Recent changes and the future roles of esophageal cancer surgery

An esophagectomy remains the mainstay treatment for esophageal cancer, and an R0 resection is the most important type of surgery performed with a curative intent. Although a transthoracic esophagectomy is thought to offer better chance for cure in comparison to a transhiatal esophagectomy, the superiority of the former procedure over the latter has not been demonstrated by randomized clinical trials (RCTs). An extended esophagectomy with a three-field lymphadenectomy is a type of esophagectomy with the highest quality of tumor clearance and the capability of prolonging patient survival, but it is contraindicated for patients with 5 or more positive nodes, with simultaneous metastasis to three anatomic compartments, with cervical metastasis from lower esophageal cancer, and with intramural metastasis, because of the absence of survival benefits in these cases. An esophagectomy performed by thoracoscopy and laparoscopy techniques is feasible, however, such an esophagectomy combined with a systematic lymphadenectomy may not qualify as minimally invasive because of the equivalent morbidity rates to an open radical esophagectomy. Whether adjuvant chemotherapy with or without radiotherapy can effectively improve patient survival remains controversial, because only two of 15 RCTs of such adjuvant therapy so far reported have demonstrated a positive survival impact in comparison to surgery alone. The recent increased use of definitive chemoradiotherapy suggests the potential need to perform a salvage esophagectomy because the presence of local persistent or recurrent disease is common after this treatment. The development of a safe and effective salvage esophagectomy should thus be urgently established.