Esophageal Cancer Surgery: Lessons

Introduction Two decades ago, cancer of the esophagus in the East and in the West was a squamous cell cancer of the intrathoracic esophagus, situated predominantly in the middle third. Today, in the East, this remains largely unchanged. In the West, however, the disease has become a Barrett’s adenocarcinoma of the distal esophagus, as a consequence of gastroesophageal reflux and dysplasia occurring in specialized intestinal meta plastic epithelium.L 2Indeed, this condition is epidemic in the West and has, like obesity, become a major health issue. Furthermore, while the epidemiology in the East has remained unchanged, in the West, Barrett’s cancer primarily affects the professional middle-age Caucasian, unlike the older blue-collar worker in the past who habituates cigarettes and alcohol. As aware ness increases in the West, the disease is diagnosed at an increasingly early stage and treatment instituted in a more timely manner. In the East, diagnosis still relies on the symptoni of dysphagia which usually indicates advanced disease. Treatment is therefore in many instances palliative, A combination of both the type of patients and the nature of the disease renders the option of treatment to be fundamentally different, which then has an impact on the risks and results of the chosen therapy. By and large, treatment in the East for squamous cell carci noma still mandates a thoracotomy, while in the West, the procedure has increasingly become a transhiatal approach. While it is expected that the mortality and morbidity rates should be lower in the West, this has not been shown to he so and the mortality rate remains at around 10-I 2%.30 In the East, no data comparable to the Veterans Affairs database is available but a survey of 13 hospitals in Hong Kong also revealed a hospital mortality rate of about l0%, Thus esophagectomy is still one of the highest risk procedures whether in the East or West.