Info

T4 Any N MO

Stage IV

Any T Any N Mí

Stage IVA

Any T Any N Mía

Stage IVB

Any T Any N Míb

Source: Reprinted with permission from Table 1 of Patel M, Ferry K, Franceschi D, et al. Esophageal carcinoma: current controversial topics. Cancer Invest 22:898, 2004.

Source: Reprinted with permission from Table 1 of Patel M, Ferry K, Franceschi D, et al. Esophageal carcinoma: current controversial topics. Cancer Invest 22:898, 2004.

exposure of the lower third of the esophagus as well as the GE junction and the diaphragmatic hiatus, and it facilitates a more complete abdominal lym-phadenectomy, which can be vital in staging cancer of the lower esophagus. Second, a combined right thoracotomy and upper midline laparotomy (Ivor-Lewis operation) can be used either for a lower esophageal tumor or a higher thoracic esophageal tumor (Fig. 8-8). Because the incision does not limit the exposure of the proximal extent of the thoracic esophagus, a wider margin on the tumor can be obtained and the anastomosis between the reconstructed stomach and the proximal esophagus can be performed more easily than the Sweet operation; the recurrence rate at the anastomotic margin is therefore thought to be lower with the Ivor-Lewis esophagectomy. Finally, the transhiatal approach (Orringer esophagectomy) uses an upper midline laparotomy and a left cervical incision (Fig. 8-9). Through the upper

Figure 8-7 An overview of Sweet operation, which can be performed for distal esophageal tumors. (A) A left thoracotomy or thoracoabdominal approach is used. (B) Tumor is removed by resecting a portion of the distal esophagus and the stomach. (C) The stomach is mobilized for intrathoracic esophagogastric anastomosis. (Source: Reprinted with permission from Zwischen-berger JB, Alpard SK, Orringer MB. Esophagus. In Townsend CM, Beauchamp RD, Evers BM, eds., Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice, 16th ed. Philadelphia, PA: W.B. Saunders, 2001: 739, which was adapted from Ellis FH Jr, Shahian DM. Tumors of the esophagus. In Glenn WWL, Baue AE, Geha AS, et al., eds., Thoracic and Cardiovascular Surgery, 4th ed. Norwalk, CT: Appleton and Lange, 1983: 566.)

Figure 8-7 An overview of Sweet operation, which can be performed for distal esophageal tumors. (A) A left thoracotomy or thoracoabdominal approach is used. (B) Tumor is removed by resecting a portion of the distal esophagus and the stomach. (C) The stomach is mobilized for intrathoracic esophagogastric anastomosis. (Source: Reprinted with permission from Zwischen-berger JB, Alpard SK, Orringer MB. Esophagus. In Townsend CM, Beauchamp RD, Evers BM, eds., Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice, 16th ed. Philadelphia, PA: W.B. Saunders, 2001: 739, which was adapted from Ellis FH Jr, Shahian DM. Tumors of the esophagus. In Glenn WWL, Baue AE, Geha AS, et al., eds., Thoracic and Cardiovascular Surgery, 4th ed. Norwalk, CT: Appleton and Lange, 1983: 566.)

Figure 8-8 An overview of Ivor-Lewis operation. (A) Exposure is made through a combined right thoracotomy and upper midline laparotomy. (B) This approach can be used either for a lower esophageal tumor or a higher thoracic esophageal tumor; the length of the esophagus required to remove the tumor is resected. (C) The stomach is mobilized for intrathoracic esophagogastric anastomosis. (Source: Reprinted with permission from Zwischenberger JB, Alpard SK, Orringer MB. Esophagus. In Townsend CM, Beauchamp RD, Evers BM, et al, eds, Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice, 16th ed. Philadelphia, PA: W.B. Saunders, 2001: 739, which was adapted from Ellis FH Jr. Esophagogastrectomy for carcinoma: technical considerations based on anatomic location of lesion. Surg Clin North Am 60:273, 1980.)

midline abdominal incision, the esophagus is resected after being bluntly dissected from adjacent structures, and the stomach, fashioned into a tubular structure by stapling off a portion of the proximal lesser curvature, is pulled through the posterior mediastinal space out through the left neck incision, where it is anastomosed with the cervical esophagus proximally. The clear advantage of the Orringer technique is that a thoracotomy is avoided, thus minimizing some of the pulmonary complications. In addition, if there is a postoperative leak at the esophageal anastomosis, the contamination in the neck wound would be more manageable than that in the mediastinum. Because of the nature of the blunt dissection technique, the theoretical concern is that a more complete mediastinal lymphadenectomy

Figure 8-9 An overview of Orringer (transhiatal) esophagectomy. (A) Exposure is made through an upper midline laparotomy and a left cervical incision. (B) The entire length of the esophagus is resected. (C) The stomach is mobilized for cervical-esophagogastric anastomosis. (Source: Reprinted with permission from Zwischenberger JB, Alpard SK, Orringer MB. Esophagus. In Townsend CM, Beauchamp RD, Evers BM, et al, eds, Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice, 16th ed. Philadelphia, PA: W.B. Saunders, 2001: 741, which was adapted from Ellis FH Jr. Esophagogastrectomy for carcinoma: technical considerations based on anatomic location of lesion. Surg Clin North Am 60:275, 1980.)

Figure 8-9 An overview of Orringer (transhiatal) esophagectomy. (A) Exposure is made through an upper midline laparotomy and a left cervical incision. (B) The entire length of the esophagus is resected. (C) The stomach is mobilized for cervical-esophagogastric anastomosis. (Source: Reprinted with permission from Zwischenberger JB, Alpard SK, Orringer MB. Esophagus. In Townsend CM, Beauchamp RD, Evers BM, et al, eds, Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice, 16th ed. Philadelphia, PA: W.B. Saunders, 2001: 741, which was adapted from Ellis FH Jr. Esophagogastrectomy for carcinoma: technical considerations based on anatomic location of lesion. Surg Clin North Am 60:275, 1980.)

cannot be performed and the patient survival rate would therefore be compromised; this concern has never been substantiated, as the current survival rates between any of these three operative approaches are indistinguishable. A variation of the Orringer esophagectomy is to make one additional incision on the right chest with a thoracoscopy or thoracotomy (three-hole esophagec-tomy); although the putative benefit is to obtain a more thorough mediasti-nal lymphadenectomy, the main advantage of this approach is to facilitate a visually more direct dissection of the midesophageal region if the primary tumor is especially large or appears to be adherent to adjacent structures through inflammation.

The effectiveness of neoadjuvant (preoperative) and adjuvant (postoperative) therapies with drugs and radiation has been a point of controversy. The literature is filled with studies that have led to mixed conclusions. However, by most accounts, there is no convincing evidence that either neoadjuvant or adjuvant therapy improves survival as compared to surgery alone.

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