Welcome to this issue of the Annals of Cardiothoracic Surgery, which focuses on staging and treatment of esophageal cancer. We have assembled international experts and pioneers in the field of esophageal surgery as the authors of the articles in this edition to update the reader about the latest surgical techniques and other therapeutic strategies for treating this deadly disease.
Over the last several decades, the management of esophageal cancer has evolved. Esophagectomy, which once carried high morbidity and mortality rates, can now often be performed via standard laparoscopic/thoracoscopic or robot-assisted minimally invasive techniques with mortality rates of 1% to 3% and equivalent oncologic outcomes to standard “open” esophagectomies. As a result of this reduction in the morbidity and mortality rates, esophagectomy has the potential to assume an expanded role in patients who may have previously been deemed to be unfit for surgery. In addition, the role of esophagectomy for patients with dysplastic Barrett’s esophagus and node-negative T1a esophageal cancers has also undergone evolution. Now, many such patients can be treated successfully with endoscopic therapy, thereby avoiding the morbidity of esophagectomy.
In this edition, we also review some of the major obstacles to successful surgical therapy for esophageal cancer. When the stomach is not suitable for esophageal replacement, alternative conduits must be used, which adds to the complexity of reconstruction. Specific details of the operation, including whether a gastric emptying procedure is necessary, remain an ongoing source of debate. Conduit-related complications, including anastomotic leaks, have long been a nemesis of esophageal surgeons and remain a significant source of morbidity and mortality. However, intraoperative technology (i.e., near-infrared fluorescence imaging) may contribute to a reduction in the incidence of conduit-related complications and a better understanding of methods to “rescue” patients from the impact of such complications will continue to contribute to a reduction in perioperative mortality rates.
Though esophagectomy remains a cornerstone of treatment for patients with resectable disease, the addition of multimodal therapy has led to a reduction in local recurrence rates and an improvement in survival rates. However, 5-year survival rates following multimodal therapy remain low—30% to 40% in most series. Nonetheless, recent advances in systemic and radiation therapy show promise for improving outcomes.
In assembling the articles for this edition, we seek to assist the reader in placing surgical therapy in its proper context given the complexity in managing esophageal cancer, the rapid growth of systemic therapies, advances in radiation therapy techniques, emergence of endoscopic therapies, and the ongoing evolution of surgical techniques. We hope that it serves as a valuable resource for all physicians caring for esophageal cancer patients.