Modified En Bloc Esophagectomy Compared With Standard Resection After Neoadjuvant Chemoradiation

Area of Science:

• Surgical Oncology
• Gastrointestinal Surgery
• Esophageal Cancer Treatment

Background:

• The practice of en bloc esophagectomy has declined with the rise of neoadjuvant therapies for esophageal cancer.
• Contemporary data supporting the superiority of en bloc esophagectomy are limited.
• This study hypothesized that radical resection via en bloc esophagectomy could be safely performed post-neoadjuvant chemoradiation without increased morbidity.

Purpose of the Study:

• To compare outcomes of en bloc esophagectomy versus standard esophagectomy in patients with esophageal adenocarcinoma who received neoadjuvant chemoradiation.
• To evaluate the impact of en bloc resection on postoperative morbidity and oncological control.

Main Methods:

• Retrospective analysis of 604 patients undergoing esophagectomy for esophageal adenocarcinoma between 2006-2018 after neoadjuvant chemoradiation.
• Comparison of outcomes between modified en bloc esophagectomy (n=133) and standard esophagectomy (n=471).
• Statistical analysis included Cox proportional hazard models and logistic regression to assess survival and morbidity.

Main Results:

• En bloc esophagectomy was associated with significantly lower positive margin rates (2% vs 7%) and a greater lymph node harvest (27 vs 22).
• Progression-free survival was prolonged with en bloc resection (HR 0.74, P=.041), with improved 3-year freedom from locoregional recurrence (90% vs 78%, P=.044).
• No significant differences were observed in major postoperative complications, including cardiopulmonary, gastrointestinal, wound complications, leaks, or chylothorax.

Conclusions:

• En bloc esophagectomy demonstrates improved locoregional disease control in esophageal cancer patients treated with neoadjuvant chemoradiation.
• This radical surgical approach is safe and feasible, offering equivalent morbidity to standard esophagectomy.
• The findings suggest en bloc esophagectomy may enhance clearance of primary tumors and nodal micrometastases, contributing to better oncological outcomes.