Surgery of esophageal cancer - Quality management

Oesophageal cancer is the sixth most common malignancy worldwide and represents 4% of newly diagnosed cancers. 5-year survival probability is given between 8 to 20%. Within North America and Europe, the incidence of adenocarcinoma rose 100% in the 1990s; strongly correlated with reflux and Barrett's metaplasia. Diagnosis: Because of the elasticity of the esophagus, usually two thirds of the lumen is obstructed before dysphagia occurs. Because dysphagia is the leading complaint in 80 to 90% of patients with esophageal carcinoma, any adult who complains of dysphagia warrants esophagoscopy and biopsy to rule out carcinoma. Further obligatory examinations include CT of chest and abdomen to assess distant metastases (M1) including the celiac trunk and cervical lymph nodes. Endoscopic ultrasound (EUS) is applied for proper assessing the depth of tumor invasion, length of tumor regional nodal disease, and involvement of adjacent structures. The power of the PET-CT for evaluation of distant metastases complementary or as an alternative for CT is not yet clear. Therapy: Treatment includes surgery, chemotherapy, radiation, or a combination of these techniques. Therapy for esophageal carcinoma is influenced by the knowledge that alocal tumor invasion or distant metastatic disease often precludes cure. Palliation is appropriate when the general condition of the patients prohibits resection or in case both technical or prognostic irresectability due to extensive invasion of vital structures or due to distant metastases. However, 50% of the patients with oesophageal carcinoma at the time of their presentation are eligible for curative treatment. In order to minimize the risk of endoluminal recurrence, a safe margin of 6- to 8-cm of normal esophagus has to be removed. Concerning the surgical approach, the extent of the lymphadenectomy and the level of the anastomosis, several techniques of oesophagectomy exist. According to the surgical approach transhiatal, thoracoabdominal and cervicoabdominal approaches are differentiated. Depending from the approach there are also different levels of lymphadenectomy: One-Field-Lymphadenectomy (only blunt dissection), two-field-lymphadenectomy (En-Bloc-Oesophagectomy) and three-field-lymphadenectomy (En-Bloc-Oesophagectomy + neck dissection). Concerning the site of anastomosis, collar vs. intrathoracic anastomosis are distinguished.