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Ann Thorac Surg 1996;61:769-770
© 1996 The Society of Thoracic Surgeons

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Update

En Bloc and Standard Esophagectomies by Thoracoscopy

As Originally Published in 1993:

Updated in 1996 by Jean-Marie Collard, MD

Digestive Surgery Unit, Louvain Medical School, Brussels, Belgium

In the middle of the ``1991 thoracoscopy boom,'' my colleagues and I started a pilot study on the feasibility of thoracoscopic esophagectomy for benign and malignant esophageal diseases [1], reproducing exactly the same surgical techniques we had used in conventional operations for many years, ie, en-bloc esophageal resection including all the posterior mediastinal lymph nodes and even the right azygos veins and the thoracic duct [2, 3], or standard esophagectomy without radical lymph node clearance in the posterior mediastinum.

Our main concern at that time was the long-term outcome of the 7 cancer patients who were discharged from the hospital after thoracoscopic R0 resection [4] (complete removal of the neoplastic process and cancer-free margins at pathologic examination). More than 2 years after publication of the original article, 5 of those 7 patients were alive without evidence of clinical recurrence, and computed tomographic scan of the chest and upper abdomen was unremarkable in the 4 patients investigated. One patient died of local recurrence and another of lung metastases at 14 and 17 months of follow-up, respectively. The patient in whom en-bloc esophagectomy had eventually been completed by thoracotomy was alive without neoplastic recurrence at 43 months of follow-up. Table 1 details the long-term outcomes of those 8 patients. In patient 2 a metachronous tonsilar cancer developed that was treated by local excision and radiotherapy 1 year after the esophagectomy. None of the other patients was given any adjuvant chemotherapy or radiotherapy at follow-up.

However, as discussed in our 1993 article [1], we have learned from our pilot series of thoracoscopic esophagectomies that the thoracoscopic approach to the esophagus does not offer substantial advantages over more conventional approaches in terms of operating time, postoperative mortality [5], respiratory complications, duration of the hospital stay, and residual chest pain. Rather, skeletonization of the vital structures in the posterior mediastinum gives the surgeon a feeling of insecurity and potentially exposes the patient to the risk of intraoperative technical complications that are uncommon in conventional esophageal operations for cancer. For all these reasons, we confirm that, at present, thoracoscopy is not the approach of choice for radical esophagectomy.

Footnotes

Address reprint requests to Dr Collard, Digestive Surgery Unit, St-Luc Academic Hospital, Hippocrate Ave, 10, B-1200 Brussels, Belgium.

References

1. Collard JM, Lengele B, Otte JB, Kestens PJ. En bloc and standard esophagectomies by thoracoscopy. Ann Thorac Surg 1993;56:675–9.[Abstract/Free Full Text]
2. Collard JM, Otte JB, Reynaert M, Fiasse R, Kestens PJ. Feasibility and effectiveness of en bloc resection of the esophagus for esophageal cancer. Results of a prospective study. Int Surg 1991;76:209–13.[Medline]
3. Collard JM, Otte JB, Reynaert M, et al. Extensive lymph node clearance for cancer of the esophagus or cardia: merits and limits in reference to 5-year absolute survival. Hepatogastroenterology 1995;42:540–8.
4. Hermanek P, Wittekind C. The pathologist and the residual tumor (R) classification. Pathol Res Pract 1994;190:115–23.[Medline]
5. Collard JM, Otte JB, Reynaert M, Michel L, Carlier MA, Kestens PJ. Esophageal resection and bypass: a 6-year experience with a low postoperative mortality. World J Surg 1991;15:635–41.[Medline]

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