clin Oncol. 2012

124. CENTRALIZATION OF ESOPHAGEAL
SURGERY
• Lower mortality rates and better clinical outcomes in large volume centres compared with
lower-volume institutions.
• The definition of low versus high volume is variable, with most studies defining "low volume" as <4
to <10 procedures and "high volume" as >9 to >40 procedures.
• As an example, in one report that used Medicare claims data, the mortality following
esophagectomy at the highest-volume hospitals (>19 procedures annually) was significantly
lower compared with the lowest-volume hospitals (<2 procedures annually)
Birkmeyer et al. Engl J Med. 2002

125. TAKE HOME MESSAGE
 T1aN0, M0 with Favourable factors- Endoscopic Resection
 T1b,T2N0 MO- Upfront Radical Esophgectomy
 T3,T4 No or Any T N+- Cross Trial.
 Transthoracic Mckeowen approach with standard 2 field lymphadenctomy is ideal for
mid and distal esophageal carcinoma
 Transthoracic Mckeowen with 3 field lymphadenctomy in Upper esophagus tumours.

126. TAKE HOME MESSAGE
 A TTE is the mainstay of treatment for all tumors of the esophagus and GEJ as it
allows probably the best chance for complete resection, optimal lymph node
dissection and improved survival.
 In case of bulky tumor alongside the airway before or after neoadjuvant treatment, a
hybrid resection using a right thoracotomy, laparoscopy and cervical anastomosis will
be performed. This approach has the potential to limit complications as shown by the
MIRO-trial

127. TAKE HOME MESSAGE
 An extended 2-field lymph node dissection can be performed in both approaches,
with frozen section of the recurrent nerve lymph node if deemed necessary to decide
whether a 3-feld lymphadenectomy should be performed.
 In the case of a proximal tumor or in case of lymph node involvement in the cervical
region (prior to neoadjuvant treatment or during surgery), a 3-field lymph node
dissection is deemed mandatory

128. TAKE HOME MESSAGE
 In case of tumors invading the stomach more extensively (more than 5 cm along the
lesser curvature), a total gastrectomy through left thoracoabdominal approach can be
performed.
 More tailored resection and extent of lymphadenectomy to patients with extensive co-
morbidities, limited cardio-respiratory function or other particular
situation

129. THANK YOU