Journal Mobile Options
Table of Contents
Vol. 31, No. 1, 2013
Issue release date: June 2013
Dig Dis 2013;31:21-29

Evolution in Surgical Management of Esophageal Cancer

Low D.E.
Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, Seattle, Wash., USA

Individual Users: Register with Karger Login Information

Please create your User ID & Password

Contact Information

I have read the Karger Terms and Conditions and agree.

To view the fulltext, please log in

To view the pdf, please log in


Esophageal resection remains the primary treatment for local regional esophageal cancer, although its role in superficial (T1A) cancers and squamous cell cancer is in evolution. Mortality associated with esophagectomy has historically been high but is improving with the current expectation of in-hospital mortality rates of 2-4% in high-volume centers. Most patients with regional cancers (T2-4 N0-3) are recommended for neoadjuvant therapy, which most commonly involves radiochemotherapy. Some centers have proposed treating with definitive chemoradiation and reserving surgery for patients who have persistent or recurrent disease. ‘Salvage resections' are possible but are associated with higher levels of perioperative morbidity and mortality, and treatment decisions should routinely be based on multidisciplinary discussion in the tumor board. Although open surgical resection (both transthoracic and transhiatal operations) remain the most common approach, minimally invasive or hybrid operations are being done in up to 30% of procedures internationally. There are some indications that minimally invasive esophagectomy may decrease the incidence of respiratory complications and decrease length of stay. At this point, oncologic outcomes appear equivalent between open and minimally invasive procedures. Recent reviews from high-volume esophagectomy centers demonstrate that elderly patients can selectively undergo esophagectomy with the expectation of increased complications but similar mortality and survival to younger patients. Multiple studies confirm that quality of life following esophagectomy can be equivalent to the general population when surgery is done in experienced centers. Patients requiring surgical treatment of esophageal cancer should be referred to high-volume centers, especially those with established care pathways or enhanced recovery programs to improve outcomes including morbidity, mortality, survival, and quality of life.

Copyright / Drug Dosage

Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.


  1. Markar SR, Karthikesalingam A, Thrumurthy S, Low DE: Volume-outcome relationship in surgery for esophageal malignancy: systematic review and meta-analysis 2000-2011. J Gastrointest Surg 2012;16:1055-1063.
  2. Kohn GP, Galanko JA, Meyers MO, Feins RH, Farrell TM: National trends in esophageal surgery - are outcomes as good as we believe? J Gastrointest Surg 2009;13:1900-1910.
  3. Rutegard M, Charonis K, Lu Y, Lagergren P, Lagergren J, Rouvelas I: Population-based esophageal cancer survival after resection without neoadjuvant therapy: an update. Surgery 2012;152:903-910.
  4. Weber WA, Ott K: Imaging of esophageal and gastric cancer. Semin Oncol 2004;31:530-541.
  5. Young PE, Gentry AB, Acosta RD, Greenwald BD, Riddle M: Endoscopic ultrasound does not accurately stage early adenocarcinoma or high-grade dysplasia of the esophagus. Clin Gastroenterol Hepatol 2010;8:1037-1041.
  6. Smith BR, Chang KJ, Lee JG, Nguyen NT: Staging accuracy of endoscopic ultrasound based on pathologic analysis after minimally invasive esophagectomy. Am Surg 2010;76:1228-1231.

    External Resources

  7. Puli SR, Reddy JB, Bechtold ML, Antillon D, Ibdah JA, Antillon MR: Staging accuracy of esophageal cancer by endoscopic ultrasound: a meta-analysis and systematic review. World J Gastroenterol 2008;14:1479-1490.
  8. Medical Research Council Oesophageal Cancer Working Group: Surgical resection with or without preoperative chemotherapy in oesophageal cancer: a randomised controlled trial. Lancet 2002;359:1727-1733.
  9. Allum WH, Stenning SP, Bancewicz J, Clark PI, Langley RE: Long-term results of a randomized trial of surgery with or without preoperative chemotherapy in esophageal cancer. J Clin Oncol 2009;27:5062-5067.
  10. Rice TW, Mason DP, Murthy SC, Zuccaro G Jr, Adelstein DJ, Rybicki LA, Blackstone EH: T2N0M0 esophageal cancer. J Thorac Cardiovasc Surg 2007;133:317-324.
  11. van Hagen P, Hulshof MC, van Lanschot JJ, Steyerberg EW, van Berge Henegouwen MI, Wijnhoven BP, Richel DJ, Nieuwenhuijzen GA, Hospers GA, Bonenkamp JJ, Cuesta MA, Blaisse RJ, Busch OR, ten Kate FJ, Creemers GJ, Punt CJ, Plukker JT, Verheul HM, Spillenaar Bilgen EJ, van Dekken H, van der Sangen MJ, Rozema T, Biermann K, Beukema JC, Piet AH, van Rij CM, Reinders JG, Tilanus HW, van der Gaast A, CROSS Group: Preoperative chemoradiotherapy for esophageal or junctional cancer. N Engl J Med 2012;366:2074-2084.
  12. Chiu PW, Chan AC, Leung SF, Leong HT, Kwong KH, Li MK, Au-Yeung AC, Chung SC, Ng EK: Multicenter prospective randomized trial comparing standard esophagectomy with chemoradiotherapy for treatment of squamous esophageal cancer: early results from the Chinese University Research Group for Esophageal Cancer (CURE). J Gastrointest Surg 2005;9:794-802.
  13. Murakami M, Kuroda Y, Okamoto Y, Kono K, Yoden E, Kusumi F, Hajiro K, Matsusue S, Takeda H: Neoadjuvant concurrent chemoradiotherapy followed by definitive high-dose radiotherapy or surgery for operable thoracic esophageal carcinoma. Int J Radiat Oncol Biol Phys 1998;40:1049-1059.
  14. Swisher SG, Winter KA, Komaki RU, Ajani JA, Wu TT, Hofstetter WL, Konski AA, Willett CG: A phase II study of a paclitaxel-based chemoradiation regimen with selective surgical salvage for resectable locoregionally advanced esophageal cancer: initial reporting of RTOG 0246. Int J Radiat Oncol Biol Phys 2012;82:1967-1972.
  15. Swisher SG, Wynn P, Putnam JB, Mosheim MB, Correa AM, Komaki RR, Ajani JA, Smythe WR, Vaporciyan AA, Roth JA, Walsh GL: Salvage esophagectomy for recurrent tumors after definitive chemotherapy and radiotherapy. J Thorac Cardiovasc Surg 2002;123:175-183.
  16. Smithers BM, Cullinan M, Thomas JM, Martin I, Barbour AP, Burmeister BH, Harvey JA, Thomson DB, Walpole ET, Gotley DC: Outcomes from salvage esophagectomy post definitive chemoradiotherapy compared with resection following preoperative neoadjuvant chemoradiotherapy. Dis Esophagus 2007;20:471-477.
  17. Kim JY, Correa AM, Vaporciyan AA, Roth JA, Mehran RJ, Walsh GL, Rice DC, Ajani JA, Maru DM, Bhutani MS, Welsh J, Marom EM, Swisher SG, Hofstetter WL: Does the timing of esophagectomy after chemoradiation affect outcome? Ann Thorac Surg 2012;93:207-212.
  18. Yoo C, Park JH, Yoon DH, Park SI, Kim HR, Kim JH, Jung HY, Lee GH, Choi KD, Song HJ, Song HY, Shin JH, Cho KJ, Kim YH, Kim SB: Salvage esophagectomy for locoregional failure after chemoradiotherapy in patients with advanced esophageal cancer. Ann Thorac Surg 2012;94:1862-1868.
  19. Nakamura T, Hayashi K, Ota M, Eguchi R, Ide H, Takasaki K, Mitsuhashi N: Salvage esophagectomy after definitive chemotherapy and radiotherapy for advanced esophageal cancer. Am J Surg 2004;188:261-266.
  20. Marks JL, Hofstetter W, Correa AM, Mehran RJ, Rice D, Roth J, Walsh G, Vaporciyan A, Erasmus J, Chang J, Maru D, Lee JH, Lee J, Ajani JA, Swisher SG: Salvage esophagectomy after failed definitive chemoradiation for esophageal adenocarcinoma. Ann Thorac Surg 2012;94:1126-1132, discussion 1132-1133.
  21. Teoh AY, Yan Chiu PW, Wong TC, Liu SY, Hung Wong SK, Ng EK: Functional performance and quality of life in patients with squamous esophageal carcinoma receiving surgery or chemoradiation: results from a randomized trial. Ann Surg 2011;253:1-5.
  22. Hulscher JB, van Sandick JW, de Boer AG, Wijnhoven BP, Tijssen JG, Fockens P, Stalmeier PF, ten Kate FJ, van DH, Obertop H, Tilanus HW, van Lanschot JJ: Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus. N Engl J Med 2002;347:1662-1669.
  23. Hulscher JB, van Lanschot JJ: Individualised surgical treatment of patients with an adenocarcinoma of the distal oesophagus or gastro-oesophageal junction. Dig Surg 2005;22:130-134.
  24. Boone J, Livestro DP, Elias SG, Borel Rinkes IH, van Hillegersberg R: International survey on esophageal cancer: part I surgical techniques. Dis Esophagus 2009;22:195-202.
  25. National Oesophago-Gastric Cancer Audit 2010. An Audit of the Care Received by People with Oesophago-Gastric Cancer in England and Wales. Third Annual Report 2010. The Information Centre, NHS. (accessed 9/10/2012).
  26. Hoppo T, Jobe BA, Hunter JG: Minimally invasive esophagectomy: the evolution and technique of minimally invasive surgery for esophageal cancer. World J Surg 2011;35:1454-1463.
  27. Lagarde SM, Vrouenraets BC, Stassen LP, van Lanschot JJ: Evidence-based surgical treatment of esophageal cancer: overview of high-quality studies. Ann Thorac Surg 2010;89:1319-1326.
  28. Low DE, Kunz S, Schembre D, Otero H, Malpass T, Hsi A, Song G, Hinke R, Kozarek RA: Esophagectomy - it's not just about mortality anymore: standardized perioperative clinical pathways improve outcomes in patients with esophageal cancer. J Gastrointest Surg 2007;11:1395-1402.
  29. Sudarshan M, Ferri L: A critical review of minimally invasive esophagectomy. Surg Laparosc Endosc Percutan Tech 2012;22:310-318.
  30. Rice TW, Blackstone EH: Minimally invasive versus open esophagectomy for cancer: more questions than answers. Ann Surg 2012;255:204-205.
  31. Luketich JD, Pennathur A, Awais O, Levy RM, Keeley S, Shende M, Christie NA, Weksler B, Landreneau RJ, Abbas G, Schuchert MJ, Nason KS: Outcomes after minimally invasive esophagectomy: review of over 1,000 patients. Ann Surg 2012;256:95-103.
  32. Javidfar J, Bacchetta M, Yang JA, Miller J, D'Ovidio F, Ginsburg ME, Gorenstein LA, Bessler M, Sonett JR: The use of a tailored surgical technique for minimally invasive esophagectomy. J Thorac Cardiovasc Surg 2012;143:1125-1129.
  33. Greenstein AJ, Litle VR, Swanson SJ, Divino CM, Packer S, Wisnivesky JP: Effect of the number of lymph nodes sampled on postoperative survival of lymph node-negative esophageal cancer. Cancer 2008;112:1239-1246.
  34. Peyre CG, Hagen JA, DeMeester SR, Altorki NK, Ancona E, Griffin SM, Holscher A, Lerut T, Law S, Rice TW, Ruol A, van Lanschot JJ, Wong J, DeMeester TR: The number of lymph nodes removed predicts survival in esophageal cancer: an international study on the impact of extent of surgical resection. Ann Surg 2008;248:549-556.
  35. Schwarz RE, Smith DD: Clinical impact of lymphadenectomy extent in resectable esophageal cancer. J Gastrointest Surg 2007;11:1384-1393.
  36. Rizk NP, Ishwaran H, Rice TW, Chen LQ, Schipper PH, Kesler KA, Law S, Lerut TE, Reed CE, Salo JA, Scott WJ, Hofstetter WL, Watson TJ, Allen MS, Rusch VW, Blackstone EH: Optimum lymphadenectomy for esophageal cancer. Ann Surg 2010;251:46-50.
  37. Wakui R, Yamashita H, Okuma K, Kobayashi S, Shiraishi K, Terahara A, Sasano N, Ohtomo K, Nakagawa K: Esophageal cancer: definitive chemoradiotherapy for elderly patients. Dis Esophagus 2010;23:572-579.
  38. Mak RH, Mamon HJ, Ryan DP, Miyamoto DT, Ancukiewicz M, Kobayashi WK, Willett CG, Choi NC, Blaszkowsky LS, Hong TS: Toxicity and outcomes after chemoradiation for esophageal cancer in patients age 75 or older. Dis Esophagus 2010;23:316-323.
  39. Braiteh F, Correa AM, Hofstetter WL, Rice DC, Vaporciyan AA, Walsh GL, Roth JA, Mehran RJ, Swisher SG, Ajani JA: Association of age and survival in patients with gastroesophageal cancer undergoing surgery with or without preoperative therapy. Cancer 2009;115:4450-4458.
  40. Rice DC, Correa AM, Vaporciyan AA, Sodhi N, Smythe WR, Swisher SG, Walsh GL, Putnam JB Jr, Komaki R, Ajani JA, Roth JA: Preoperative chemoradiotherapy prior to esophagectomy in elderly patients is not associated with increased morbidity. Ann Thorac Surg 2005;79:391-397.
  41. Morita M, Egashira A, Yoshida R, Ikeda K, Ohgaki K, Shibahara K, Oki E, Sadanaga N, Kakeji Y, Maehara Y: Esophagectomy in patients 80 years of age and older with carcinoma of the thoracic esophagus. J Gastroenterol 2008;43:345-351.
  42. Smith GL, Smith BD, Buchholz TA, Liao Z, Jeter M, Swisher SG, Hofstetter WL, Ajani JA, McAleer MF, Komaki R, Cox JD: Patterns of care and locoregional treatment outcomes in older esophageal cancer patients: the SEER-Medicare Cohort. Int J Radiat Oncol Biol Phys 2009;74:482-489.
  43. Abrams JA, Buono DL, Strauss J, McBride RB, Hershman DL, Neugut AI: Esophagectomy compared with chemoradiation for early stage esophageal cancer in the elderly. Cancer 2009;115:4924-4933.
  44. Markar SR, Karthikesalingam A, Thrumurthy S, Ho A, Muallem G, Low DE: Systematic review and pooled analysis assessing the association between elderly age and outcome following surgical resection of esophageal malignancy. Dis Esophagus 2012, E-pub ahead of print.
  45. Markar SR, Low DE: Physiology not chronology dictates outcomes following esophagectomy for esophageal cancer: outcomes in patients 80 years and older. Ann Surg Oncol 2012;20:1020-1026.
  46. Chang LC, Oelschlager BK, Quiroga E, Parra JD, Mulligan M, Wood DE, Pellegrini CA: Long-term outcome of esophagectomy for high-grade dysplasia or cancer found during surveillance for Barrett's esophagus. J Gastrointest Surg 2006;10:341-346.
  47. Headrick JR, Nichols FC, III, Miller DL, Allen MS, Trastek VF, Deschamps C, Schleck CD, Thompson AM, Pairolero PC: High-grade esophageal dysplasia: long-term survival and quality of life after esophagectomy. Ann Thorac Surg 2002;73:1697-1702.
  48. Moraca RJ, Low DE: Outcomes and health-related quality of life after esophagectomy for high-grade dysplasia and intramucosal cancer. Arch Surg 2006;141:545-549.
  49. Parameswaran R, Blazeby JM, Hughes R, Mitchell K, Berrisford RG, Wajed SA: Health-related quality of life after minimally invasive oesophagectomy. Br J Surg 2010;97:525-531.
  50. Derogar M, Orsini N, Sadr-Azodi O, Lagergren P: Influence of major postoperative complications on health-related quality of life among long-term survivors of esophageal cancer surgery. J Clin Oncol 2012;30:1615-1619.
  51. Scarpa M, Valente S, Alfieri R, Cagol M, Diamantis G, Ancona E, Castoro C: Systematic review of health-related quality of life after esophagectomy for esophageal cancer. World J Gastroenterol 2011;17:4660-4674.
  52. Viklund P, Lindblad M, Lagergren J: Influence of surgery-related factors on quality of life after esophageal or cardia cancer resection. World J Surg 2005;29:841-848.
  53. Viklund P, Lagergren J: A care pathway for patients with oesophageal cancer. Eur J Cancer Care (Engl) 2007;16:533-538.
  54. Portale G, Hagen JA, Peters JH, Chan LS, DeMeester SR, Gandamihardja TA, DeMeester TR: Modern 5-year survival of resectable esophageal adenocarcinoma: single institution experience with 263 patients. J Am Coll Surg 2006;202:588-596.
  55. Orringer MB, Marshall B, Chang AC, Lee J, Pickens A, Lau CL: Two thousand transhiatal esophagectomies: changing trends, lessons learned. Ann Surg 2007;246:363-372.
  56. Smithers BM, Gotley DC, Martin I, Thomas JM: Comparison of the outcomes between open and minimally invasive esophagectomy. Ann Surg 2007;245:232-240.
  57. van Heijl M, van Lanschot JJ, Blom RL, Bergman JJ, ten Kate FJ, Busch OR, Reitsma JB, Obertop H, van Berge Henegouwen MI: Outcomes of 16 years of oesophageal surgery: low postoperative mortality and improved long-term survival (in Dutch). Ned Tijdschr Geneeskd 2010;154:A1156.

    External Resources

  58. Luketich JD, Alvelo-Rivera M, Buenaventura PO, Christie NA, McCaughan JS, Litle VR, Schauer PR, Close JM, Fernando HC: Minimally invasive esophagectomy: outcomes in 222 patients. Ann Surg 2003;238:486-494.
  59. Palanivelu C, Prakash A, Senthilkumar R, Senthilnathan P, Parthasarathi R, Rajan PS, Venkatachlam S: Minimally invasive esophagectomy: thoracoscopic mobilization of the esophagus and mediastinal lymphadenectomy in prone position - experience of 130 patients. J Am Coll Surg 2006;203:7-16.
  60. Nguyen NT, Follette DM, Wolfe BM, Schneider PD, Roberts P, Goodnight JE Jr: Comparison of minimally invasive esophagectomy with transthoracic and transhiatal esophagectomy. Arch Surg 2000;135:920-925.
  61. Braghetto I, Csendes A, Cardemil G, Burdiles P, Korn O, Valladares H: Open transthoracic or transhiatal esophagectomy versus minimally invasive esophagectomy in terms of morbidity, mortality and survival. Surg Endosc 2006;20:1681-1686.
  62. Hamouda AH, Forshaw MJ, Tsigritis K, Jones GE, Noorani AS, Rohatgi A, Botha AJ: Perioperative outcomes after transition from conventional to minimally invasive Ivor-Lewis esophagectomy in a specialized center. Surg Endosc 2010;24:865-869.
  63. Parameswaran R, Veeramootoo D, Krishnadas R, Cooper M, Berrisford R, Wajed S: Comparative experience of open and minimally invasive esophagogastric resection. World J Surg 2009;33:1868-1875.
  64. Zingg U, McQuinn A, DiValentino D, Esterman AJ, Bessell JR, Thompson SK, Jamieson GG, Watson DI: Minimally invasive versus open esophagectomy for patients with esophageal cancer. Ann Thorac Surg 2009;87:911-919.
  65. Safranek PM, Cubitt J, Booth MI, Dehn TC: Review of open and minimal access approaches to oesophagectomy for cancer. Br J Surg 2010;97:1845-1853.
  66. Gao Y, Wang Y, Chen L, Zhao Y: Comparison of open three-field and minimally-invasive esophagectomy for esophageal cancer. Interact Cardiovasc Thorac Surg 2011;12:366-369.
  67. Pham TH, Perry KA, Dolan JP, Schipper P, Sukumar M, Sheppard BC, Hunter JG: Comparison of perioperative outcomes after combined thoracoscopic-laparoscopic esophagectomy and open Ivor-Lewis esophagectomy. Am J Surg 2010;199:594-598.
  68. Schoppmann SF, Prager G, Langer FB, Riegler FM, Kabon B, Fleischmann E, Zacherl J: Open versus minimally invasive esophagectomy: a single-center case controlled study. Surg Endosc 2010;24:3044-3053.
  69. Kinugasa S, Tachibana M, Yoshimura H, Dhar DK, Shibakita M, Ohno S, Kubota H, Masunaga R, Nagasue N: Esophageal resection in elderly esophageal carcinoma patients: improvement in postoperative complications. Ann Thorac Surg 2001;71:414-418.
  70. Moskovitz AH, Rizk NP, Venkatraman E, Bains MS, Flores RM, Park BJ, Rusch VW: Mortality increases for octogenarians undergoing esophagogastrectomy for esophageal cancer. Ann Thorac Surg 2006;82:2031-2036.
  71. Internullo E, Moons J, Nafteux P, Coosemans W, Decker G, De LP, Van RD, Lerut T: Outcome after esophagectomy for cancer of the esophagus and GEJ in patients aged over 75 years. Eur J Cardiothorac Surg 2008;33:1096-1104.
  72. Cijs TM, Verhoef C, Steyerberg EW, Koppert LB, Tran TC, Wijnhoven BP, Tilanus HW, de Jonge J.: Outcome of esophagectomy for cancer in elderly patients. Ann Thorac Surg 2010;90:900-907.
  73. Zehetner J, Lipham JC, Ayazi S, Banki F, Oezcelik A, DeMeester SR, Hagen JA, DeMeester TR: Esophagectomy for cancer in octogenarians. Dis Esophagus 2010;23:666-669.

Pay-per-View Options
Direct payment This item at the regular price: USD 38.00
Payment from account With a Karger Pay-per-View account (down payment USD 150) you profit from a special rate for this and other single items.
This item at the discounted price: USD 26.50