Esophageal cancer surgery. Reflexions concerning 1000 patients

Introduction: Our series of esophageal cancer included 792 casesof squamous cell carcinoma, 183 cases of adenocarcinoma, 25 otherlesions in the form of pseudosarcomas, high grade dysplasia, adenocarcinomatousmetastasis and three cases of primary melanoma.Patients and methods: The series concerned 907 males and 93females. The age of half of our patients varied between 60 and 70years. Two hundred and fifty two cases had past history of pulmonarydisease. Eigthy five per cent of these patients were operablewhile 92 % had resectable tumours.Surgery was contra indicated in 138 patients due to metastasis,organ invasion, decompensated liver cirrhosis or major respiratoryproblems. The total number of patients operated was 862. We performed767 complete resections and 32 by-pass procedures.In our series, the surgical procedure of choice was the interventionof Ivor Lewis which was performed in 616 cases. Twenty one Akiyamaprocedures were performed in the beginning of our series butwere given up, and 92 oesophagectomies without thoracotomy.Twenty eight patients had intestinal transposition repair or intrathoracic Y procedure, 32 patients had by-pass repair and 10 colonicinterpositions were performed in patients previously operated forstomach lesions. We adopted a three access installation which allowedus to have simultaneous surgical access to the abdomen,thorax and neck.The anastomosis was always performed at the thoracic apex about 4cm inferior to the Killian area.In performing the cervical access, we gave up the retrosternal pathwayand we adopted the posterior mediastinal one due to lowerincidence of fistula.Results: Mortality: Postoperative mortality was about 6 % afterLewis-Santy, 8 % after esophagectomy without thoracotomy andabout 10 % after Akiyama.Morbidity: concerning the procedure of Lewis-Santy, 67 % of patientshad simple postoperative course, 6,5 % had postoperativefistulas and 25 % of patients had respiratory complications. Weobserved that the incidence of postoperative fistulas doubled afteresophagectomy without thoracotomy. Sixty four per cent of patientswithout relapse practiced their usual activities within one year postoperativelyand 58 % of patients had a Karnofsky score superior to80. Long term follow-up at 5 years of squamous cell carcinomas R0 isabout 40 % and less than 10 % in the presence of distant lymphnode metastasis.Two hundred and twenty five patients had had pre-operative adjuvantradio-chemotherapy. We observed retrospectively that theincidence of post-operative mortality (11%) was two times morethan patients operated without the preoperative radio-chemotherapy(5.7%).Conclusion: Surgical resection appears to be the treatment ofchoice of esophageal cancer. For the time being, radiochemotherapydoes not demonstrate any improvement regarding thesurvival rate except for resected cases responding well to radiochemotherapy, with increased rate of postoperative morbidity.