En-bloc Esophagectomy—The Three-Field Dissection

Why we fail

The primary argument for the poor results seen in the treatment of esophageal cancer by any modality is the fact that the great majority of patients develop metastatic disease, suggesting that the disease may have already disseminated at the time of diagnosis. Although this is undoubtedly the case in some patients, a careful analysis of the patterns of failure after surgical resection also suggests inadequate local control using current treatment modalities. For example, the locoregional

En-bloc two-field esophagectomy

Standard techniques for esophageal resection, regardless of surgical access (transthoracic versus transhiatal), entail extirpation of the esophagus with its adjoining lymph nodes, without an attempt to perform a thorough lymphadenectomy of the mediastinum and upper abdomen. Additionally, the narrow confines of the posterior mediastinum present a significant challenge to the surgeon in obtaining a wider radial margin of resection, thus limiting the dissection to the esophageal adventitia and

En-bloc three-field esophagectomy

The concept of three-field lymph node dissection for esophageal cancer was developed by Japanese surgeons in the 1980s in response to the observation that as many as 40% of patients who had resected squamous cell esophageal cancer developed isolated cervical lymph node metastases [24]. A nationwide retrospective study was subsequently reported describing the findings and potential benefits of esophagectomy with three-field dissection [25]. The additional third field of dissection included

Surgical procedure

All patients are explored through a right thoracotomy, followed by a laparotomy and cervical incision. In the thorax, the tumor-bearing esophagus is resected en-bloc within an envelope of adjoining tissues that includes both pleural surfaces laterally, the pericardium anteriorly (except in T₁a lesion), and all lymphovascular tissues wedged dorsally between the esophagus and the spine. The thoracic duct is included within the en-bloc resection throughout its course in the posterior mediastinum.

Postoperative care

Patients are cared for in an intensive care unit for 24 hours for fluid management and mechanical ventilation. Separation from mechanical ventilation is usually achieved in most patients by the morning after the procedure. Intense pulmonary hygiene is required, often with repeated bronchoscopy for the first 48 hours after extubation, because most patients develop a variable degree of bronchorrhea, which generally resolves on the third or fourth postoperative day. Oral intake is begun once

Hospital mortality and morbidity

In a previously published series of 80 consecutive patients [27], there were three in-hospital deaths, for a hospital mortality of 3.75%. An additional patient died following discharge from massive hematemasis. The overall 30-day mortality was 5%. Nearly 50% of patients had an eventful postoperative course. Major complications occurred in 31% of patients and are listed in Table 5. Significantly, injury to the recurrent nerve occurred in only 7 patients, and was transient in 4. No patient

Cervical nodal metastases

Twenty-nine patients (36.25%) had metastatic carcinoma in the cervicothoracic nodes, including 3 who also had celiac nodal disease. Thus, dissection of the third field yielded important staging information in 26 patients (32.5%). Metastases involved the right recurrent nodes in 22 patients, the left recurrent nodes in 1, and both groups in 4. Metastases to the deep cervical nodes were present in 4 patients, 2 of whom also had metastases in the recurrent nodes.

The frequency of cervicothoracic

Perspective

There can no longer be any doubt that occult cervical nodal metastases are present in 30% to 40% of patients who undergo a presumably curative surgical resection. This high prevalence of occult residual disease is independent of either cell type or location of the tumor within the esophagus. Additionally, the prevalence of occult cervical nodal disease approaches 50% in those patients who have any mediastinal or abdominal nodal metastases; undoubtedly the great majority of patients. A possible