**2. Esophageal resection**

adenocarcinoma in Western populations could have been determined by the increase in the

There are two main subtypes of the disease, namely esophageal squamous cell carcinoma and esophageal adenocarcinoma. The most common causes of squamous cell carcinoma are tobacco and alcohol, and the most common causes of adenocarcinoma are tobacco, obesity and acid reflux [5]. There has been a major increase in the incidence of adenocarcinoma in North America and Europe, while squamous cell carcinoma is still the most common type of

The two subtypes of esophageal cancer have different clinical and biological characteristics. While squamous cell carcinomas occur in the middle or upper third of the esophagus, adenocarcinomas occur in the lower third of the esophagus. Abdominal lymph node metastasis is usually present in adenocarcinomas, and the incidence of cervical or upper mediastinal lymph node metastasis is more frequent in squamous cell carcinomas. Thus, the therapeutic

The prognosis of esophageal cancer is quite poor, despite advances in surgical procedures (two-field and three-field lymph node dissection) and perioperative management, which is still controversial [7]. The use of chemotherapy and radiotherapy in combination with surgery might be a new approach for future treatment. Progress in optical technology has led to the development of a new minimally invasive surgical approach for the treatment of esophageal cancer, namely esophagectomy. Long-term survival in resectable esophageal cancer is also influenced by definitive chemoradiotherapy [8]. Salvage esophagectomy is used in patients with esophageal cancer who were treated with chemoradiation as definitive therapy [9].

Although cancer of the esophagus is among the most common cancers in the world, there are few studies on this malignancy. There have been significant changes in the epidemiology of esophageal cancer in the past 30 years, with a striking increase in incidence in Western populations, where the number of adenocarcinomas has exceeded those of the squamous cell type [6]. On the other hand, squamous cell carcinoma is the most frequent subtype in Asian countries, mainly developing in the middle third of the esophagus, without any dramatic increase in the incidence of adenocarcinoma on this continent. New diagnostic, staging, and

Early stage adenocarcinoma of the esophagogastric junction (AEG) could be detected based on efficient screening for gastroesophageal reflux disease (GERD) and Barrett's metaplasia,

The infection with *Helicobacter pylori* harboring the cagA gene seems to be associated with a

The potential role of COX-2 inhibitors in the effective chemoprevention of esophageal adenocarcinoma, characterized by COX-2 overexpression, is another aspect to be considered [13]. The types of surgery for cancer of the esophagus are divided based on the complex lymphatic

therapeutic options have improved survival rates for esophageal cancer.

which might be cured using endoscopic ablation or surgery [10].

drainage from the esophagus and gastric cardia and their anatomy.

reduced risk of esophageal adenocarcinoma [11, 12].

incidence of obesity and obesity-induced reflux [4, 5].

esophageal cancer in Asia [6].

22 Esophageal Abnormalities

approach is different for each subtype [7].

Hulscher et al. conducted a meta-analysis and obtained a 20% 5-year survival rate [14] following any of the two approaches. However, there were much higher rates of early morbidity and mortality in the case of transthoracic resection. On the other hand, in another study conducted by Hagen et al. [15], better survival rates (41% vs. 14%; p < 0.001) were obtained in 30 patients following en bloc esophagectomy compared with 39 patients undergoing transhiatal esophagectomy, suggesting the use of extended en bloc esophagectomy instead of transhiatal resection in the case of carcinoma of the lower third of the esophagus and gastric cardia [15].

Outcomes in esophageal cancer are often poor [16]. The best and most efficient surgical method in patients without evidence of spread to other parts of the body is the combination between esophagectomy and reconstruction surgery [7]. There are three more frequent minimally invasive techniques for esophagectomy: transhiatal esophagectomy, the Ivor Lewis esophagectomy (upper midline laparotomy combined with a right posterolateral thoracotomy), and the McKeown technique (right thoracotomy, upper midline laparotomy, and left neck incision). Several randomized trials compared transhiatal esophagectomy and standard transthoracic esophagectomy, showing no significant differences between them. The differences between transthoracic and transhiatal esophagectomy were examined in three randomized trials [17–21]. The results of these clinical trials showed no significant differences between the two approaches in what concerns patient survival. Hulscher et al. [22] conducted a randomized trial in patients with adenocarcinoma of the esophagus and gastric cardia (106 patients with transhiatal esophagectomy and 114 with transthoracic esophagectomy). There were lower morbidity rates in the case of transhiatal esophagectomy than in transthoracic esophagectomy with extended en bloc lymph node dissection. Despite the absence of statistically significant differences in terms of disease-free, median overall, and quality-adjusted survival, there was an improvement in long-term survival of patients with extended transthoracic resection. Asia, especially Japan, accounts for the majority of the more aggressive surgery records. Five-year survival rates following three-field lymph node dissection were 48.7% in a study conducted by Kato et al. [23] and 55.0% in a study by Akiyama et al. [24].

Esophagectomy can be either transhiatal or transthoracic, performed using the Ivor Lewis technique (combined laparotomy and right thoracotomy) and the modified McKeown procedure, involving laparotomy, right thoracotomy with neck anastomosis, left thoracotomy, or left thoracoabdominal incision [25]. The approach is chosen depending on tumor location and surgeon preferences. Good treatment outcomes result from the complexity of these surgical procedures, the experience of the surgeons, and intensive care resources [26].

A comprehensive randomized study assessing the differences between the transthoracic and the transhiatal approach indicated similar mortality rates for both procedures, whereas morbidity rates were lower for the transhiatal approach. The transthoracic group showed non-significant associations between this procedure and overall and disease-free survival. However, there was an improvement in locoregional disease-free survival following transthoracic esophagectomy in a subgroup of patients who did not present extensive nodal involvement [27].

Long-term survival rates following open esophagectomy do not differ significantly when comparing these surgical procedures, as shown by various meta-analyses and randomized trials [28]. In their study, Tabira et al. [29] recommended the use of three-field lymph node dissection in patients with one to four lymph node metastases. As indicated by Shiozaki et al. [30], neck dissection might be eliminated in patients with carcinoma in the middle or lower third of the esophagus without lymph node metastasis along the recurrent nerve chain. Lerut et al. [31] also proved an improvement in patient survival following three-field lymph node dissection.

When comparing three-field with two-field lymph node dissection for squamous cell carcinoma of the esophagus, Kato et al. obtained 5-year survival rates of 48.7% for the first approach and 33.7% for the second. However, this study was contested due to differences in patient characteristics. Isono et al. [32] conducted a nationwide study and obtained better survival rates when using three-field dissection instead of the two-field approach. Fujita et al. [33] also presented much better survival rates following three-field lymph node dissection (p < 0.05) for carcinoma in the upper or middle third of the esophagus spreading to the lymph nodes. Still, there were no differences in mortality, morbidity, and postoperative quality of life between the two approaches [33]. Radical esophagectomy helps remove ≥80 lymph nodes and 5-year survival rates are around 40–60% [34].
