Transthoracic versus transhiatal esophagectomy: a prospective study of 945 patients

Risk Factor Analysis for Developing Major Complications Following Esophageal Surgery-A Two-Center Study

BACKGROUND

Esophagectomy carries a high risk of morbidity and mortality compared to other major surgeries. With the aim of creating an easy-to-use clinical preoperative risk assessment tool and to validate previously described risk factors for major complications following surgery, esophagectomies at two tertiary medical centers were analyzed.

METHODS

A total of 450 patients who underwent esophagectomy for esophageal carcinoma at the University Medical Centre, Hamburg, or at the Medical Center University Duisburg-Essen, Germany (January 2008 to January 2020) were retrospectively analyzed. Epidemiological and perioperative data were analyzed to identify the risk factors that impact major complication rates. The primary endpoint of this study was to determine the incidence of major complications.

RESULTS

The mean age of the patients was 63 years with a bimodal distribution. There was a male predominance across the cohort (81% vs. 19%, respectively). Alcohol abuse (p = 0.0341), chronic obstructive pulmonary disease (p = 0.0264), and cardiac comorbidity (p = 0.0367) were associated with a significantly higher risk of major complications in the multivariate analysis. Neoadjuvant chemotherapy significantly reduced the risk of major postoperative complications (p < 0.0001).

CONCLUSIONS

Various patient-related risk factors increased the rate of major complications following esophagectomy. Patient-tailored prehabilitation programs before esophagectomy that focus on minimizing these risk factors may lead to better surgical outcomes and should be analyzed in further studies.

Short-term outcome for high-risk patients after esophagectomy

Transthoracic esophagectomy (TTE) for esophageal cancer facilitates mediastinal dissection; however, it has a significant impact on cardiopulmonary status. High-risk patients may therefore be better candidates for transhiatal esophagectomy (THE) in order to prevent serious complications. This study addressed short-term outcome following TTE and THE in patients that are considered to have a higher risk of surgery-related morbidity. This population-based study included patients who underwent a curative esophagectomy between 2011 and 2018, registered in the Dutch Upper GI Cancer Audit. The Charlson comorbidity index was used to assign patients to a low-risk (score ≤ 1) and high-risk group (score ≥ 2). Propensity score matching was applied to produce comparable groups between high-risk patients receiving TTE and THE. Primary endpoint was mortality (in-hospital/30-day mortality), secondary endpoints included morbidity and oncological outcomes. Additionally, a matched subgroup analysis was performed, including only cervical reconstructions. Of 5,438 patients, 945 and 431 high-risk patients underwent TTE and THE, respectively. After propensity score matching, mortality (6.3 vs 3.3%, P = 0.050), overall morbidity, Clavien-Dindo ≥ 3 complications, pulmonary complications, cardiac complications and re-interventions were significantly more observed after TTE compared to THE. A significantly higher mortality after TTE with a cervical reconstruction was found compared to THE (7.0 vs. 2.2%, P = 0.020). Patients with a high Charlson comorbidity index predispose for a complicated postoperative course after esophagectomy, this was more outspoken after TTE compared to THE. In daily practice, these outcomes should be balanced with the lower lymph node yield, but comparable positive node count and radicality after THE.

Transhiatal versus transthoracic esophagectomy for esophageal SCC: outcomes and complications

Background

Transhiatal esophagectomy (THE) and transthoracic esophagectomy (TTE) are both accepted procedures for esophageal cancer but still the most effective surgical approach continues to be controversial. This study aimed to determine post-operative complications and outcomes of TTE compared with THE.

Methods

A retrospective analysis was performed on data of 243 adult patients with resectable esophageal cancer who underwent THE or TTE between December 2016 and October 2018. Demographic data, consisting of preoperative co-morbidities, disease stage, and perioperative morbidity and mortality were collected.

Results

Among the patients, 99 individuals (40.7%) had a transhiatal resection and 144 (59.3%) had a transthoracic resection. Most patients (83.1%) were above 50 years old with no significant difference between groups (p = 0.297). The frequency distribution of comorbidities was similar in both groups. The most common site of the tumor in TTE group was middle esophagus and in THE group was lower esophagus. The most common complication was recurrence of dysphagia which was more common in THE group without significant difference. The other complications including pulmonary and cardiac events, tracheal and recurrent laryngeal nerve injury, chylothorax and anastomosis stricture did not differ between the groups. The operative mortality within 30 days after the operation was 2.8% with significant difference favored the THE group (THE 0%, TTE 5.2%, p = 0.033).

Conclusion

Because of the controversies, the decision on the type of surgical technique in esophageal cancer treatment hinges on patient’s co-morbidities, cancer stage, tumor location and surgeon’s experience.

Baseball bat-like gastric tube for end-to-side oesophageal-gastric anastomosis decreased risks of anastomotic leakage after oesophagectomy for oesophageal cancer: A retrospective propensity score matched comparative study with 613 patients

PURPOSE

To investigate the relationship between baseball bat-like gastric tubes for end-to-side oesophageal-gastric anastomosis and occurrence of anastomotic leakage after oesophagectomy for oesophageal cancer.

METHODS

From July 2019 to June 2021, 613 patients with bat-like or narrow gastric tubes for end-to-side oesophageal-gastric anastomosis in oesophagectomy were retrospectively enrolled, in which 120 patients had narrow gastric tubes and 493 had bat-like gastric tubes. Clinical data including baseline characteristics, in-hospital variables and follow-up outcomes were collected.

RESULTS

Higher occurrence of anastomotic leak was observed in the narrow group in the unmatched cohort (14.2%, 17/120 vs. 7.3%, 36/493; P = 0.016) or the matched cohort after Propensity Score Matching (PSM) analysis (14.2%, 17/120 vs. 7.5%, 27/360, P = 0.028) when compared to the bat-like group; Multivariable analysis for risk factors of postoperative anastomotic leak in the unmatched cohort showed that the use of bat-like gastric tube was an independent protective factor (OR: 0.502, 95% CI: 0.270-0.935, P = 0.030).

CONCLUSIONS

Bat-like gastric tube can be used for end-to-side oesophageal-gastric anastomosis in oesophagectomy. This technique by improving blood supply to the area distal to the anastomosis decreased the incidence of anastomotic leak.

TRANSHIATAL ESOPHAGECTOMY IN SQUAMOUS CELL CARCINOMA OF THE ESOPHAGUS: WHAT ARE THE BEST INDICATIONS?

BACKGROUND

Overall survival in patients who underwent transhiatal esophagectomy submitted or not to neoadjuvant therapy. Southern Brazil has one of the highest incidences of esophageal squamous cell carcinoma in the world. Transthoracic esophagectomy allows more complete abdominal and thoracic lymphadenectomy than transhiatal. However, this one is associated with less morbidity.

AIM

To analyze the outcomes and prognostic factors of squamous esophageal cancer treated with transhiatal procedure.

METHODS

All patients selected for transhiatal approach were included as a potentially curative treatment and overall survival, operative time, lymph node analysis and use of neoadjuvant therapy were analyzed.

RESULTS

A total of 96 patients were evaluated. The overall 5-year survival was 41.2%. Multivariate analysis showed that operative time and presence of positive lymph nodes were both associated with a worse outcome, while neoadjuvant therapy was associated with better outcome. The negative lymph-node group had a 5-year survival rate of 50.2%.

CONCLUSION

Transhiatal esophagectomy can be safely used in patients with malnutrition degree that allows the procedure, in those with associated respiratory disorders and in the elderly. It provides considerable long-term survival, especially in the absence of metastases to local lymph nodes. The wider use of neoadjuvant therapy has the potential to further increase long-term survival.

Esophageal cancer in Aleppo, Syria 2010-2020: a rare cancer in a war zone

The management of diseases such as cancer in developing countries are often suboptimal given a lack of resources and access to specialists and therapeutics. In March 2020, Syria descended into its ninth year of the war with a rising death toll and millions of Syrian refugees. Aside from the inherent dangers of war, cancer care during war is especially difficult with partially or non-functional infrastructure due to destruction, inconsistent electrical power, inaccessibility, or the inherent dangers of living in a war zone. Furthermore, limitations to therapeutics are exacerbated when supply chains responsible for bringing in essential medications such as chemotherapeutics are disrupted by international economic sanctions. Aleppo, Syria is the site of some of the fiercest fighting which ended in December 2016. Since then, Aleppo has made a slow recovery to rebuild its infrastructure while the war continues elsewhere in the country. In this article, we aim to highlight the challenges in the management of cancer, particularly esophageal cancer, during a time of war in Aleppo, Syria. We aim to discuss current challenges and limitations to care in a war zone. We will also touch upon areas of need for continued improvement in the care of cancer patient's in Aleppo, Syria.

Preoperative Type and Screen is Unnecessary in Elective Anatomic Lung Resection and Esophagectomy

BACKGROUND

Preoperative type and screen (TS) is routinely performed before elective thoracic surgery. We sought to evaluate the utility of this practice by examining our institutional data related to intraoperative and postoperative transfusions for two common, complex procedures.

MATERIALS AND METHODS

A single-center, retrospective review of a prospective thoracic surgery database was performed. Patients who underwent consecutive elective anatomic lung resection (ALR) and esophagectomy from January 2015 to April 2018 were included. Perioperative characteristics between patients who received transfusion of packed red blood cells and those who did not were compared. The rates of emergent and nonemergent transfusions were evaluated. Cost data were derived from institutional charges and Centers for Medicare & Medicaid Services fee schedules.

RESULTS

Of 370 patients, 16 (4.3%) received a transfusion and four (1.1%) were deemed emergent by the surgeons and 0 (0%) by blood bank criteria. For ALR (n = 321), 13 (4.0%) received a transfusion, and four (1.2%) were emergent. For esophagectomies (n = 49), three (6.1%) received a transfusion, and none were emergent. Patients who underwent ALR requiring a transfusion had a lower preoperative hemoglobin (11.7 versus 13.4 gm/dL, P = 0.001), higher estimated blood loss (1325 versus 196 mL, P < 0.001), and longer operative time (291 versus 217 min, P = 0.003) than nontransfused patients. Based on current volumes, eliminating TS in these patients would save at least an estimated $60,100 per year.

CONCLUSIONS

Emergent transfusion in ALR and esophagectomy is rare. Routine preoperative TS is most likely unnecessary for these cases. These results will be used in a quality improvement initiative to change practice at our institution.

The treatments and postoperative complications of esophageal cancer: a review

Abstract

Esophageal cancer is still one of the most common cancers in the world. We review the appropriate treatments at different stages of esophageal cancer and also analyze the advantages and disadvantages of these treatments. The prognosis and recovery of different treatment regimens are further discussed. In particular, post-operative complications are the major causes of high mortality derived from the esophageal cancer. Therefore, we particularly discuss the main complications resulting in high mortality after surgery of esophageal cancer, and summarize their risk factors and treatment options.

Background

As the common cancer, the complications of esophageal cancer after surgery have been not obtained systematic treatment strategy, focusing on treatment regimens based on the different stages of esophageal cancers.

Methods and overview

This paper systematically summarizes the appropriate treatment strategies for different stages of esophageal cancers, and their advantages and disadvantages. We particularly focus on the postoperative survival rate of patients and postoperative complications, and discuss the causes of high mortality risk factors after surgery. The risk factors of death and corresponding treatment methods are further summarized in this study.

Conclusion

Postoperative complications is the main cause responsible for the hard cure of esophageal cancers. The existing literatures indicate that postoperative anastomotic fistula is one of the most important complications leading to death, while it has not received much attention yet. We suggest that anastomotic fistula should be detected and dealt with early by summarizing these literatures. It is, therefore, necessary to develop a set of methods to predict or check anastomotic fistula in advance.

Comparative Perioperative Outcomes by Esophagectomy Surgical Technique

INTRODUCTION

Surgical resection is vital in the curative management of patients with esophageal cancer. However, a myriad of surgical procedures exists based on surgeon preference and training. We report on the perioperative outcomes based on esophagectomy surgical technique.

METHODS

A prospectively managed esophagectomy database was queried for patients undergoing esophagectomy from 1996 and 2016. Basic demographics, tumor characteristics, operative details, and post-operative outcomes were recorded and analyzed by comparison of transhiatal vs Ivor-lewis and minimally invasive (MIE) vs open procedures.

RESULTS

We identified 856 patients who underwent esophagectomy. Neoadjuvant therapy was administered in 543 patients (63.4%). There were 504 (58.8%) open esophagectomies and 302 (35.2%) MIE. There were 13 (1.5%) mortalities and this did not differ among techniques (p = 0.6). While there was no difference in overall complications between MIE and open, complications occurred less frequently in patients undergoing RAIL and MIE IVL compared to other techniques (p = 0.003). Pulmonary complications also occurred less frequently in RAIL and MIE IVL (p < 0.001). Anastomotic leaks were less common in patients who underwent IVL compared to trans-hiatal approaches (p = 0.03). MIE patients were more likely to receive neoadjuvant therapy (p = 0.001), have lower blood loss (p < 0.001), have longer operations (p < 0.001), and higher lymph node harvests (p < 0.001) compared to open patients.

CONCLUSION

Minimally invasive and robotic Ivor Lewis techniques demonstrated substantial benefits in post-operative complications. Oncologic outcomes similarly favor MIE IVL and RAIL.

Transhiatal versus Left Transthoracic Esophagectomy for Gastroesophageal Junction Cancer; The Impact of Surgical Approach on Postoperative Complications

BACKGROUND Esophagectomy is the mainstay of treatment for esophageal cancer. Although different surgical approaches have been described, choosing the most appropriate technique is still on debate. We compared the complications of transhiatal esophagectomy (THE) versus left transthoracic esophagectomy (LTE) among a group of Iranian patients with gastroesophageal junction cancer. METHODS This was a retrospective study between 2011 and 2013 on 40 patients with gastroesophageal cancer. 23 patients underwent THE and the others underwent LTE. 30-day postoperative mortality, complications, duration of hospital stay, and number of dissected lymph nodes were studied. RESULTS 37.5% of the patients had squamous cell carcinoma. No mortality was seen. Totally, 10 patients suffered from complications. Cardiac and pulmonary complications occurred in eight and six patients, respectively. No patients suffered from vocal cord injuries and anastomotic leakage. The mean duration of postoperative hospital stay was 11.82 ± 3.8 days, and the mean number of dissected lymph nodes was 8.2 ± 3.9. No significant difference was seen between the two groups (p > 0.05). CONCLUSION Choosing between the approaches for resection of gastroesophageal cancer may not impact the complications and mortality rates. We propose that LTE approach could be used safely in comparison with THE, and that selecting between THE and LTE may be based on the surgeon's preference and experience.

Current challenges in gastric cancer surgery: European perspective

Gastric cancer (GC) remains one of the most common causes of cancer death worldwide with expected 5-year survival rates around 25% in Western countries. In order to improve treatment strategy, a most effective staging process should be completed. A novel TNM staging for GC has been proposed recently, along with a separate staging system for GC patients who underwent preoperative therapy (ypStage). Availability of high-quality imaging and access to diagnostic laparoscopy with lavage cytology should be applied while planning the multimodal therapy. In the European setting, GC treatment is based on a combination of surgery and perioperative chemotherapy. However, in selected groups of patients with high risk of locoregional recurrence, adjuvant chemoradiotherapy should be considered. New epidemiological trends of GC in the Western countries include an upward shift in the location of the primary tumour and a relative increase of advanced and diffuse type tumours. These trends dictate modification of surgical techniques towards a more individualized GC treatment approach.

Diagnosis, assessment, and management of surgical complications following esophagectomy

Despite improvements in operative strategies for esophageal resection, anastomotic leaks, fistula, postoperative pulmonary complications, and chylothorax can occur. Our review seeks to identify potential risk factors, modalities for early diagnosis, and novel interventions that may ameliorate the potential adverse effects of these surgical complications following esophagectomy.

Ketorolac and Other NSAIDs Increase the Risk of Anastomotic Leakage After Surgery for GEJ Cancers: a Cohort Study of 557 Patients

OBJECTIVE

The objective of this study is to investigate the impact of ketorolac and other nonsteroidal anti-inflammatory drugs on anastomotic leakage after surgery for gastro-esophageal-junction cancer. Within the last two decades, the incidence of gastro-esophageal-junction cancer has increased in the western world and surgery is the curative treatment modality of choice. Anastomotic leakage is a feared complication of gastro-esophageal surgery, as it increases recurrence, morbidity, and mortality. Nonsteroidal anti-inflammatory drugs are widely used for postoperative pain relief. Nonsteroidal anti-inflammatory drugs have, however, in colorectal surgery, been shown to increase the risk of anastomotic leakage.

METHOD

In a historical cohort study, we investigated the impact of nonsteroidal anti-inflammatory drugs on anastomotic leakage in 557 patients undergoing surgery for gastro-esophageal-junction cancer. Data were collected from a prospective maintained database, the Danish National Patient Registry, and patient medical records. Data were analyzed using univariate and multivariate statistical models and were stratified for theoretical confounders.

RESULTS

In univariate analysis, we did not observe any difference in age, gender, tobacco exposure, or comorbidity status between patients experiencing anastomotic leakage and those without. In multivariate analysis, gender, histology, and type of anastomosis proved to affect odds ratios for anastomotic leakage. After adjustment for possible confounders, we found an odds ratio of 6.05 (95% confidence interval 2.71; 13.5) for ketorolac use and of 5.24 (95% confidence interval 1.85; 14.8) for use of other nonsteroidal anti-inflammatory drugs for anastomotic leakage during the first seven postoperative days.

CONCLUSION

In the present study, we found a strong association between the postoperative use of ketorolac and other nonsteroidal anti-inflammatory drugs and the risk for anastomotic leakage after surgery for gastro-esophageal-junction cancers.

Definitive chemoradiotherapy versus neoadjuvant chemoradiotherapy followed by surgery for stage II to III esophageal squamous cell carcinoma

OBJECTIVE

Definitive chemoradiotherapy (CRT) remains the most commonly used treatment for locally advanced esophageal squamous cell carcinoma (SCC), because of perceptions that esophagectomy offers an unclear survival advantage. We compare recurrence, overall survival (OS), and disease-free survival (DFS) in patients treated with definitive CRT or neoadjuvant CRT followed by surgery (trimodality).

METHODS

This was a retrospective cohort study of patients with stage II and III SCC of the middle and distal esophagus in patients who completed CRT. Treatment groups were matched (1:1) on covariates using a propensity score-matching approach. The effect of trimodality treatment, compared with definitive CRT, on OS, DFS, and site-specific recurrence was evaluated as a time-dependent variable and analyzed using Cox regression with a gamma frailty term for matched units.

RESULTS

We included 232 patients treated between 2000 and 2016: 124 (53%) with definitive CRT and 108 (47%) with trimodality. Trimodality was used less frequently over time (61% before 2009 and 29% after 2009; P < .0001). After matching, each group contained 56 patients. Median OS and DFS were 3.1 and 1.8 years for trimodality versus 2.3 and 1.0 years for CRT. Surgery was independently associated with improved OS (hazard ratio, 0.57; 95% confidence interval, 0.34-0.97; P = .039) and DFS (hazard ratio, 0.51; 95% confidence interval, 0.32-0.83; P = .007).

CONCLUSIONS

CRT followed by surgery might decrease local recurrence and increase DFS and OS in patients with esophageal SCC. Until better tools to select patients with pathological complete response are available, surgery should remain an integral component of the treatment of locally advanced esophageal SCC.

Surgical Management of Early-Stage Esophageal Adenocarcinoma Based on Lymph Node Metastasis Risk

BACKGROUND

In early-stage esophageal adenocarcinoma (EAC), esophagectomy improves staging but also increases mortality compared with endoscopic resection. Our objective was to quantify esophagectomy mortality and lymph node metastasis (LNM) risk in early-stage EAC to improve surgical treatment allocation.

METHODS

We identified National Cancer Database (2004-2014) patients with nonmetastatic, Tis, T1a, or T1b EAC who had primary surgical resection and microscopic examination of at least 15 lymph nodes. Univariate and multivariable logistic regression identified predictors of LNM. Cox regression identified predictors of death. The Kaplan-Meier method predicted overall survival (OS).

RESULTS

In 782 patients, LNM rates were: all patients 13.8%, Tis 0%, T1a 3.6%, T1b 23.4%. Independent predictors of LNM were submucosal invasion, lymphovascular invasion (LVI), decreasing differentiation, and tumor size ≥ 2 cm (P < 0.05). For T1a tumors with poor differentiation or size ≥ 2 cm, LNM rates were 10.2 and 6.7%, respectively; 90-day mortality was 3.1%. The LNM rate in well differentiated T1b tumors < 2 cm was 4.2%; 90-day mortality was 6.0%. Estimated 5-year OS was 80.2% versus 64.4% (T1a vs. T1b). LNM increased risk of death for T1a (hazard ratio [HR] 8.52, 95% confidence interval [CI] 3.13-23.22, P < 0.001) and T1b tumors (HR 2.52, 95% CI 1.59-4.00, P < 0.001).

CONCLUSIONS

In T1a EAC with poor differentiation or size ≥ 2 cm, esophagectomy should be considered, whereas in T1b EAC with low-risk features (well-differentiated T1b EAC < 2 cm without LVI), endoscopic resection may be sufficient. Treatment guidelines for early-stage EAC should include all high-risk tumor features for LNM and stage-specific esophagectomy mortality.

Are Thoracotomy and/or Intrathoracic Anastomosis Still Predictors of Postoperative Mortality After Esophageal Cancer Surgery?: A Nationwide Study

BACKGROUND

Intrathoracic (vs cervical) anastomosis and a thoracotomy (vs absence) have previously been associated with increasing postoperative mortality (POM). Recent improvements in surgical practices and perioperative management may have changed these dogmas.

OBJECTIVES

The aim of this study was to evaluate the impact of performing intrathoracic anastomosis and/or thoracotomy on POM after esophageal cancer surgery in recent years.

METHODS

All consecutive patients who underwent esophageal cancer surgery with reconstruction between 2010 and 2012 in France were included (n = 3286). Patients with a thoracoscopic approach were excluded (n = 4). We compared 30-day POM between patients having received intrathoracic (vs cervical) anastomosis and between those having received a thoracotomy or not. Multivariate analyses and propensity score matching were used to adjust for confounding factors.

RESULTS

Patients had either cervical (n = 548) or intrathoracic (n = 2738) anastomosis. Thirty-day POM was higher after cervical anastomosis (8.8% vs 4.9%, P < 0.001). Having received a thoracotomy (n = 3061) was associated with a decreased risk of 30-day POM (5.3% vs 9.3%, P = 0.011). After adjustment for confounding factors, cervical anastomosis was associated with 30-day POM [odds ratio (OR) 1.71; 95% confidence interval (CI) 1.05-2.77); P = 0.032], whereas performing a thoracotomy was not associated with 30-day POM (OR 0.97; 95% CI 0.51-1.84; P = 0.926).

CONCLUSIONS

Nowadays, intrathoracic anastomosis provides a lower 30-day POM rate compared to cervical anastomosis, and performing a thoracotomy is not associated with POM. Systematic anastomosis neck placement or thoracotomy avoidance is not a relevant argument anymore to decrease POM.

Traveling to a High-volume Center is Associated With Improved Survival for Patients With Esophageal Cancer

BACKGROUND

An association between volume and outcomes has been observed for esophagectomy, though little is known about why or how patients choose low- or high-volume centers. The purpose of this study was to evaluate how travel burden and hospital volume influence treatment and outcomes of patients with locally advanced esophageal cancer.

METHODS

Predictors of receiving esophagectomy for patients with T1-3N1M0 mid or distal esophageal cancer in the National Cancer Data Base from 2006 to 2011 were identified using multivariable logistic regression. Survival was compared using propensity score-matched groups: patients in the bottom quartile of travel distance who underwent treatment at low-volume facilities (Local) and patients in the top quartile of travel distance who underwent treatment at high-volume facilities (Travel).

RESULTS

Of 4979 patients who met inclusion criteria, we identified 867 Local patients who traveled 2.7 [interquartile range (IQR): 1.6-4 miles] miles to centers that treated 2.6 (IQR: 1.9-3.3) esophageal cancers per year, and 317 Travel patients who traveled 107.1 (IQR: 65-247) miles to centers treating 31.9 (IQR: 30.9-38.5) cases. Travel patients were more likely to undergo esophagectomy (67.8% vs 42.9%, P < 0.001) and had significantly better 5-year survival (39.8% vs 20.6%, P < 0.001) than Local patients.

CONCLUSIONS

Patients who travel longer distances to high-volume centers have significantly different treatment and better outcomes than patients who stay close to home at low-volume centers. Strategies that support patient travel for treatment at high-volume centers may improve esophageal cancer outcomes.

Specific gene expression profiles are associated with a pathologic complete response to neoadjuvant therapy in esophageal adenocarcinoma

BACKGROUND

Predicting treatment response to chemo-radiotherapy (CRT) in esophageal cancer remains an unrealized goal despite studies linking constellations of genes to prognosis. We aimed to determine if specific expression profiles are associated with pathologic complete response (pCR) after neoadjuvant CRT.

METHODS

Eleven genes previously associated with esophageal cancer prognosis were identified. Esophageal adenocarcinoma (EAC) patients treated with neoadjuvant CRT and esophagectomy were included. Patients were classified into two groups: pCR and no-or-incomplete response (NR). Polymerase chain reaction was used to evaluate gene expression. Omnibus testing was applied to overall gene expression differences between groups, and log-rank tests compared individual genes.

RESULTS

Eleven pCR and eighteen NR patients were analyzed. Combined expression profiles were significantly different between pCR and NR groups (p < 0.01). The gene CCL28 was over-expressed in pCR patients (Log-HR: 1.53, 95%CI: 0.46-2.59, p = 0.005), and DKK3 was under-expressed in pCR (Log-HR: -1.03 95%CI: -1.97, -0.10, p = 0.031).

CONCLUSION

EAC tumors that demonstrated a pCR have genetic profiles that are significantly different from typical NR profiles. The genes CCL28 and DKK3 are potential predictors of treatment response.

Meta-analysis of Transhiatal Esophagectomy in carcinoma of esophagogastric junction, does it have an advantage?

PURPOSE

Compare the clinical outcome of Transhiatal Esophagectomy (THE) approach and open Thoracic Esophagectomy (TTE) approach in the carcinoma of esophagogastric junction (CEGJ).

METHODS

Relevant literature published until 2016 from PubMed, Cochrane Library, Ovid (Medline) and EMBASE were retrieved. Meta-analysis was achieved by using the Stata12 software.

RESULTS

A total of 18 studies and 2202 cases of patients were involved in this meta-analysis. THE showed to decrease the hospital stay, hospital mortality, surgical time, and blood loss in the operation. However, fewer lymph nodes would be yielded by this surgical option. A 5-year survival advantage of THE was only observed in North America subgroup.

CONCLUSIONS

Except the above operative related advantages, there was no clear evidence that THE has a further advantage in CEGJ.

Perioperative blood transfusions increases the risk of anastomotic leakage after surgery for GEJ-cancer

OBJECTIVE

To investigate the effect of blood transfusions on the risk of anastomotic leakage (AL) in patients with gastro-esophageal-junction (GEJ) cancer.

BACKGROUND

The incidence of GEJ cancer is increasing in the western world. Surgery is the curative treatment of choice. AL increases mortality and morbidity, and increases the risk cancer reoccurrence. In colo-rectal surgery a relation between AL and blood transfusions have been demonstrated.

METHOD

The risk of AL in relation to blood transfusions was investigated in a cohort study. 253 consecutive patients undergoing surgery for GEJ cancer was included. Data was based on a prospective maintained database and analyzed using logistic regressions models adjusting for multiple confounders.

RESULTS

We found an increased risk of AL when blood was transfused OR: 3.47, (1.51; 7.99). This relation was consistent after adjustment for multiple confounders OR: 4.60, (1.29; 16.4). Increasing number of blood units did not increase risk of AL further.

CONCLUSION

We present data demonstrating a strong correlation between receiving blood transfusions and the risk of AL after surgery in GEJ cancers patients.

Esophageal Cancer Treatment Is Underutilized Among Elderly Patients in the USA

OBJECTIVES

Large numbers of elderly patients in the USA receive no treatment for esophageal cancer, despite evidence that multimodality treatment can increase survival. Our goal is to identify factors that may contribute to lack of treatment.

MATERIALS AND METHODS

Using Surveillance Epidemiology and End Results (SEER)-Medicare Linked Database (2001-2009), we identified regional esophageal cancer patients ≥65 years old. Treatment was defined as receiving any medical or surgical therapy for esophageal cancer. Logistic regression analysis was performed to identify factors associated with failure to receive treatment. Overall survival (OS) was analyzed using the Kaplan-Meier method and Cox proportional hazard model.

RESULTS

There were 5072 patients (median age, 75 years; interquartile range (IQR), 71-81 years). Majority were treated with definitive chemoradiation (48.49 %). Factors associated with lack of treatment included West geographic region and ≥80 years old. Patients who received therapy had better OS (log-rank, p < 0.001). Compared with treated patients, non-treated patients had worse adjusted OS (HR, 1.43; 95 % confidence interval (CI), 1.33-1.55; p < 0.001).

CONCLUSIONS

Elderly patients with locally advanced esophageal cancer who received treatment had improved 5-year survival compared with patients without treatment. Disparities in utilization of treatment are associated with regional and socioeconomic factors, not presence of comorbidities.

Patient Selection for Oesophagectomy: Impact of Age and Comorbidities on Outcome

INTRODUCTION

Surgical resection of oesophageal cancer is a major procedure with potential for significant morbidity and mortality. Patient selection can be challenging, as operative benefit must be balanced against risk and impact on quality of life. This study defines modern trends in patient selection, and evaluates the impact of age, stage, and comorbidities on complications and survival following oesophagectomy, in a tertiary Australian experience.

METHODS

Data were compiled across two 15-year operative eras ('Era 1': 1981-1995; and 'Era 2': 1996-2010), with patients followed minimum 3 years. A total of 180 unselected records were analysed (powered for a relative hazard ratio of 0.5). Analyses defined patient selection trends, and for Era 2, the impact of age, comorbidities (Charlson score), and disease (T/N stage) on complications (Clavien-Dindo grade) and survival (Kaplan-Meier). A further sub-analysis was conducted with data divided into three 10-year periods.

RESULTS

The age of operated patients increased from Era 1 to 2 (mean+5 years; P<0.001), but survival and complication rates were unchanged, including in patients≥75 years (P>0.5). In Era 2, reflecting recent practice, survival duration matched T/N stage (P<0.001) but was independent of age at surgery (P=0.56) and comorbidity score (P=0.78). However, grade of worst post-operative complication, including death (rate: 3.8%), was correlated with both age (P<0.01) and comorbidity score (P<0.01).

DISCUSSION

Older patients are now undergoing oesophagectomy. However, if they are selected appropriately, then older patients and those with comorbidities can expect similar stage-matched survival outcomes to younger fitter patients, despite their higher operative risk. Poor outcomes persist in patients with locally advanced disease, and selection in this group should prioritise quality of life.

Transthoracic versus transhiatal resection for esophageal adenocarcinoma of the lower esophagus: A value-based comparison

BACKGROUND AND OBJECTIVE

Our objective was to compare clinical outcomes, costs, and resource use based on operative approach, transthoracic (TT) or transhiatal (TH), for resection of esophageal cancer.

METHODS

This cohort analysis utilized the Surveillance, Epidemiology, and End Results--Medicare linked data from 2002 to 2009. Only adenocarcinomas of the lower esophagus were examined to minimize confounding. Medicare data was used to determine episode of care costs and resource use. Propensity score matching was used to control for identified confounders. Kaplan-Meier method and Cox-proportional hazard modeling were used to compare long-term survival.

RESULTS

537 TT and 405 TH resections were identified. TT and TH esophagectomy had similar complication rates (46.7% vs. 50.8%), operative mortality (7.9% vs 7.1%), and 90 days readmission rates (30.5% vs. 32.5%). However, TH was associated with shorter length of stay (11.5 vs. 13.0 days, P = 0.006) and nearly $1,000 lower cost of initial hospitalization (P = 0.03). No difference in 5-year survival was identified (33.5% vs. 36%, P = 0.75).

CONCLUSIONS

TH esophagectomy was associated with lower costs and shorter length of stay in an elderly Medicare population, with similar clinical outcomes to TT. The TH approach to esophagectomy for distal esophageal adenocarcinoma may, therefore, provide greater value (quality/cost).

Fluid administration and morbidity in transhiatal esophagectomy

BACKGROUND

Esophagectomy is associated with significant morbidity. Optimizing perioperative fluid administration is one potential strategy to mitigate morbidity. We sought to investigate the relationship of intraoperative fluid (IOF) administration to outcomes in patients undergoing transhiatal esophagectomy with particular attention to malnourished patients, who may be more susceptible to the effects of fluid overload.

MATERIAL AND METHODS

Patients who underwent transhiatal esophagectomy from 2000-2013 were identified from a retrospective database. IOF rates (mL/kg/hr) were determined and their relationship to outcomes compared. To examine the impact of malnutrition, we stratified patients based on median preoperative serum albumin and compared outcomes.

RESULTS AND DISCUSSION

211 patients comprised the cohort. 74% of patients underwent esophagectomy for esophageal adenocarcinoma. Linear regression analyses were performed comparing independent perioperative variables to four outcomes variables: length of stay, complications per patient, major complications, and Clavien-Dindo classification. IOF rate was significantly associated with three of four outcomes on univariate analysis. Significantly more patients with a preoperative albumin level ≤3.7 g/dL who received more than the median IOF rate experienced more severe complications.

CONCLUSIONS

Increased intraoperative fluid administration is associated with perioperative morbidity in patients undergoing transhiatal esophagectomy. Patients with lower preoperative albumin levels may be particularly sensitive to the effects of volume overload.

Radical lymphadenectomy in esophageal cancer: from the past to the present

Lymphadenectomy as an essential part of the surgical treatment has been one of the most controversial aspects in the management of esophageal cancers. The purpose of this article was to review the evolution, the current role, and the optimal extent of lymphadenectomy for the treatment of esophageal cancers. Studies discussing the outcome of esophagectomy with lymph nodes dissection and comparing among different extent of lymphadenectomy were used in the analysis. Several studies including recently published articles reveal that additional radical lymphadenectomy may be beneficial in some patients with non-extreme esophageal cancer undergoing esophagectomy, whereas two-field lymph node dissection is suitable for distal esophageal cancers regardless of the histology of the tumor. Minimally invasive surgery and neoadjuvant therapy combined with radical surgery seem to show more benefit in selected cases, but further studies should be required to clearly demonstrate their efficacy and safety. The expertise and experience of the surgeons should also be taken into account in determining the success of these radical procedures.

Treatment modalities for T1N0 esophageal cancers: a comparative analysis of local therapy versus surgical resection

BACKGROUND

To investigate the role of nonsurgical treatment for early-stage esophageal cancer, we compared the outcomes of local therapy to esophagectomy, using a large, national database.

METHODS

Five-year cancer-specific and overall survival (OS) of patients, with T1N0M0 squamous cell or adenocarcinoma of the mid or distal esophagus treated with either surgery or local therapy, with ablative and/or excision techniques, in the Surveillance Epidemiology and End Results cancer registry from 1998 to 2008, were compared using the Kaplan-Meier approach, and multivariable and propensity-score adjusted Cox proportional hazard, and competing risk models.

RESULTS

Of 1458 patients with T1N0 esophageal cancer, 1204 (83%) had surgery and 254 (17%) had local therapy only. The use of local therapy increased significantly from 8.1% in 1998 to 24.1% in 2008 (p < 0.001). The 5-year OS after local excisional therapy and surgery was not significantly different (55.5% versus 64.1% respectively, p = 0.07), and 5-year cancer-specific survival (CSS) also did not differ (81.7% versus 75.8%, p = 0.10). However, after propensity-score adjustment, CSS was better for patients who underwent local therapy compared with those who underwent surgery (hazard ratio: 0.46, 95% confidence interval: 0.27-0.77, p = 0.003), whereas OS remained similar.

CONCLUSION

The use of local therapy for T1N0 esophageal cancers increased significantly from 1998 to 2008. Compared with those treated with esophagectomy, patients treated with local therapy had similar OS but improved CSS, indicating a higher chance of dying from other causes. Further studies are needed to confirm the oncologic efficacy of local therapy when used in patients whose lifespans are not limited by conditions other than esophageal cancer.

Impact of pretreatment imaging on survival of esophagectomy after induction therapy for esophageal cancer: who should be given the benefit of the doubt?: esophagectomy outcomes of patients with suspicious metastatic lesions

PURPOSE

We examined survival of patients who underwent esophagectomy for locally advanced esophageal cancer with foci that were suspicious for metastatic disease on initial imaging but whose disease did not progress after induction chemoradiation treatment (CRT).

METHODS

The impact of pre- and posttherapy staging characteristics on survival of patients who underwent esophagectomy after CRT between 2003 and 2009 was evaluated using multivariable logistic regression. Survival of patients with and without possible metastatic disease on initial imaging was compared with the log-rank test.

RESULTS

During the study period, 71 (32%) of 220 patients who underwent CRT followed by esophagectomy had possible distant metastatic disease on initial imaging. Patients with initial suspicion of metastases had a 5-year survival of 24.8%. Overall survival of patients with and without possible metastatic disease on initial imaging was not significantly different (p = 0.4), but pretreatment positron emission tomography (PET) suggesting a liver lesion (hazard ratio [HR] 3.2, p = 0.003) predicted worse survival. Additional predictors of worse survival were clinical T4 status (HR 3.1, p = 0.001), post-CRT pathologic nodal status (HR 1.6, p = 0.04), and pathologically confirmed metastatic disease at or before resection (HR 3.1, p = 0.01). None of 10 patients with pathologic metastatic disease at resection lived longer than 2.5 years.

CONCLUSIONS

Patients with possible liver metastases on pretreatment PET and patients with confirmed metastatic disease at the time of surgery do not benefit from resection. However, patients with pretreatment imaging that shows possible metastatic disease in sites other than the liver still have reasonable long-term survival after resection.

Trends and outcomes in the use of surgery and radiation for the treatment of locally advanced esophageal cancer: a propensity score adjusted analysis of the surveillance, epidemiology, and end results registry from 1998 to 2008

We examined outcomes and trends in surgery and radiation use for patients with locally advanced esophageal cancer, for whom optimal treatment isn't clear. Trends in surgery and radiation for patients with T1-T3N1M0 squamous cell or adenocarcinoma of the mid or distal esophagus in the Surveillance, Epidemiology, and End Results database from 1998 to 2008 were analyzed using generalized linear models including year as predictor; Surveillance, Epidemiology, and End Results doesn't record chemotherapy data. Local treatment was unimodal if patients had only surgery or radiation and bimodal if they had both. Five-year cancer-specific survival (CSS) and overall survival (OS) were analyzed using propensity-score adjusted Cox proportional-hazard models. Overall 5-year survival for the 3295 patients identified (mean age 65.1 years, standard deviation 11.0) was 18.9% (95% confidence interval: 17.3-20.7). Local treatment was bimodal for 1274 (38.7%) and unimodal for 2021 (61.3%) patients; 1325 (40.2%) had radiation alone and 696 (21.1%) underwent only surgery. The use of bimodal therapy (32.8-42.5%, P = 0.01) and radiation alone (29.3-44.5%, P < 0.001) increased significantly from 1998 to 2008. Bimodal therapy predicted improved CSS (hazard ratios [HR]: 0.68, P < 0.001) and OS (HR: 0.58, P < 0.001) compared with unimodal therapy. For the first 7 months (before survival curve crossing), CSS after radiation therapy alone was similar to surgery alone (HR: 0.86, P = 0.12) while OS was worse for surgery only (HR: 0.70, P = 0.001). However, worse CSS (HR: 1.43, P < 0.001) and OS (HR: 1.46, P < 0.001) after that initial timeframe were found for radiation therapy only. The use of radiation to treat locally advanced mid and distal esophageal cancers increased from 1998 to 2008. Survival was best when both surgery and radiation were used.

Esophageal cancer: staging system and guidelines for staging and treatment

Survival of esophageal cancer is improving but remains poor. Esophageal cancer stage is based on depth of tumor invasion, involvement of regional lymph nodes, and the presence or absence of metastatic disease. Appropriate work-up is critical to identify accurate pre-treatment staging so that both under-treatment and unnecessary treatment is avoided. Treatment strategy should follow guideline recommendations, and generally should be developed after multidisciplinary evaluation.

Surgical indications and optimization of patients for resectable esophageal malignancies

Esophageal cancer is a devastating diagnosis with very dire long-term survival rates. This is largely due to its rather insidious progression, which leads to most patients being diagnosed with advanced disease. Recently, however, a greater understanding of the pathogenesis of esophageal malignancies has afforded surgeons and oncologists with new opportunities for intervention and management. Coupled with improvements in imaging, staging, and medical therapies, surgeons have continued to enhance their knowledge of the nuances of esophageal resection, which has resulted in the development of minimally invasive approaches with similar overall oncologic outcomes. This marriage of more efficacious induction therapy and diminished morbidity after esophagectomy offers new promise to patients diagnosed with this aggressive form of cancer. The following review will highlight these most recent advances and will offer insight into our own approach to patients with resectable esophageal malignancy.

Usefulness of stroke volume index obtained with the FloTrac/ Vigileo system for the prediction of acute kidney injury after radical esophagectomy

PURPOSE

To assess the impact of stroke volume index (SVI) at the end of esophagectomy upon postoperative renal function.

METHODS

We reviewed medical records of 128 patients undergoing esophagectomy. Intraoperative hemodynamics were monitored with the FloTrac sensor/Vigileo monitor system in addition to standard monitors. Patients were divided into two groups according to SVI at the end of surgery: the normal SVI group (n = 76), with SVI ≥ 35 ml/m2, and the low SVI group (n = 52), with SVI<35 ml/m2. We compared postoperative renal function, indicated by serum creatinine and estimated glomerular filtration rate, on post-operative days 0 through 3. We also compared numbers of patients who developed postoperative acute kidney injury (AKI).

RESULTS

Although there were no intergroup differences in preoperative renal function or other intraoperative hemodynamic variables, including arterial pressure, central venous pressure, stroke volume variation, a volume of infusion, urine output, and the total intraoperative in-out balance, estimated glomerular filtration rate was significantly lower and serum creatinine was significantly higher in the low SVI group than in the normal SVI group on postoperative days 1 and 2 (P<0.05). In addition, more patients developed postoperative AKI in the low SVI group than in the normal SVI group (12 of 52 vs. 5 of 76, P = 0.015).

CONCLUSIONS

Low SVI at the end of esophagectomy may represent a risk factor for AKI in the early postoperative period. Further studies are required to examine whether maintaining SVI above 35 ml/m2 reduces the incidence of AKI after esophagectomy.

Update on clinical impact, documentation, and management of complications associated with esophagectomy

The assessment and monitoring of complications associated with esophageal resection suffers from the absence of an internationally recognized system for documenting the incidence and severity of complications. The impact of complications is significant, with direct effects being identified on mortality, length of stay, postoperative quality of life, and long-term survival. Newer systems of assessing surgical complication severity and the resources required to treat complications include the Accordion and Clavien grading systems. New endoscopic and interventional approaches to treating anastomotic leak and stricture and chyle leak can selectively decrease length of stay and costs of managing complications.

Barrett's esophagus: cancer and molecular biology

The following paper on the molecular biology of Barrett's esophagus (BE) includes commentaries on signaling pathways central to the development of BE including Hh, NF-κB, and IL-6/STAT3; surgical approaches for esophagectomy and classification of lesions by appropriate therapy; the debate over the merits of minimally invasive esophagectomy versus open surgery; outcomes for patients with pharyngolaryngoesophagectomy; the applications of neoadjuvant chemotherapy and chemoradiotherapy; animal models examining the surgical models of BE and esophageal adenocarcinoma; the roles of various morphogens and Cdx2 in BE; and the use of in vitro BE models for chemoprevention studies.

Predictors of anastomotic leak after esophagectomy: an analysis of the society of thoracic surgeons general thoracic database

BACKGROUND

Anastomotic leak is an important cause of morbidity and mortality after esophagectomy. Few studies have targeted risk factors for the development of leak after esophagectomy. The purpose of this study is to use The Society of Thoracic Surgeons Database to identify variables associated with leak after esophagectomy.

METHODS

The Society of Thoracic Surgeons Database was queried for patients treated with esophagectomy for esophageal cancer between 2001 and 2011. Univariate and multivariate analysis of variables associated with an increased risk anastomotic leak was performed.

RESULTS

There were 7,595 esophagectomies, with 804 (10.6%) leaks. Thirty-day mortality and length of stay were higher for patients with anastomotic leak. Mortality in patients requiring surgical management was 11.6% (38 of 327) compared with 4.4% (20 of 458) in medically managed leaks (p < 0.001). The leak rate was higher in patients with cervical anastomosis compared with those with intrathoracic anastomoses, 12.3% versus 9.3%, respectively (p = 0.006). There was no difference in leak-associated mortality between the two approaches. Factors associated with leak on univariate analysis include obesity, heart failure, coronary disease, vascular disease, hypertension, steroids, diabetes, renal insufficiency, tobacco use, procedure duration greater than 5 hours, and type of procedure (p < 0.05). Multivariable regression analysis associated heart failure, hypertension, renal insufficiency, and type of procedure as risk factors for the development of leak (p < 0.05).

CONCLUSIONS

Anastomotic leak after esophagectomy is an important cause of postoperative mortality and increased length of stay. We have identified important risk factors for the development of esophageal anastomotic leak after esophagectomy. Further studies aimed at risk reduction are warranted.

Prognostic impact of lymph node involvement and the extent of lymphadenectomy (LAD) in adenocarcinoma of the esophagogastric junction (AEG)

BACKGROUND

The prognostic importance of lymph node (LN) involvement for patients with adenocarcinoma of the esophagogastric junction (AEG) is well-known. In the latest edition of the UICC staging system, the number of metastatic LNs was taken into account, while the extent of lymphadenectomy (LAD) remains unaddressed. Removal of at least six LNs is recommended, but there is no defined minimum number as to classify as (y)pN0. We examined the prognostic value of the number of positive LNs, number of LNs removed, and LN ratio (LNR) in order to determine the influence of an adequate LAD on overall survival (OS).

METHODS

We analyzed data of 316 patients with AEG treated in our institution (2001-2011) regarding clinicopathological data, treatment, morbidity, mortality, and long-term prognosis. Univariate and multivariate analysis was performed using Cox regression to evaluate the prognostic impact of(y)pN category, number of LNs removed and LNR.

RESULTS

OS decreased with higher count of positive LNs (p < 0.001) and higher LNR (p < 0.001). Whether >6, >15, or >30 LNs were removed did not influence OS, neither in the entire study population nor within individual (y)pT or (y)pN categories. Multivariate analysis revealed LNR (p < 0.001) besides M category (p = 0.015) and tracheotomy during the postoperative course (p = 0.005) as independent predictors of OS.

CONCLUSION

The classification according to the number of involved LNs in the latest edition of the UICC staging system improves prognostication in patients with AEG. The importance of an adequate LAD is shown by the high prognostic relevance of the LNR rather than the absolute number of LNs removed.

Laparoscopic ischemic conditioning of the stomach prior to esophagectomy

Several complications after esophagectomy with gastric pull-up are associated with ischemia within the gastric conduit. The aim of this study is to assess the feasibility of laparoscopic ischemic preconditioning of the stomach prior to thoracotomy, esophagectomy, and gastric pull-up with an intrathoracic anastomosis. A retrospective review of 24 consecutive patients between October 2008 and July 2011 with esophageal adenocarcinoma (stage I-III) undergoing laparoscopic gastric ischemic conditioning prior to esophagectomy was conducted. Conditioning included laparoscopic ligation of the left and short gastric arteries, celiac node dissection, and jejunostomy tube placement. Formal resection and reconstruction was then performed 4-10 days later. Of the 24 patients, 88% received neoadjuvant chemotherapy/radiation therapy. Twenty-three of the 24 patients underwent successful laparoscopic ischemic conditioning and subsequent esophagectomy. Total mean number of lymph nodes harvested was 21.8 (±8.0), and a mean of 5.3 (±2.4) celiac lymph nodes identified. There were no conversions to an open procedure. Length of stay was 3.8 (±4.8) days with a median length of stay of 2 (1-24) days. Three patients experienced anastomotic leak, six patients experience delayed gastric emptying, and two patients developed anastomotic stricture. There were no surgical site infections. R0 resection was achieved in all patients who underwent laparoscopic ischemic conditioning followed by esophagectomy. Laparoscopic ischemic conditioning of the gastric conduit has been shown to be feasible and safe.

Treatments for esophageal cancer: a review

Esophageal cancer is the eighth most common form of cancer worldwide. The treatments for esophageal cancer depend on its etiology. For mucosal cancer, endoscopic mucosal resection and endoscopic submucosal dissection are standard, while for locally advanced cancer, esophagectomy remains the mainstay. The three most common techniques for thoracic esophagectomy are the transhiatal approach, the Ivor Lewis esophagectomy (right thoracotomy and laparotomy), and the McKeown technique (right thoracotomy followed by laparotomy and neck incision with cervical anastomosis). Surgery for carcinoma of the cervical esophagus requires an extensive procedure with laryngectomy in many cases. When the tumor is more advanced, neoadjuvant chemotherapy or neoadjuvant chemoradiotherapy is added. The theoretical advantages of adding chemotherapy to the treatment of esophageal cancer are potential tumor down-staging prior to surgery, as well as targeting micrometastases and, thus, decreasing the risk of distant metastasis. Cisplatin- and 5-fluorouracil-based regimes are used worldwide. Chemoradiotherapy is the standard for unresectable esophageal cancer and could also be considered as an option for resectable tumors. For patients who are medically or technically inoperable, concurrent chemoradiotherapy should be the standard of care. Although neoadjuvant chemoradiotherapy followed by surgery or salvage surgery after definitive chemoradiotherapy is a practical treatment; judicious patient selection is crucial. It is important to have a thorough understanding of these therapeutic modalities to assist in this endeavor.