Clinical Application of Exclusive Right-Thoracic Approach in Surgery with or without Laparotomy for Mid-Upper Esophageal Cancer

Discussion

There are many surgical approaches for esophageal cancer. Two types of route may be used: a transthoracic (right or left) or a transhiatal route. Recently, minially invasive esophagectomy (MIE)^[5] was reported to be safe and comparable to an open approach with respect to postoperative recovery and cancer survival, but the sample number was relatively small. Ivor-Lewis surgery and transhiatal^[6] esophagectomy are two main surgeries in Western countries, whereas esophagectomy through a left-sided approach is the predominant approach in China, as noted by Chen et al.^[2], who reported that 87.3% (3,169/3,630) patients received esophagectomies through a left-sided approach.

With regard to the choice of surgical approaches, it is based on the site of the lesion, general condition of the patients and the proference of the surgeons^[1]. Though there are advantages and disadvantages between a varity of surgical procedures, two principles regarding resection should be noted: R0 resection(removal of all macroscopic and microscopic tumor) and resection of lymph nodes. Yekebas et al.^[7] recently showed that compared to transhiatal esophagectomy, transthoracic radical en-bloc esophagectomy can increase 5-year survival of esophageal cancer patients if there are no micro-metastases. They also showed the necessity of radical resecton of the primaty tumor and lymph nodes.

Belsey surgery was first reported in 1974. He had operated on 140 cases of esophageal cancer using an exclusive right thoracic approach. Since then, no furthur reports appeared in Western countries, but rare reports were found in China^[8,9]. The morbidity rate was reported to be 0~28.1%, the most common complications being anastomotic leakage, pulmonary infectons and delayed intrathoracic stomach emptying. The morbidity rate in our study was within the range of that reported in the literature, and 5-year survival was also similar to survival from a large series of esophagectomies for esophageal cancer^[2]. Belsey surgery has the advantage of a more efficient approach with minimal injury, shortened operation time and less pain^[4,8]. But it is difficult to resect abdominal lymph nodes, especially the left gastric lymph nodes by this prodecure, so it is not in accord with surgical oncological principles. Based on the literature and our data, we conclud that Belsey surgery is not a preferred procedure for mid-thoracic esophageal cancer, but it can be selectively used as a palliative procedure for mid-thoracic esophageal cancer.

Owing to dissecting a primary lesion and the lymph nodes of the thoracic and abdominal fields, Ivor-Lewis surgery has been a “standard operation” for esophageal cancer in Western countries since 1946. Recently, there have been increasing reports regarding esophagectomy for esophageal cancer using Ivor-Lewis surgery in China^[3,10-12]. The morbidity rate has been reported to be 7.3~16%, and 5-year survival rate between 30~48.8%. It has the advantage of a complete resection of the esophageal cancer and recurrent nerve lymph nodes, and post-aortic and supra-aortic lymph nodes which can not be approached through a left-sided thoracic incision^[12]. In order to overcome the disadvantage of changing the patients’ position intraoperatively, we modified the procedure as follows: right thoracotomy was performed first, then if it was definitive that the lesion would be dissected after exploration, the operation bed was titled to the chief surgeon and a laparotomy was conducted, After the stomach was pulled up into the chest, an anastomosis is connected between the esophagus and stomach in the right thorax using a stapling device. We named it as a modified Ivor-Lewis surgery. It has several advantages over classic Ivor-Lewis surgery. First, if the esophageal lesion can not be resected, then surgery would terminate, avoiding injury from laparotomy. Second, a modified Ivor-Lewis surgery shortened the operation time which benefits patients’ recovery. In spite of the low morbidity rate, our limited data need further investigation due to a relative short follow-up period.

Similar to classic Ivor-Lewis surgery, modified Ivor-Lewis surgery may also be employed to resect a primary tumor and lymph nodes simutaneously from the mediastinal and abdominal fields, and it is especially appopriate for mid-upper thoracic esophageal cancer. The differences between our modified Ivor-Lewis surgery and the modified Ivor-Lewis surgery of Wang et al.^[3] and Lu et al.^[9] lie in that in the latter operation, they commence the thoracotomy and laparotomy simutaneously, whereas we do not conduct palliative esophagectomy if the esophageal lesion cannot be resected completely. We recommend a non-operative treatment such as radiotherapy and stent for these patients.