Surgical approach to invasive adenocarcinoma of the distal esophagus (Barrett's cancer)

Barrett's carcinoma, usually arising in the distal esophagus, must be considered a separate entity from squamous cell esophageal cancer. Epidemiology, etiology, patients' risk profiles, biology of metastases, and prognosis differ markedly between these two major esophageal tumor types. The preoperative work-up of patients with Barrett's cancer is primarily directed toward assessing the chances for R0 resection and estimating the risk of the patient to survive an esophagectomy. If R0 resection appears likely and the surgical risk is acceptable, the indication for an operative approach is given. From the oncologic point of view there is no difference between a radical transmediastinal approach and a transthoracic approach. A possible advantage of a transthoracic approach is the extension of lymphadenectomy to the upper mediastinum. Lymph node metastases in the upper mediastinum, however, usually indicate advanced lymphatic and subclinical systemic tumor dissemination, i.e., a poor prognosis even with extended surgery. Consequently the controversies about the surgical approach are reduced to technical and functional aspects. A better swallowing function argues for an intrathoracic anastomosis; the lower morbidity, for a cervical approach. We prefer transthoracic en bloc esophagectomy with an intrathoracic anastomosis in patients with moderate risk and early tumor stages. In all other patients radical transmediastinal esophagectomy with a cervical anastomosis is the procedure of choice. The overall 5-year survival rate of more than 40%, which is superior to most published data, supports this therapeutic strategy.

[Carcinoma of the oesophagogastric junction and Barrett's esophagus: an almost clear oncologic model?]

From a clinical and biological point of view, the term "adenocarcinoma of the esophagogastric junction" (AEG) encompasses several distinct tumor entities. The topographic anatomic classification into adenocarcinoma of the distal esophagus (AEG I), true carcinoma of the cardia (AEG II), and subcardiac gastric cancer (AEG III) also reflects differences regarding the pathogenesis of these tumors and is increasingly accepted worldwide. Associated Barrett's esophagus, which usually develops as a consequence of chronic gastroesophageal reflux, can be documented in practically all patients with AEG I tumors and constitutes the most important precancerous lesion. A metaplasia-dysplasia-carcinoma sequence has been confirmed for these tumors. Barrett's esophagus is thus considered a model for studies on carcinogenesis and the prevention of esophageal adenocarcinoma. Its pathogenetic role in AEG II and III tumors must, however, be discussed differently. Our own experience shows that pathogenetic mechanisms similar to those in AEG I tumors may be present in up to 30% of tumors classified as AEG II. The majority of AEG II tumors, however, show morphologic, biologic and pathogenetic similarities with AEG III tumors and proximal gastric cancer.

Experimental evidence for mutagenic potential of duodenogastric juice on Barrett's esophagus

The aim of this article is to review the current experimental knowledge of mutagenesis in Barrett's esophagus (BE) with special emphasis on the effect of bile salts and acid. Human evidence of direct mutagenicity is rare. Only the correlation of increased quantities and a change in the quality of bile salts with the complications of duodenogastric reflux such as BE and esophageal adenocarcinoma as an indirect marker of mutagenicity has been shown in several studies. Further evidence comes from p53 studies demonstrating an increased number of mutated p53 genes in patients with BE, esophageal adenocarcinoma, or both. Most animal and cellular experiments are carried out in a neutral pH environment, not reflecting the true nature of a reflux episode. The few studies using moderate low acid reflux conditions in combination with bile salts demonstrated a combined effect on mutagenicity. Our current knowledge of bile salt mutagenicity is predominantly based on experiments with hepatocytes and colon cancer cell lines. Future studies must be aimed at esophageal cell lines, cultured Barrett's tissue, and esophageal adenocarcinoma cell lines.

Intratracheal long-term pH monitoring: a new method to evaluate episodes of silent acid aspiration in patients after esophagectomy and gastric pull up

Aspiration of gastric contents is considered a leading cause of postoperative pulmonary complications after esophagectomy and gastric pull up but has been difficult to diagnose. We used intratracheal long-term pH monitoring to evaluate the prevalence of aspiration of gastric contents in patients undergoing these operations. Continuous intratracheal pH monitoring was carried out during the first 72 postoperative hours in 16 patients with esophageal carcinoma who had undergone esophagectomy and gastric pull up. A drop in the pH to less than 4 was defined as an episode of acid aspiration. All patients except one tolerated the probe without any difficulties. Episodes of acid aspiration could be detected in 12 (80%) of 15 patients (5 of 8 after transhiatal esophagectomy, 7 of 7 after transthoracic esophagectomy, 2 of 5 with reconstruction in the anterior mediastinum, and 9 of 10 with reconstruction in the posterior mediastinum). The number of aspiration episodes was significantly higher during postoperative day 1 (P=0.03) compared to postoperative days 2 and 3. Two patients developed pneumonia later in the postoperative course. Both of them had several episodes of acid aspiration detected by pH monitoring immediately postoperatively. Intratracheal pH monitoring is a safe, feasible, and well-tolerated method for detecting episodes of acid aspiration after esophagectomy and gastric pull up. Aspiration of gastric contents is a common phenomenon particularly during the first 24 postoperative hours after transthoracic esophagectomy and gastric pull up in the posterior mediastinum and appears to correlate with the development of postoperative pneumonia.

[Laparoscopic fundoplication--what is proven?]

Laparoscopic fundoplication has become a popular procedure but several questions remain unresolved. Although randomised trials suggest that antireflux surgery is a good alternative to continuous medical therapy, the selection of patients for surgery remains crucial to achieve success. There is currently no proof that antireflux surgery will reduce the risk for developing esophageal adenocarcinoma. Complications, side effects and failures appear to be higher after a laparoscopic approach as compared to conventional open surgery, particularly in un-experienced hands. Partial fundoplications and tailored approaches have so far not shown convincingly better results than those that can be achieved by short and floppy 360 fundoplication.

[Lymph node excision in invasive Barrett carcinoma]

Similar to squamous cell esophageal cancer, the lymph node status constitutes the major prognostic factor after complete tumor resection (R0-resection) in patients with adenocarcinoma of the distal esophagus (the so-called Barrett's cancer). Lymphatic spread in patients with Barrett's cancer, however, appears to follow certain rules. Lymphatic spread is closely correlated to the pT-category of the primary tumor, starts only after infiltration of the submucosa und is initially limited to the regional lymph nodes. Distant lymph node metastases are almost exclusively found in patients with multiple positive regional nodes, skipping of regional lymph nodes is rare. These observations set the stage for tailored lymphadenectomy-strategies based on the, sentinel-lymphadenectomy' concept.

Barrett's esophagus and Barrett's carcinoma

The alarming rise in the incidence of esophageal adenocarcinomas in the Western world has focused interest on so-called Barrett's esophagus. Barrett's esophagus is characterized by specialized intestinal epithelium replacing the normal squamous epithelium in the distal esophagus and is considered a consequence of long-lasting and severe gastroesophageal reflux disease. A metaplasia-dysplasia-carcinoma sequence links Barrett's esophagus with adenocarcinoma of the distal esophagus (Barrett's cancer). Despite intensive research, many questions concerning the pathogenesis, diagnosis, and treatment of Barrett's esophagus and associated adenocarcinoma are still unanswered. Based on current data, the malignant progression of Barrett's esophagus cannot be substantially prevented by medical or surgical therapy for reflux. Although no firm data are available to show that surveillance strategies can reduce overall mortality from Barrett's cancer, early detection and cure are possible. Management of Barrett's esophagus and carcinoma is reviewed with reference to the sequence of disease from metaplasia to carcinoma.

Cervical esophageal perforation with severe mediastinitis due to an impacted dental prosthesis

We herein report about a case of perforation of the cervical esophagus by an artificial denture, which had been swallowed by the patient after a horse-related-injury. Impactation of the foreign body at the level of the upper esophageal sphincter was followed by its penetration through the esophageal wall, causing severe infection of the cervical soft tissue, mediastinitis and sepsis. We discuss the well-known phenomena of prosthesis ingestion and frequently delayed diagnosis, as well as our treatment strategy of cervical esophageal perforation with placement of a T-tube into the cervical esophagus and mediastinal drainage.

Endoluminal methods of treating gastroesophageal reflux disease

Several endoluminal methods of treating gastroesophageal reflux disease (GERD) have either been approved, or are under investigation and development. This review outlines the two approved methods (Bard's endoluminal sewing machine and Curon's Stretta radiofrequency treatment), and describes the available data on new methods under investigation. The various methods can be divided into three broad categories: methods that create a controlled stricture, methods that bulk the gastroesophageal junction, and methods that attempt to create a fundoplication. The pros and cons of each method are discussed. Unlike medical treatment, these methods attack the reflux itself, not just the symptoms. This is a promising approach. However, the controlled stricture and bulking methods do not approach the success rate of a standard fundoplication.

Pneumatosis cystoides intestinalis coli

The rare case of a 63-year-old male diagnosed with pneumatosis cystoides intestinalis coli is presented and discussed. The patient was found to have an unsymptomatic pneumoperitoneum on plain chest x-ray. The results of a contrast enema, computed tomography scan, and laparoscopy are presented. The patient had an uneventful hospital course without any specific therapy. Causes and possible therapeutic options are discussed.

Neoadjuvant treatment of esophageal cancer: Immunosuppression following combined radiochemotherapy

BACKGROUND

The biologic effects of neoadjuvant tumor therapies on the immune system of cancer patients are largely unknown. Immune deviations may be particularly detrimental if they occur in conjunction with postoperative immunosuppression. The effects of combined radiochemotherapy (RCTx) on T cell functions in patients with squamous cell carcinoma of the esophagus were investigated.

METHODS

T cell proliferation was stimulated by incubation of peripheral blood mononuclear cells with bacterial superantigens or by exposure of enriched T cells to superantigens presented by B lymphoma cells. Cytokine production of enriched T cells was induced by cross-linking of CD3 and CD28 and the secretion of interleukin (IL)-2, IL-4, IL-10, and interferon-gamma was measured by enzyme-linked immunosorbent assay. T cell expression of human leukocyte antigen-DR (HLA-DR) molecules was determined by flow cytometry.

RESULTS

T lymphocytes from patients having undergone RCTx exhibited a significantly reduced proliferative response following stimulation with 3 independent superantigens. Cytokine production of T cells and the antigen presenting capacity of patient's peripheral blood mononuclear cells was not diminished following RCTx. T cell expression of HLA-DR was increased following RCTx.

CONCLUSIONS

RCTx of patients with squamous cell carcinoma of the esophagus results in the suppression of T lymphocyte functions. The proliferative defects of T cells after RCTx may be linked to an impaired immune surveillance of cancer and to a higher risk of surgical complications associated with esophagectomy.

[Distal esophageal resection and jejunum interposition for early Barrett carcinoma]

Distal esophageal resection and jejunum interposition for early Barrett carcinoma. Limited resection with regional lymphadenectomy and jejunal interposition is safe, prevents gastroesophageal reflux and is associated with good quality of life. The procedure represents an oncologically adequate and thus attractive limited surgical alternative to radical esophagectomy or endoscopic resection and ablation techniques in patients with high grade dysplasia or T1 adenocarcinoma in Barrett's esophagus.

Preoperative chemotherapy unmasks underlying Barrett's mucosa in patients with adenocarcinoma of the distal esophagus

BACKGROUND

Intestinal metaplasia of the distal esophagus frequently cannot be detected in patients with esophageal adenocarcinoma. It has therefore been questioned whether Barrett's esophagus is the primary precursor lesion of such lesions. We hypothesized that the underlying Barrett's mucosa may be masked by tumor overgrowth in the majority of these patients.

METHODS

The pretherapeutic endoscopy and biopsy records of 79 patients with locally advanced esophageal adenocarcinoma who had undergone preoperative chemotherapy were reviewed and compared to findings on restaging endoscopy/biopsy and subsequent resection and histopathologic analysis of the resected specimen.

RESULTS

Pretherapeutic endoscopy and biopsy showed associated Barrett's esophagus in 59/79 patients, whereas there was no evidence of associated intestinal metaplasia in 20/79 patients on extensive biopsies. Following neoadjuvant chemotherapy, Barrett's mucosa was unmasked and later documented by biopsy or histopathologic assessment of the resected specimen in 18 of the latter 20 patients. This resulted in an overall association of Barrett's mucosa with adenocarcinoma in the distal esophagus of 97.4%

CONCLUSION

Underlying Barrett's mucosa is frequently masked by tumor overgrowth in patients with locally advanced adenocarcinoma of the distal esophagus.

Site-dependent resection techniques for gastric cancer

In addition to tumor stage and growth pattern, the tumor site is a major factor in determining the extent of resection and lymphadenectomy necessary in patients with gastric carcinoma. Total gastrectomy with D2-lymphadenectomy is the procedure of choice for tumors of the gastric corpus. Extended total gastrectomy with trans-hiatal resection of the distal esophagus is required for tumors of the proximal region; in these patients lymphadenectomy may also include splenic hilum and left retroperitoneal nodes. In patients with distal gastric carcinoma, a subtotal gastrectomy often achieves a complete tumor resection. Extended lymphadenectomy in these patients includes the retroduodenal and right para-aortic nodes in addition to a D2-dissection. In patients with early tumor stages, anatomically oriented limited resection techniques are increasingly important. The concept of the sentinel lymph node may result in more selective lymphadenectomy strategies in the near future [15]. For patients with a locally advanced disease, these surgical concepts must be evaluated within multimodal treatment protocols [16].

[Progress in oncological visceral surgery--esophageal carcinoma]

Compared to adenocarcinoma of the esophagus (Barrett cancer) the prevalence of esophageal squamous cell cancer is decreasing. Patients with squamous cell cancer have a less favorable risk profile for surgical therapy, a higher prevalence of lymphatic spread in early tumor stages, and more frequently an invasion of lymphatic vessels (lymphangiosis carcinomatosa) than patients with adenocarcinoma. A transthoracic en-bloc esophagectomy is therefore the procedure of choice for squamous cell esophageal cancer. The prognosis after surgical resection is worse for squamous cell esophageal cancer as compared to adenocarcinoma. In patients with early Barrett cancer a limited surgical approach is possible. The results of radical transmediastinal esophagectomy compare favorably to transthoracic esophagectomy in patients with locoregional Barrett cancer.

A scintigraphic study of local oesophageal bolus transit: differences between patients with Barrett's oesophagus and healthy controls

BACKGROUND

In Barrett's patients, functional disorders of oesophageal motility are currently measured by oesophageal manometry. Yet abnormalities of oesophageal volume transport in the critical regions of the upper oesophageal sphincter (UOS) and lower oesophageal sphincter (LOS) cannot be determined using these methods.

AIMS

To further characterise the activity of the sphincter regions, we developed a quantitative method for differentiation of oesophageal volume transport in Barrett's patients and healthy controls.

METHODS

We used a new technique of processing scintigraphic images, with data analysis based on a new concept of relative local transit time. Twelve patients with Barrett's oesophagus and 11 healthy volunteers were examined using alimentary scintigraphy after a semisolid test meal in a multiple swallow test. In individual scintigraphic images of five swallows we studied: (1) overall oesophageal clearance and (2) the topographic profile of the relative local transit time obtained by image conversion to a two dimensional line graph. This profile was reconstructed by assembling constituent Gauss bands, allocating their integrals to five oesophageal regions according to their band position.

RESULTS

(1) Overall oesophageal clearance was not significantly different between the two groups. (2) In comparison with healthy volunteers, relative regional transit times of all 12 Barrett's patients were significantly increased in the hypopharyngeal region and decreased in the region of the distal oesophagus. The extent of the decrease in the region of the distal oesophagus showed a close correlation with the length of Barrett's metaplasia.

CONCLUSION

Improvement in image processing allows alimentary scintigraphy to describe different regional patterns of oesophageal volume transport. Local oesophageal bolus transit is markedly abnormal in Barrett's patients without alteration in clearance. The presence of metaplasia itself implies a negative impact on both sphincter functions. These findings substantiate the diagnostic value of refined oesophageal scintigraphy.

Role of acid and bile in the genesis of Barrett's esophagus

Clinical and experimental studies have shown that acid and bile reflux are increased in patients who have Barrett's esophagus. The combination of both seems the key factor in the pathogenesis of Barrett's esophagus. This factor has been confirmed by immunohistochemical studies that show that environmental factors, such as acid and bile, are involved in the pathogenesis of Barrett's esophagus. There is a critical pH range between 3 and 6 in which bile acids exist in their soluble, un-ionized form; can penetrate cell membranes; and accumulate within mucosal cells. At a lower pH, bile acids are precipitated, and at a higher pH, bile acids exist in their noninjurious ionized form. Thus incomplete gastric acid suppression, as is the case with most medical treatment regimens for gastroesophageal reflux, may in fact predispose to the development of Barrett's esophagus.

Lymphatic vessel invasion is an independent prognostic factor in patients with a primary resected tumor with esophageal squamous cell carcinoma

BACKGROUND

Little data exist about the prognostic role of a lymphatic vessel invasion (LVI) in patients with esophageal carcinoma. The objective of this study was to clarify the presence and prognostic impact of LVI in a large group of patients resected for esophageal squamous cell carcinoma (SCC) at one surgical center.

METHODS

Three hundred sixty-six patients, who had a primary resection for SCC, were analyzed by univariate and multivariate analysis. Follow-up was complete for 93.7% patients with a median follow-up of 8.3 years.

RESULTS

The total rate of LVI was 39.1% (n = 143). Univariate analysis revealed a significant relation between LVI and different T classifications (P = 0.001), N classifications (P < 0.0001), M classifications (P < 0.0001), International Union Against Cancer (UICC) stages (P < 0.0001), and residual tumor (P < 0.0001). Multivariate analysis of the patients with R0-resected tumors proved LVI as an independent prognostic factor. The 2-, 5- and 10-year survival rates in patients with LVI were 28.5%, 11.1%, and 9.2% compared with 63.4%, 46.6%, and 27%, respectively, without LVI (P < 0.0001). Patients with LVI had a median survival time of 11.4 months compared with 28.6 months without LVI (P < 0.0001). Patients with R0-resected tumors without LVI had a median survival time of 54.1 months compared with 12.1 months in patients with LVI (P < 0.0001) and compared with 11.3 months in patients with R1-resected tumors P < 0.0001).

CONCLUSIONS

These data clearly show that LVI is an independent prognostic factor in patients with SCC and confirm the importance of a systematic pathohistologic workup. The prognosis of patients with R0-resected tumors with LVI is equal to patients with an incomplete tumor resection. This supports the inclusion of LVI in the UICC classification system for esophageal carcinoma.

Lymphatic vessel invasion is an independent prognostic factor in patients with a primary resected tumor with esophageal squamous cell carcinoma

BACKGROUND

Little data exist about the prognostic role of a lymphatic vessel invasion (LVI) in patients with esophageal carcinoma. The objective of this study was to clarify the presence and prognostic impact of LVI in a large group of patients resected for esophageal squamous cell carcinoma (SCC) at one surgical center.

METHODS

Three hundred sixty-six patients, who had a primary resection for SCC, were analyzed by univariate and multivariate analysis. Follow-up was complete for 93.7% patients with a median follow-up of 8.3 years.

RESULTS

The total rate of LVI was 39.1% (n = 143). Univariate analysis revealed a significant relation between LVI and different T classifications (P = 0.001), N classifications (P < 0.0001), M classifications (P < 0.0001), International Union Against Cancer (UICC) stages (P < 0.0001), and residual tumor (P < 0.0001). Multivariate analysis of the patients with R0-resected tumors proved LVI as an independent prognostic factor. The 2-, 5- and 10-year survival rates in patients with LVI were 28.5%, 11.1%, and 9.2% compared with 63.4%, 46.6%, and 27%, respectively, without LVI (P < 0.0001). Patients with LVI had a median survival time of 11.4 months compared with 28.6 months without LVI (P < 0.0001). Patients with R0-resected tumors without LVI had a median survival time of 54.1 months compared with 12.1 months in patients with LVI (P < 0.0001) and compared with 11.3 months in patients with R1-resected tumors P < 0.0001).

CONCLUSIONS

These data clearly show that LVI is an independent prognostic factor in patients with SCC and confirm the importance of a systematic pathohistologic workup. The prognosis of patients with R0-resected tumors with LVI is equal to patients with an incomplete tumor resection. This supports the inclusion of LVI in the UICC classification system for esophageal carcinoma.

Esophageal cancer: patient evaluation and pre-treatment staging

Improvements in the overall survival of patients with esophageal cancer can in the future only be achieved by tailored therapeutic strategies which are based on the individual histologic tumor type, tumor location, tumor stage at the time of presentation, consideration of established prognostic factors and the physiologic status of the patient. The major aim of every diagnostic strategy is to assess whether a complete macroscopic and microscopic tumor resection (i.e. an R0 resection) can be achieved by primary surgical approach with a high degree of likelihood. This requires histologic classification of the tumor type (squamous cell cancer or adenocarcinoma), the exclusion of distant solid organ metastases, localization of the primary tumor in relation to the tracheobronchial tree, and determination of the T-category and the surrounding structures of the primary tumor. This is currently achieved by a combination of contrast radiography, endoscopy with biopsy, endoscopic ultrasonography and CT scan. PET scanning will in the future be more widely used in esophageal cancer staging because it appears to be superior to current imaging modalities in the exclusion of distant solid organ and lymph node metastases and allows early assessment of response of the primary tumor to neoadjuvant treatment. Systematic risk analysis with a dedicated composite scoring system is essential to assess the physiologic status of the patient and reduce postoperative mortality. Only hospitals with a sufficient case load of esophageal cancer patients ('hospital volume') and a dedicated interest in the management of this disease ('centers of excellence') can provide the required expertise and standards for patient evaluation and tailored therapy.

Lymphatic vessel invasion is an independent prognostic factor in patients with a primary resected tumor with esophageal squamous cell carcinoma

BACKGROUND

Little data exist about the prognostic role of a lymphatic vessel invasion (LVI) in patients with esophageal carcinoma. The objective of this study was to clarify the presence and prognostic impact of LVI in a large group of patients resected for esophageal squamous cell carcinoma (SCC) at one surgical center.

METHODS

Three hundred sixty-six patients, who had a primary resection for SCC, were analyzed by univariate and multivariate analysis. Follow-up was complete for 93.7% patients with a median follow-up of 8.3 years.

RESULTS

The total rate of LVI was 39.1% (n = 143). Univariate analysis revealed a significant relation between LVI and different T classifications (P = 0.001), N classifications (P < 0.0001), M classifications (P < 0.0001), International Union Against Cancer (UICC) stages (P < 0.0001), and residual tumor (P < 0.0001). Multivariate analysis of the patients with R0-resected tumors proved LVI as an independent prognostic factor. The 2-, 5- and 10-year survival rates in patients with LVI were 28.5%, 11.1%, and 9.2% compared with 63.4%, 46.6%, and 27%, respectively, without LVI (P < 0.0001). Patients with LVI had a median survival time of 11.4 months compared with 28.6 months without LVI (P < 0.0001). Patients with R0-resected tumors without LVI had a median survival time of 54.1 months compared with 12.1 months in patients with LVI (P < 0.0001) and compared with 11.3 months in patients with R1-resected tumors P < 0.0001).

CONCLUSIONS

These data clearly show that LVI is an independent prognostic factor in patients with SCC and confirm the importance of a systematic pathohistologic workup. The prognosis of patients with R0-resected tumors with LVI is equal to patients with an incomplete tumor resection. This supports the inclusion of LVI in the UICC classification system for esophageal carcinoma.

Histologic tumor type is an independent prognostic parameter in esophageal cancer: lessons from more than 1,000 consecutive resections at a single center in the Western world

OBJECTIVE

To analyze the changing pattern in tumor type and postoperative deaths at a national referral center for esophageal cancer in the Western world and to assess prognostic factors for long-term survival after resection.

SUMMARY BACKGROUND DATA

During the past two decades, the epidemiology and treatment strategies of esophageal cancer have changed markedly in the Western world. The influence of these factors on postoperative deaths and long-term prognosis has not been adequately evaluated.

METHODS

Between 1982 and 2000, 1,059 patients with primary esophageal squamous cell cancer or adenocarcinoma had resection with curative intention at a single center. Patient and tumor characteristics and details of the surgical procedure and outcome were documented during this period. Follow-up was available for 95.8% of the patients. Changing patterns in tumor type and postoperative deaths were analyzed. Prognostic factors for long-term survival were assessed by multivariate analysis.

RESULTS

The prevalence of adenocarcinoma in patients with resected esophageal cancer increased markedly during the study period. The postoperative death rate decreased from about 10% before 1990 to less than 2% since 1994, coinciding with the introduction of a procedure-specific composite risk score and exclusion of high-risk patients from surgical resection. In addition to the well-established prognostic parameters, tumor cell type "adenocarcinoma" was identified as a favorable independent predictor of long-term survival after resection. The independent prognostic effect of tumor cell type persisted in the subgroups of patients with primary resection and patients with primary resection and R0 category.

CONCLUSION

Esophagectomy for esophageal cancer has become a safe procedure in experienced hands. Esophageal adenocarcinoma has a better long-term prognosis after resection than squamous cell carcinoma.