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Eur J Cardiothorac Surg 1999;15:626-630
© 1999 Elsevier Science NL

Oesophagectomy for carcinoma of the oesophagus and oesophagogastric junction

Department of Cardiothoracic Surgery Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK

Received 12 October 1998; received in revised form 18 January 1999; accepted 16 February 1999.

Corresponding author. Tel.: +44-1703-796238; fax: +44-1703-796614

	Abstract

Top Abstract 1. Introduction 2. Materials and patients... 3. Results 4. Discussion 5. Conclusions References

 
Objective: Oesophageal carcinoma has a poor prognosis; surgical resection remains the only chance of cure but is still associated with a significant morbidity and mortality. The aim of this study was to review the results of one surgeon for oesophageal resection for carcinoma of the oesophagus and oesophagogastric junction over a 23 year period. Methods: Between January 1974 and December 1996, 591 patients (408 males; 183 females; mean age 66 years) underwent an oesophageal resection for carcinoma of the oesophagus or oesophagogastric junction. Results: In hospital mortality was 8.8% (52/591). This has decreased to less than 5% for resections between 1985 and 1996. Non-fatal complications occurred in 21% of patients (123/591). Survival, including in hospital mortality (±SEM), was 53.98% (±2), 31.77% (±2) and 15.3% (±2) at 1, 2 and 5 years respectively. Conclusion: Early mortality following oesophageal resection has fallen in recent years. Despite considerable experience, long term survival remains disappointingly low.

Key Words: Carcinoma • Oesophagus • Surgery • Resection • Survival

	1. Introduction

Top Abstract 1. Introduction 2. Materials and patients... 3. Results 4. Discussion 5. Conclusions References

 
Oesophageal carcinoma has a poor prognosis. Survival following resection depends largely on tumour stage at the time of presentation. For all resections, 5 year survival remains around 20% [1], this improves however in patients with early disease - over 60% for patients with stage I tumours [2]. Median survival without resection is less than 6 months [3]. Less than 25% of cases are resectable at presentation [2].

The role of chemotherapy and radiotherapy in the treatment of oesophageal carcinoma are continually evolving [4], to date, resection remains the only chance of cure. It also has the benefit of providing excellent palliation from dysphagia [5].

This study reviews the experience of surgical resection for carcinoma of the oesophagus and oesophago-gastric junction, for patients under the care of one surgeon between January 1974 and December 1996.

	2. Materials and patients

Top Abstract 1. Introduction 2. Materials and patients... 3. Results 4. Discussion 5. Conclusions References

 
Five hundred and ninety one consecutive patients (408 males, 183 females, mean age (±SEM) 65.7 years (±10.6) are included in the series. Lesions arising from the corpus of the stomach or diffuse primary gastric malignancies which involve the oesophagogastric junction such as linitus plastica were excluded.

Variables were recorded from the medical notes, operative findings and histology reports. Follow up was ascertained from general practitioners and the Office of National Statistics (National Health Services Branch). Staging was based on the UICC system.

2.1. Operative procedure
Three hundred and sixty one patients (61%) underwent a left oesophagogastrectomy (intrathoracic anastomosis-323), 218 (37%) an Ivor–Lewis oesophagectomy with Roux-en-Y reconstruction and 2 (0.03%) a pharyngo-laryngo-oesophagectomy.

The approach was primarily determined by the site of the lesion, left oesophagogastrectomy for lower third and oesophagogastric lesions, Ivor–Lewis oesophagectomy for mid third lesions. A total gastrectomy and distal oesophagectomy with Roux-en-Y reconstruction was performed in patients with a history of previous gastric surgery for peptic ulceration and with tumours of the lower third or oesophagogastric junction. Two patients had pharyngo-laryngo-oesophagectomies with colon graft reconstruction for growths high in the upper third of the oesophagus.

The tumour-free resection margin in both oesophagus and stomach was at least 5 cms. The anastomosis was hand sewn in over 95% of cases. Radical lymphadenectomy was not performed.

For the past 11 years patients have routinely entered an intensive treatment unit (ITU) following resection. Fluids were started on day three postoperatively, a contrast swallow was only performed if a leak was clinically suspected.

No adjuvant treatment either in the form of chemotherapy, radiotherapy or a combination has been routinely used in these patients.

2.2. Statistical analysis
Statistical analysis were performed according to standard statistical protocols incorporated in the SAS statistical package JMP (SAS Institute Inc. SAS Campus Drive, Cary NC). Risk factors for operative mortality were analysed using Chi squared tests and logistic regression. Survival was analysed using Kaplan–Meier curves. Survival between groups was compared using Log rank and Wilcoxon tests. Cox's proportional hazards method was used to relate variables to survival. A P value of less than 0.05 was taken to be significant.

	3. Results

Top Abstract 1. Introduction 2. Materials and patients... 3. Results 4. Discussion 5. Conclusions References

 
3.1. Presentation
The mean duration of dysphagia was 15 weeks (range 0–260 weeks), with an average preoperative weight loss of 5 kg (range 0–50 kg, median 3 kg). 116 patients (19.6%) had a history of oesophageal/gastric disorders, not including those with dyspeptic complaints. 57 patients (14%) had significant intercurrent cardiovascular or respiratory disease. Diagnosis was by oesophagogastroscopy±biopsy in every case. A barium swallow was performed in 367 patients (63.6%). For the purpose of staging, 229 patients (38.7%) underwent computerised tomography (CT) scanning of the thorax and abdomen, and 70 patients (11.8%) had an abdominal ultrasound scan performed. Computerised tomography scanning has been used in the majority of cases since 1985 but rarely prior to this.

Staging was based on operative findings and histological reports on resected specimens (Table 1). Squamous cell carcinomas presented at a significantly earlier stage than adenocarcinomas (t-test, P=0.004). 97% of adenocarcinomas were located in the lower oesophagus and oesophagogastric junction, as compared to 68% of squamous cell carcinomas. The remainder of the squamous cell carcinomas were in the mid third of the oesophagus. Twenty tumours involved more than one segment.

Fifty two (8.8%) patients died within 30 days (Table 2). In cases of more than one complication, death was attributed to anastomotic leak if present. There were four fatal leaks from cervical anastomoses, and eight from intrathoracic anastomoses.

One hundred and fifty six predominantly pulmonary non-fatal complications occurred in 123 patients (Table 3).

View larger version (12K): [in this window] [in a new window]   Fig. 1. Overall survival following resection of oesophageal carcinoma.

View larger version (27K): [in this window] [in a new window]   Fig. 2. Survival according to TNM stage.

	4. Discussion

Top Abstract 1. Introduction 2. Materials and patients... 3. Results 4. Discussion 5. Conclusions References

 
The incidence of oesophageal cancer in the West is rising, this probably reflects the increase in the incidence of adenocarcinoma of the oesophagus [6]. ‘True’ oesophageal adenocarcinoma arising from the relatively rare Barrett's metaplasia was found in only 34 patients in this series. Adenocarcinomas of the oesophagus, oesophagogastric junction and cardia were included in this study, as in symptomatology, early mortality and survival, these tumours behave more like oesophageal than gastric cancer [1,7].

In the West, few oesophageal cancers are detected at an early stage, 3.4% stage I in this series compared to 14.75% in Japan [8]. The relative rarity of oesophageal cancer in Britain - an incidence of around 10 per 100 000 per year - renders a screening programme impractical. Distant spread of malignancy is common at time of diagnosis; less than 50% of patients have tumours amenable to resection [9]. Even in studies such as this, reporting solely on resections, the majority of patients (66%) have lymph node involvement at the time of surgery. In this series adenocarcinomas presented at a later stage. These tumours in the lower third or oesophagogastric junction, presumably do not cause dysphagia until late in the course of the disease, and lymphatic spread to both the abdominal and posterior mediastinal compartments has occurred. Detecting these asymptomatic lesions before they metastasize remains a challenge.

Preoperative staging is continually evolving, CT and MRI have now largely been surpassed by endosonography [10], positron emission tomography [11] and surgical minimally invasive staging [12]. As experience with these techniques improves the incidence of incomplete resection or resection in the presence of distant metastases will decrease. In addition the proportion of patients found to have unresectable disease at operation will also decrease.

The optimal extent of resection and lymphadenectomy is controversial. At present achieving an R₀ (no residual macroscopic tumour) result is the only chance of cure. Throughout the period of the study there was scant prospective data which showed that radical surgery improved survival. The survival rates reported here are similar to those who advocate non-radical resection.

It has now been shown that as many as 30% of patients with distal oesophageal adenocarcinoma and 20% with adenocarcinomas of the oesophagogastric junction have involved cervical lymph nodes at operation [13]. Three field lymphadenectomy is the only way to achieve an R₀ resection in these cases. At present accurate preoperative identification of patients with distant nodal involvement is not possible and therefore radical lymphadenectomy is routinely performed in certain centres. Several authors report increased survival with radical intervention [14] which becomes significant in more advanced disease. Further prospective data however is needed.

Reported early mortality rates vary widely. The early mortality following resection has fallen from 29% in a meta-analysis published in 1980 to 8% by the end of the 1980’s [1] and now to below 5%. Some centres report operative mortalities approaching zero [13]. In common with other series, we have experienced a decrease in early mortality [9,15]. The reasons for this are multifactorial and include: improved preoperative investigation, an increasingly experienced surgical team, more advanced monitoring technology in theatre and ITU, and increased provision and use of ITU facilities. The cause of the relationship between raised alkaline phosphate and operative mortality is unclear and preoperative alkaline phosphate does not impact on our decision making. Despite our finding that age is associated with a significant increased risk of operative mortality, age alone does not influence our decision to proceed with surgery. We believe that resection can be performed with acceptable results in the elderly [16].

In this series, 92 patients (15.5%) encountered respiratory complications, which lead to death in 15 patients. Respiratory complications cause significant postoperative morbidity and are often the commonest cause of early mortality [9]. The routine use of extrapleural infusions and patient controlled analgesia has decreased the incidence of respiratory complications to 8.7% for the last decade.

Anastomotic leakage remains a cause of concern, however the incidence of clinically significant anastomotic leaks in this study, both fatal and non-fatal, was 3.9%, lower than other studies [6]. We have found hand sewn anastomosis to be preferable. Despite extreme care and the creation of a tension free, well vascularised anastomosis clinically significant leaks still occur. Continual awareness and suspicion ensure early diagnosis and prompt treatment. There was no significant difference in the incidence of non fatal leaks depending on anastomotic site.

The TNM stage is an important predictor of survival following resection [6,15]. In particular, the presence or absence of lymph node involvement is most significant [17]. The number of lymph nodes involved may also be predictive of late mortality [18,19]. The most surprising finding in this series is the relationship between survival and splenectomy. Splenectomy at the same time as tumour resection was associated with worse survival independent of tumour stage. A splenectomy was not performed routinely at this centre. The indication to remove the spleen was either as part of the tumour resection or because it was damaged intraoperatively. Unfortunately on retrospective analysis it was not always possible to delineate the reason for splenectomy however using Cox's proportional hazards model splenectomy was associated with worse survival when the model included TNM stage and completeness of resection. Therefore independent of the stage at operation and completeness of resection, removal of the spleen was associated with worse survival. It has previously been shown that splenectomy has as adverse influence on survival [20] and our findings support this. Clearly TNM stage is the most important predictor of survival but it appears that preservation of the spleen confers survival benefit.

	5. Conclusions

Top Abstract 1. Introduction 2. Materials and patients... 3. Results 4. Discussion 5. Conclusions References

 
Operative mortality and morbidity following oesophagogastrectomy for oesophageal carcinoma has declined. Despite considerable experience, 5 year survival remains disappointingly low. The key to improved survival lies in early diagnosis, stage being the most important prognostic factor. Realisation of this goal remains a challenge. Adjuvant therapy and more radical resection may improve the outlook for patients with advanced disease, at present early diagnosis remains the key to curative treatment.

	Footnotes

 
Presented at the 12th Annual Meeting of the European Association for Cardio-thoracic Surgery, Brussels, Belgium, September 20–23, 1998.

	References

Top Abstract 1. Introduction 2. Materials and patients... 3. Results 4. Discussion 5. Conclusions References

 

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