An appropriate esophagectomy for esophageal cancer: a lack of evidence and a growing disparity between Western and Eastern standards.

Definitive chemoradiotherapy has been demonstrated to offer a chance of cure for esophageal cancer as often as a radical esophagectomy. However, it is generally accepted that an esophagectomy remains the mainstay of treatment for patients with resectable esophageal cancer, while chemoradiotherapy is the standard for patients with medically inoperable or surgically unresectable esophageal cancer. The mortality rates and the 5-year survival rates after an esophagectomy were 29% and 4%, respectively, in an early extensive reviews involving 122 English papers on esophageal cancer surgery published between 1960 and 1979. The respective rates have improved to 6.7% and 27.9% in the most recent systematic reviews involving 312 papers published between 1990 and 2000. The overall survival at 5 years was 36.1% after esophagectomy in 11,642 patients between 1988 and 1997 in Japan. A 3-field lymphadenectomy involving the 3 anatomical compartments of the neck, mediastinum, and abdomen was introduced as an important component of a curative esophageal resection in the early 1980s in Japan, and has been reported to be effective for improving not only the staging accuracy, but also the long-term survival in patients with esophageal cancer, with the average 5-year survival rate being 40 to 60%. At present, 63% of all Japanese patients with esophageal cancer undergo an esophagectomy. Of these patients undergoing surgery, a 3-field and a conventional 2-field lymphadenectomy is performed in 35% and 33%, respectively. Alternatively, a transhiatal esophagectomy without a systematic lymphadenectomy has become one of the preferred types of surgery for patients with esophageal cancer in Western countries. An Appropriate Esophagectomy for Esophageal Cancer: A Lack of Evidence and a Growing Disparity between Western and Eastern Standards