Adenocarcinoma of the esophagus has the most rapidly increasing incidence of any cancer in the United States. At the time of diagnosis, most persons present with locally advanced disease, making the prognosis of patients with esophageal cancer very poor.
Surgery is one of the potential curative treatment modalities in this setting. With improved staging, selection and perioperative care, mortality rates have fallen and postoperative survival has risen to around 30% at 5 years.Even so, the operative procedure remains a significant intervention for the patient. Open resection involves a long operation, large incisions, obligatory postoperative care in the intensive care unit, and significant risk for morbidity and death. Indeed, esophagectomy has the highest mortality rate within the sphere of elective gastrointestinal surgery, with a 30-day mortality rate of around 13% in all centers and 5% in high-volume centers.
The 2 classic and widespread operations to treat esophageal cancer are the Ivor-Lewis operation (right-side thoracotomy in combination with laparotomy using a thoracic anastomosis) and the transhiatal esophagectomy described by Orringer and Sloan. The main advantage of the Ivor-Lewis esophagectomy is the improved, direct exposure allowing for an en-block resection of the esophagus and surrounding structures. The disadvantages are the pain and pulmonary complications related to the necessary thoracotomy. These serious complications can be overcome by the transhiatal approach, in which the esophagus is dissected through the hiatus and afterward, divided through a cervical abdominal approach, avoiding a thoracotomy. Nonetheless, the potential disadvantage is the poor exposure and lack of vision to and within the mediastinum, which may compromise the radial resection margins and lymphadenectomy.
A 59-year-old white man with a longstanding history of gastroesophageal reflux disease dating back to childhood and adolescence underwent a screening upper endoscopy and was found to have long-segment (8 cm) Barrett's esophagus with a 1.5-cm nodule that proved to be adenocarcinoma. He has no dysphagia or other alarm signs. He is otherwise healthy. Which of the following is the most appropriate imaging technique for loco-regional staging of this tumor?
Computed tomography (CT)
Endoscopic ultrasound (EUS)
Positron emission tomography (PET)
Upper gastrointestinal (UGI) series
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Medscape J Med. 2008;10(12):277 © 2008
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