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Draft guidelines for surgical resection of oesophageal cancer

Prepared by Roger Vaughan , Consultant Thoracic Surgeon, Northern General Hospital, Sheffield.

Please e-mail all comments to Mr Vaughan to facilitate evolution of the guidelines.

General Rationale

The resection of oesophageal malignancy with intent to cure, is based on the concept that if all neoplastic tissue can be removed, a worthwhile period of survival and possible cure might be achieved. Surgical therapy is the only treatment that has repeatedly been shown to provide prolonged survival, albeit in only around 20% of cases (Muller et al 1990). When detected early however, the results of surgical resection in the West can be excellent, both for squamous cell carcinoma and adenocarcinoma. Five year rates are over 80% when tumours are confined to the mucosa and between 50% and 80% when the submucosa is involved (Bonavina et al 1995 , Hölscher et al 1997). Conversely, resection has no place in patients with haematogenous metastases (Lerut et al 1992 ). It is essential that oesophagectomy should be undertaken with an acceptably low hospital mortality and complication rate. Case selection, case volume and surgical experience all play an important part. Pre-operative risk analysis has been shown to cause a reduction in post-operative mortality from 9.4% to 1.6% (Bartells et al 1998 ). In 1986, Matthews et al demonstrated a negative correlation between the number of carcinomas resected and hospital mortality among surgeons in the West Midlands (Matthews et al 1986 ). A team based approach and increasing expertise within that team, has also demonstrated a significant decrease in the mortality of oesophagectomy over time (Ellis et al 1959 , Ellis 1989 , Skinner 1983 , Skinner et al 1986 , Sugimachi et al 1994 ).

Choice of Operative Approach

This should be determined by the histological tumour type, its location and the extent of the proposed lymphadenectomy. Adequate mediastinal lymphadenectomy is essential in squamous cell carcinoma but needs to be extended to the abdomen in junctional adenocarcinoma. This makes transhiatal oesophagectomy unsuitable for squamous cell carcinoma. A left thoraco-abdominal approach is limited proximally by the aortic arch, which may compromise the proximal limit of resection. Tumours which lie at the level of the arch are difficult to deal with from the left side and this approach should be avoided when the tumour lies at this level or higher.

Standards of Tumour Resection

All operations should be designed to deal adequately with the local tumour to minimise the risk of local recurrence and permit an adequate lymphadenectomy, which will minimise the risk of staging error. The extent to which lymphadenectomy per sé minimises the risk of symptomatic local recurrence, is not known. The evidence that more thorough lymphadenectomy is associated with better survival, may simply reflect more accurate staging. Longitudinal submucosal spread is characteristic of all types of oesophageal carcinoma. This accounts for a high rate of resection margin positivity, when limited longitudinal resections are employed, even with negative frozen section biopsy margins (Giuli 1985 ). Extensive studies by Miller (1962 ), Giuli et al (1986 ), Wong (1984 ) and Cusiu (1986 ) support the view that the proximal extent of resection should ideally be 10 cm above the macroscopic tumour and 5 cm distal to it, when the oesophagus is in its natural state. Obviously, these ideal resection limits may need to be modified for more proximally located tumours. Local recurrence can be prevented in this situation by the use of post operative radiotherapy (Tam et al 1987 ) and this should be strongly considered in squamous cell carcinoma, particularly when the proximal level of the tumour is high. Adenocarcinoma of the lower oesophagus commonly infiltrates the gastric cardia, fundus and lesser curve. Some degree of gastric excision is essential to accomplish an adequate lymphadenectomy in the abdomen and this should be created in such a way as to obtain a minimum distance of 5 cm beyond the distal extent of the macroscopic tumour. It is interesting to note however, that positive distal resection margins in adenocarcinoma are often found in patients with locally advanced disease, where the resection in retrospect was unlikely to be curative. Most of these patients do not die from symptomatic loco-regional recurrence (Sons & Borchard 1986 ). Adequate radial margins should also be considered and efforts made to minimise this, particularly with junctional tumours, where continguous excision of the crura and diaphragm need to be considered (Alderson et al 1994 )

Standards of Lymphadenectomy

The majority of patients who undergo surgery for either adenocarcinoma or squamous cell carcinoma of the oesophagus, will have lymph node metastases (Müller et al 1990 ). The principal aims of lymphadenectomy should be to minimise staging error, reduce loco-regional risks of recurrence and by increasing the number of patients undergoing an R0 resection, potentially improve cure rates. In squamous cell carcinoma, when a methodical approach to lymphadenectomy is applied, the numbers of lymph nodes involved are of prognostic significance (Akiyama et al 1994 ), as is the ratio of invaded to removed nodes (Roder et al 1994 ). Although there is considerable enthusiasm for the performance of lymphadenectomy in three fields (abdomen, thorax and neck) in Japan (Akiyama et al 1994 ), this approach has not been adopted widely by Western surgeons. It is, however, clear that methodical lymph node dissection contributes to the accuracy of the final staging of the disease (Akiyama et al 1994 , Lerut et al 1994 ). Studies have shown that when no residual tumour is left behind, there is an improved five year survival compared to patients where this has not occurred (Roder et al 1994 , Lerut et al 1994 ). A formal one field lymph node dissection is confined to the abdomen. This involves dissection of the right and left cardiac node, the nodes along the lesser curvature, left gastric, hepatic and splenic artery territories. Two field dissection additionally embraces a thoracic lymphadenectomy and includes the para-aortic nodes along with the thoracic duct, para-oesophageal nodes, right and left pulmonary hilar nodes, those at the tracheal bifurcation and in Japan, para-tracheal nodes including those along the left recurrent laryngeal nerve. Three field dissection extends the lymphadenectomy to the neck to clear the brachiocephalic, deep lateral and external cervical nodes and the deep anterior cervical nodes adjacent to the recurrent laryngeal nerve chains in the neck. A number of studies have shown that two field lymphadenectomy can be carried out without any significant increase in operative morbidity or mortality (Akiyama et al 1994 , Siewert & Roder 1992 , Lerut et al 1994 ). Conversely, although the three field operation is advocated in Japan, its benefits may largely simply reflect the reduction in staging error, as nearly a quarter of all Japanese patients will have cervical lymph node metastases (Akiyama et al 1994 ). There is no evidence that three field lymphadenectomy improves survival in patients with adenocarcinoma and it must be accepted that the operation is associated with a higher risk of post-operative morbidity (see below).

Choice of Conduit, Route and Anastomosis

The commonest conduit is stomach. The function of the intrathoracic stomach as an oesophageal replacement has been extensively studied (Hölscher et al 1988 ). A prospective randomised trial demonstrated that the addition of a drainage procedure did not affect gastric emptying or clinical outcome (Cheung et al 1987 ). When stomach is not available, colon interposition is the next most suitable conduit. Again, functional performance has been studied in detail (DeMeester et al 1988 ). Most surgeons favour a prevertebral route for reconstruction and this was shown to be superior to an anterior reconstruction in one randomised study (Bartels et al 1993 ), although another small prospective randomised comparison with a retrosternal gastric tube showed no differences in technical complications or functional outcome (Van Lanschott et al 1999 ). Both retrospective and prospective studies comparing manual versus mechanical oesophagogastric anastomosis, have shown no difference in leak rates or other complications (Fok et al 1991 , Valverde et al 1996 ). Fewer strictures are demonstrated with single layer anastamoses (Zieren et al 1993 ).

Post-Operative Management

Meticulous attention to the maintenance of fluid balance and respiratory care are essential in the immediate post-operative period. Pain control and pulmonary physiotherapy are crucial. Although some authors advocate the routine use of a feeding jejunostomy, there have been no prospective trials to examine its value (Wakefield et al 1995 ). Early mobilisation is important in the prevention of venous thrombosis and pulmonary embolism.

Post-Operative Complications

Pulmonary

Respiratory complications are common following oesophagectomy. Pain from extensive incisions can be a major contributor to decreased ventilation and atelectasis, leading to pneumonia and respiratory failure. Incisions of the diaphragm may impair its movement and extensive lymphadenectomy can cause poor lymphatic drainage of the pulmonary alveoli, resulting in a form of acute pulmonary oedema (Fan et al 1987 , Nagawa et al 1994 , Watson et al 1994 ).

Anastomotic Leakage

Early disruption (within the first 72 hours) reflects technical error. Once confirmed, if the general condition of the patient is good, then re-exploration and correction of the technical fault is appropriate. The majority of disruptions occur later (up to two weeks) and probably reflect local ischaemia and/or tension in the anastomotic site. A high index of clinical suspicion is important. Although water-soluble contrast radiology should be used to establish that leakage has occurred, the technique is not completely accurate and may miss clinically significant leaks, as well as demonstrate radiological leakages of no clinical significance (Vigneswaran et al 1993 , Sauvanet et al 1998 ). The majority of anastomotic leakages, whether in the neck or the chest, can be managed conservatively with nasogastric suction, appropriate local drainage, antibiotics and jejunal feeding. Dehiscence of the gastric resection line is usually due to ischaemia and dramatic in its presentation. Early endoscopy should be considered if radiology is inconclusive. Re-exploration is essential (Paterson & Wong 1989 ). There seems to be no real difference in clinically significant leak rates and subsequent effects, between neck and chest anastomoses. The placement of an anastomosis in the neck does not guarantee that leakage will not be into the thoracic cavity (Lam et al 1992 ). The overall anastamotic leak rate should not exceed 5% (Muller et al 1990 ).

Chylothorax

Chylothorax occurs in about 2-3% of transthoracic oesophagectomies. It is easily recognised as turbid, creamy fluid in the chest drain. The rate may be higher with transhiatal oesophagectomy, although this is not always the case (Bolger et al 1991 , Douganis et al 1992 , Orringer et al 1988 , Dugue et al 1998 ). The condition has a high mortality if conservative treatment becomes prolonged due to hypoalbuminaemia and leucocyte depletion (Bolger et al 1991 ). The rate of chyle output on about the fifth post-operative day, may predict the likelihood of spontaneous closure. Chyle production of greater than 10 ml per kg per day at that time, is an indication for early re-operation and ligation of the thoracic duct (Dugue et al 1998 ).

Recurrent Laryngeal Nerve Injuries

Reccurrent laryngeal nerve injuries are more common during dissectionof the upper third of the oesophagus. The majority of injuries are unilateral and transient. The left recurrent laryngeal nerve is at risk during mediastinal lymphadenectomy and if cervical anastomosis is used in association with such a dissection, it is wiser to place this on the left side, in order to minimise the risk of damage to both recurrent laryngeal nerves. Recurrent laryngeal nerve injury impairs the patients ability to cough in the early post-operative period and adequately protect the airway during swallowing. It can therefore be a potent contributor to pulmonary morbidity. In most patients there is adequate compensation from the opposite cord. Tracheostomy should be considered to protect the airway and improve pulmonary toilet. Thyroplasty or vocal cord injections are rarely required (Griffin et al 1992 ).

Benign Anastomotic Stricture

These can occur within the first few months after surgery, where they relate to post-operative fibrosis or late (ie years), when they are due to reflux. The incidence of early anastomotic stricture formation seems to be higher with cervical rather than intrathoracic anastomosis & in stapled procedures(Orringer 1984 , Finley et al 1989 ). These early post-operative anastomotic strictures are easily dealt with by endoscopic dilatation, although multiple sessions may be necessary (Pierie et al 1993 ).

Hospital Mortality

The review by Muller (Muller et al 1990 ) confirmed that the average hospital mortality following resection in papers published between 1980 and 1988 was 13%. Many European centres have reported hospital mortalities well below this figure throughout the 1990’s and it should be accepted that a hospital mortality of less than 10% is desireable.

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Last revised Dec-07-1999
Revised by Bruce E. Keogh.