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BACKGROUND

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“The history of esophageal surgery is the tale of men repeatedly losing to a stronger adversary yet persisting in this unequal struggle until the nature of the problems became apparent and the war was won.1’’

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The evolution of esophagectomy techniques has been wrought with challenges that have demanded resilience on the part of both surgeons and their patients. Beginning with the first successful esophagectomy by Torek in 1913, a variety of open approaches, esophageal substitutes, and anastomotic techniques have evolved from decades of wrestling with the principal challenges with esophagectomy outcomes: (1) low 5-year survival rates (approximately 20% in some series), (2) high perioperative mortality rates (which can exceed 20%),2 and (3) high morbidity rates (which can exceed 50%).3

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The advent of minimally invasive surgery paved the way for foregut surgeons to explore the potential benefit of a minimally invasive esophagectomy (MIE) to reduce the morbidity of laparotomies and thoracotomies without compromising oncologic outcomes.

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EPIDEMIOLOGY

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Esophageal carcinoma is the eighth most common cancer worldwide. In 2008, the estimated worldwide incidence was 484,000.4 Although esophageal squamous cell carcinoma remains the preponderate histological subtype worldwide, esophageal adenocarcinoma has become the predominant histological subtype in many Western countries. In fact, the incidence of esophageal adenocarinoma is rising at an epidemic rate in the United States. Since 1975, the incidence of esophageal adenocarcinoma in the United States has risen more than sixfold, faster than any other malignancy.5 The risk factors for, pathology of, and the surgical approach to these two most common histological subtypes are distinct.

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A number of potential risk factors have been reported for squamous cell carcinoma of the esophagus (Table 88-1).6-9 The importance of each of these risk factors varies across geographic regions, based on cultural and environmental factors. In the United States, it has been estimated that alcohol and smoking (which have a synergistic effect on one another) and diets low in fruits and vegetables account for 90% of cases.10 In contrast, alcohol consumption is rare in the high incident region of Northern China and therefore is not a significant risk factor.8 Unique dietary factors (i.e., nitrate consumption in smoked and pickled foods, mycotoxin contamination of food products, vitamin and mineral deficiencies ([i.e., vitamins A, B2, C, and E; selenium, zinc, and calcium] in underdeveloped countries, betel quid consumption in Southeast Asia, mate consumption in South America, etc.) play a more important role in particular regions outside of the United States.7,8

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Table Graphic Jump Location
TABLE 88-1:

Risk Factors for Esophageal Carcinoma

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