Experimental Surgeries in Esophageal Cancer

Nishi Jain 21′

An example biopsy of cancerous esophageal tissue.
(Source: Wikimedia Commons)

Esophageal cancer has become increasingly prevalent in the Western world and continues to have a very poor survival rate. Without surgery or other intervention, the five-year survival rate was a dismal 10-15%. However, recent improvements in surgical technique, the centralization of surgical practice to a few centers, training of new physicians specialized in treating esophageal cancer, and the introduction of other therapies alongside surgical intervention has led to a dramatic increase in five-year survival to about 40%.1 Esophageal cancer can be characterized as localized (cancerous tissue contained within the esophagus), regional (cancerous tissue has traveled nearby, such as to local lymph nodes), and metastatic (cancerous tissue has traveled elsewhere in the body, including, most dangerously, the brain).2

There are multiple methods of surgical intervention, including open surgery, minimally invasive surgeries (laparoscopic, thoracoscopic, and endoscopic), and now a hybrid, minimally invasive technique. Open surgery involves the surgeon making a full incision along the area where there appears to be cancerous tissue; this is something that is frequently done during the early stages of the disease to diagnose and remove the more proximal portions of the tumor.1 Laparoscopic minimally invasive surgeries involve multiple small incisions along the abdomen of the patient. The first of these incisions allows passage of a tube that pushes carbon dioxide into the abdominal cavity so the surgeon can see its contents. Through the second incision the surgeon pushes a small light and video camera attached to a probe. The surgeon then operates through the third incision.2 Thoracoscopic surgeries are nearly the same as laparoscopic surgeries except the surgery is done on the chest cavity as opposed to the abdomen. Endoscopic surgery is used for tumors that are pressing up against the esophagus, and, they frequently involve the surgeon operating through the mouth to resect the solid tumor mass without making any extra surgical incisions.1

Recently, a consortium of physicians across the country tested the efficacy of a hybrid minimally invasive surgical technique – with positive findings.  The hybrid minimally invasive procedure included an Ivor-Lewis procedure within the upper quadrants of the abdomen (partial removal of the esophagus and upper GI tract), open right thoracotomy (open surgery to the chest), and laparoscopic gastric mobilization (a laparoscopic procedure that ligates vessels away from the GI tract to make it more receptive to surgical intervention). It showed a remarkable 77% decrease in the risk for both postoperative and intraoperative complications. The minimally invasive nature of this surgery compared to the open surgery also resulted in a 50% decrease in post-operative pulmonary complications– this can likely be attributed to a reduction in surgery-related trauma.3

Despite the reduced number of complications, there was unfortunately no increase in the overall survival rate or disease-free survival. 44% of patients still died during the follow-up procedure. The overall three-year survival rate was 60% compared to a previous 40%, but due to the limited sample size the increase was not considered statistically significant.3 Fortunately, other therapies are under development that aim to further improve outcomes for patients with this devastating illness. Optimization on both ends (both surgical and therapeutic) may increase the current 40% survival rate.

Bibliography

[1] Ajani J, D’Amico TA, Hayman JA, et al. (2003). Esophageal Cancer: Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 1(1), 14–27. https://doi.org/10.6004/jnccn.2003.0004

[2] Hulscher JB, van Sandick JW, de Boer AG, et al. (2002). Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus. N Engl J Med.  347(21), 1662–1669. DOI: 10.1056/NEJMoa022343

[2] Marriete C, et al. (2019). Hybrid Minimally Invasive Esophagectomy for Esophageal Cancer. N Engl J Med 380(17), 152-162. DOI: 10.1056/NEJMoa1805101

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