Ann Thorac Surg 2001;71:1808
© 2001 The Society of Thoracic Surgeons
Invited commentary
Alex G. Little, MDa
a Department of Surgery, University of Nevada School of Medicine, 2040 W Charleston Blvd, #601, Las Vegas, NV 89102, USA
This article succeeds in fulfilling its stated goal of establishing a benchmark for the results of surgical treatment of esophageal carcinoma using an Ivor Lewis esophagectomy technique in all patients. The value of this lies in the authors’ observation that having such a benchmark in patients not receiving any neoadjuvant or preoperative therapy can be used for comparison purposes both for other techniques of esophageal resection and to outcomes in patients receiving multimodality therapy.
The demographics of the patients in this article are representative; most patients were elderly and had adenocarcinoma of the distal esophagus, most had dysphagia, many had lost weight and there are more men than women. Consequently the outcomes in these patients can credibly be compared to the outcomes in the patient population in the typical surgeon’s practice.
Not surprisingly, the Mayo Clinic group has set the bar rather high. The mortality rate is quite low as is the complication rate. As a result, the median hospital stay was only eleven days and there were few serious complications. Of importance, despite the skill of the surgeons as documented by the low morbidity and mortality rates, long term outcome is poor for patients with disease Stages IIB and higher. This is an old message but deserves emphasis; once lymph nodes are involved, cure with surgical therapy alone is unlikely. As referenced in the manuscript, these outcomes are quite similar to those previously reported with other types of operations, such as transhiatal esophagectomy at one end of the aggressiveness spectrum to resections with extensive lymphadenectomy at the other end. This again confirms that long term prognosis is more dependent upon the biology, as reflected by the postoperative stage, of the cancer than the operative technique.
Another implication of this article is that operative and hospital results are dependent to some extent upon the volume of surgery performed by the operating surgeon. Each surgeon in this study appears to have done at least 40 and perhaps 50 esophagectomies over a two-year time span. This suggests, as has been stated before, that patients do best when treated in institutions with relatively high volumes of these challenging operations and complex patients.
Related Article
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Ivor Lewis esophagogastrectomy for esophageal cancer
- Antonio L. Visbal, Mark S. Allen, Daniel L. Miller, Claude Deschamps, Victor F. Trastek, and Peter C. Pairolero
Ann. Thorac. Surg. 2001 71: 1803-1808.
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