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J Thorac Cardiovasc Surg 1997;113:836-848
© 1997 Mosby, Inc.

GENERAL THORACIC SURGERY

ESOPHAGOGASTRECTOMY FOR CARCINOMA OF THE ESOPHAGUS AND CARDIA: A COMPARISON OF FINDINGS AND RESULTS AFTER STANDARD RESECTION IN THREE CONSECUTIVE EIGHT-YEAR INTERVALS WITH IMPROVED STAGING CRITERIA

F. Henry Ellis, Jr., MD, PhD, Gerald J. Heatley, MS, M. J. Krasna, MD, Warren A. Williamson, MD, Karoly Balogh, MD, From the Division of Cardiothoracic Surgery and the Department of Anatomic Pathology, Deaconess Hospital, Boston, and the Departments of Thoracic and Cardiovascular Surgery and Statistics, Lahey Hitchcock Medical Center, Burlington, Mass.

Supported in part by the Jarabek Fund, Deaconess Hospital, Boston, Mass.

Received for publication July 3, 1996 accepted for publication Oct. 21, 1996. Address for reprints: F. Henry Ellis, Jr., MD, PhD, Division of Cardiothoracic Surgery, Deaconess Hospital, 110 Francis St., Boston, MA 02215.

Abstract

Objective: A review of findings and results after standard resection for carcinoma of the esophagus and cardia without neoadjuvant therapy was done to provide a basis for comparison with current reports of radical resection and neoadjuvant therapy. Methods: A 24-year experience on one surgical service with 454 operations for carcinoma of the esophagus and cardia was reviewed. A comparison of findings and results in three consecutive 8-year intervals was analyzed, and new staging criteria were developed and compared with those currently favored by the American Joint Committee on Cancer. Results: From January 1, 1970, to January 1, 1994, 454 patients with carcinoma of the esophagus or cardia underwent operation, of whom 408 (90%) had esophagogastrectomy with a 30-day mortality rate of 2.5% and an additional hospital mortality rate of 1.2%. Of the 121 complications (30.7%), 71 (18%) were major and 50 (12.7%) were minor. Cardiovascular complications predominated. The overall 5-year survival was 24.7%, with a 33.7% survival after complete resections in the most recent interval under study. Palliation of dysphagia was achieved in nearly 80% of patients who survived the operation. During the three intervals under review, resectability, mortality, and complication rates remained constant. The percentages of left thoracotomies and transhiatal resections increased, and there was a decrease in thoracoabdominal incisions. The percentages of patients with Barrett's esophagus and stage 0 and I tumors increased. The percentage of complete resections (R0) increased, whereas that for resections with residual microscopic tumor (R1) decreased, and there was no change in the percentage of patients with residual gross tumor after resection (R2). Modified WNM staging criteria are proposed that provide better prognostic stratification of the disease than those currently favored by The American Joint Committee on Cancer. Conclusions: Standard esophagogastrectomy is applicable in 90% of patients with operable carcinoma of the esophagus or cardia, with consistently low mortality and morbidity rates and satisfactory palliation of dysphagia. The 5-year survival (24.7% overall) remains suboptimal, but the current figure for complete resections (33.7%) is encouraging. There is a need for revision of the current American Joint Committee on Cancer staging criteria.




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