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Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
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What the authors could have addressed more fully is the question of which surgical approaches are more likely to be encountered today. A recent study by Daly et al (2) addresses this question by evaluating the manifestations and stage distribution of esophageal cancer and the current trends in management reported by members of the American College of Surgeons. In the United States, there is an increasing prevalence of adenocarcinoma, which usually involves the distal third of the esophagus and is frequently associated with Barrett esophagus. Squamous carcinoma, which is still the most common esophageal tumor, tends to occur in the midesophagus but involves the distal thoracic esophagus in about one-third of cases.
Daly et al report that histologic findings and stage influence the treatment regimen, which commonly includes radiation therapy and chemotherapy in addition to surgery. The most common therapy for squamous carcinoma is combined radiation therapy and chemotherapy, followed (in decreasing order) by radiation therapy alone, partial resection alone, and partial resection with adjuvant therapy. In their study, patients with adenocarcinoma were more likely to undergo surgical resection than those with squamous carcinoma, and the likelihood of surgical intervention declined with increasing stage for both types of tumor (2).
Given these trends, one can understand why certain procedures were reported as more popular than others. Thoracotomy with laparotomy was more likely used for lower esophageal tumors, whereas a transhiatal approach was typically used for upper thoracic lesions. Understanding which surgical approach has been used in a given case is important for the radiologist who interprets the postoperative images.
Kim et al list all possible complications but mention one of the most common and potentially life-threatening complications—anastomotic leak—last. Along with pneumonia, it is the most common complication to be detected at radiography. Intrathoracic leaks can be devastating and lethal. When they occur in the immediate postoperative period, surgical intervention is required. Even with chronic leaks, drainage is necessary to prevent erosion into the adjacent trachea and other mediastinal structures. Although cervical anastomotic leaks commonly occur in transhiatal esophagectomy, the sequelae are less damaging due to unimpeded drainage at the cervical level.
In summary, Kim et al have provided extensive discussion and illustration of the various approaches to esophageal resection and bypass surgery. In conjunction with an understanding of the current trends in tumor histology, location, and therapy, this article can help the radiologist gain insight into the interpretation of postoperative images obtained in patients who have undergone esophageal surgery.
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Department of Radiology, Samsung Medical Center, Young Mog Shim, MD, Department of Thoracic Surgery, Samsung Medical Center, Seoul, Korea
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Esophageal surgery remains the primary and most effective therapy for patients with early-stage esophageal cancer (1). This surgery may also play an important role as a component of multimodality therapy, even in patients with advanced-stage esophageal cancer (2–5). Some surgeons may perform extensive surgery for resectable tumor and may achieve better results. A 5-year survival rate of 55.8% was achieved after three-field lymph node dissection (cervical incision for cervical lymph node dissection, right thoracotomy, laparotomy) for esophageal cancer (1). In this particular type of surgery, the survival rate may be as high as 83.9% if resected nodes are negative for malignancy (1). The reported efficacy of neoadjuvant chemotherapy is still not promising. There is no difference in survival rate between the "surgery only" group and the neoadjuvant chemotherapy group (2–4). Clinical trials of neoadjuvant therapy combining chemotherapy and radiation therapy have yielded favorable results compared with those of surgery only (5).
As Dr Aquino rightly points out, in the series by Daly et al (6), thoracotomy with laparotomy was more frequently used for lower esophageal tumors and a transhiatal approach was used for upper thoracic lesions. However, the cases in their study were collected from 828 hospitals, at each of which less than 25 esophageal resection surgeries were performed. Still, the most commonly performed operation for esophageal cancer, both in the United States and elsewhere, is the Ivor Lewis procedure (right thoracotomy and laparotomy), especially for midesophageal cancer (mostly squamous cell carcinoma) (1–5). Some surgeons are reluctant to perform transhiatal esophagectomy without thoracotomy because they do not consider the procedure to be curative. Transhiatal esophagectomy is performed for lower thoracic esophageal cancer (without adjacent organ invasion and with relatively good surgical access) and for cancer in patients with impaired pulmonary function (5). The optimal surgical approach for adenocarcinoma of the distal esophagus is controversial. Some surgeons advocate radical surgery with thoracotomy and laparotomy (7), whereas others support limited resection and lymph node dissection with an individualized surgical strategy based on tumor location (8).
Because curative resection is still the most effective treatment for esophageal cancer, it is important for radiologists to let surgeons know the exact extent of direct invasion of the surrounding structures and details regarding preoperative tumor staging and classification.
The most frequent postoperative complication of esophagectomy is pneumonia. Although immediate postoperative anastomotic leak in the thorax is one of the most dreaded and lethal complications of esophageal surgery, its prevalence (0%–30%) varies considerably from one institution to another (9). In the series by Daly et al (6), the leak rate was 8.7%. Again, however, their study involved cases collected from 828 institutions, at none of which were more than 25 esophageal resection surgeries performed. in each of which less than 25 esophageal resection surgeries were performed. Actually, the prevalence of anastomotic leak depends entirely on surgical skill. As experience with esophageal surgery accumulates, the number of significant complications decreases. At our institution, anastomotic leak occurred in 13 of 80 patients (16%) who underwent esophagectomy and cervical anastomosis and in none of 179 patients (0%) who underwent esophagectomy and intrathoracic anastomosis. Intrathoracic anastomotic leak occurring in the immediate postoperative period mandates urgent surgical intervention.
In conclusion, radiologists should be familiar with various surgical approaches for esophageal cancer and with the most recent trends in its management. Surgery continues to play an invaluable role in the management of early-stage esophageal cancer. Currently, neoadjuvant therapy combining chemotherapy and radiation therapy with surgery results in an additive effect in advanced-stage cancer. By understanding the basic concepts of esophageal resection and reconstruction, radiologists can be familiar with postoperative anatomic changes and radiologically detectable complications.
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