7 - The Role of Surgery in the Management of Esophageal Cancer and Palliation of Inoperable Disease

Summary

Introduction

In spite of improvements in diagnosis, staging, and treatment, the outcome for patients with esophageal cancer remains poor. Although 1-year survival has improved in recent years, there has been little change in the 5-and 10-year survival (Figure 7.1). This is because many of the patients have metastatic disease, with a large percentage having micrometastases. These have been found in the bone marrow in patients undergoing resection in 88% of cases.

A significant factor in the improved 1-year survival is the reduction in inhospital operative mortality (Table 7.1). This relates to improvement in staging, fitness testing, technique, perioperative care, and probably most importantly centralization of services in large centers (Table 7.2). In a study from the United Kingdom there was a 40% reduction in operative mortality for every 10 patient increase in a surgeon's caseload.. Such large centers with dedicated teams can achieve inhospital mortality figures of less than 2% by utilizing a multidisciplinary team approach.

Another factor in improved short-term survival is the recognition that surgery alone is not the answer for most cases and that survival benefits can accrue by the use of preoperative neoadjuvant chemotherapy and possible chemoradiotherapy. This is certainly now the practice in the United Kingdom for all cases other than early T1/2 N0 disease. Whether such treatment acts as a prolongation of disease-free interval only or improves long-term cure remains to be determined.