Esophageal cancer is a treatable disease, but it is rarely curable. Approximately 16,470 new cases of esophageal cancer were diagnosed in the United States in 2009, and more than 14,500 patients died that year. Patients with early stages of the disease have a better chance of survival. Most esophageal cancers are either adenocarcinoma or squamous cell carcinoma.

• Squamous Cell Carcinoma The esophagus is normally lined with squamous cells. The cancer starting in these cells is called squamous cell carcinoma and can occur anywhere along the length of the esophagus although it usually affects the upper and middle part of the esophagus. Squamous cell carcinoma is the most common type of esophageal cancer worldwide, however in North America adenocarcinomas which occur in the lower part of the esophagus near the stomach are more predominant.
• Adenocarcinoma This type of cancer develops in glandular tissue and is usually found in the lower part of the esophagus. These type of cells are not normally part of the inner lining of the esophagus. Before an adenocarcinoma can develop, glandular cells must replace an area of squamous cells. Many adenocarcinomas of the esophagus are associated with Barrett's Disease. (LINK TO: http://www.gwhospital.com/Hospital-Services-A-N/Gastroenterology/About-Barrett-s-Disease) Some studies estimate that patients with Barrett's Disease have at least a 30 to 40 times higher risk for developing an invasive adenocarcinoma. These people require close medical monitoring in order to find cancer early. Still, although they have a higher risk, most people with Barrett's esophagus don't go on to develop cancer of the esophagus.

Treatment
As with many cancers, esophageal cancer treatment has a greater chance of success if the cancer is caught early. Unfortunately, by the time most esophageal cancer is diagnosed, it is often already in an advanced state, having spread throughout the esophagus and beyond.

Surgery to remove all or a portion of the esophagus is called an esophagectomy. During this procedure lymph nodes near the esophagus will also be removed. The stage of the tumor and where it is located determine how much of the esophagus and which lymph nodes are removed. The upper part of the esophagus is then re-connected to the stomach which is pulled up into the chest area to replace the missing portion of esophagus. If a cancer is located in the part of the esophagus near the stomach or at the juncture where the esophagus and stomach meet, the surgeon will remove part of the stomach and part of the esophagus containing the cancer.

If the cancer has not yet spread beyond the esophagus, removing the esophagus may be able to cure the cancer.

For others surgery may still be recommended as a palliative measure to help reduce symptoms including trouble with swallowing and make it easier to eat and maintain good nutrition.

Over the past decade the program for esophageal carcinoma has followed the concept of tumor and lymph node removal (en bloc resection of esophageal cancer with extensive periesophageal lymphadenectomy).

• Open esophagectomy: There are different surgical approaches in performing an esophagectomy. The esophagus can be removed via an incision in the chest (transthoracic esophagectomy) or the main incision may be placed in the abdomen (tranhiatal esophagectomy).
• Minimally invasive esophagectomy: In a minimally invasive esophagectomy, portions of the esophagus may be removed through several small incisions instead of 1 or 2 large incisions. During this procedure the surgeon makes small pencil-sized holes in the body while video equipment is used to provide a magnified view of the surgical site. Endoscopic instruments are inserted through the small incisions and used to perform the surgery. A successful minimally invasive esophagectomy allows the patient to leave the hospital sooner and recover faster. This approach is used most often for early and small cancers.

Squamous Cell Carcinoma
Historically the role of surgery in squamous cell carcinoma of the esophagus has been palliative—meant to relieve the pain and difficulty swallowing caused by cancer, and is often used for patients who are in an advanced stage of cancer, or who are near the end of their lives.

Adenocarcinoma
With adenocarcinoma, there has been a shift in the surgical approach from a palliative one to one with curative intent. Recent refinements in operative techniques and peri-operative management have allowed for accomplishing the more efficacious tumor and lymph node removal (en bloc tumor resection and nodal exoneration).

Improvements in the overall survival rates and decrease in operative risk may be attributed to the earlier diagnosis of esophageal carcinoma, refinement of surgical technique and perioperative care and greater use of multi-modality therapy.

Robotic Esophagectomy
During this procedure the surgeon makes small pencil-sized holes in the body while robotic arms and a video camera is inserted to provide a 3-D magnified view of the surgical site. A rotobic esophagectomy allows the patient to leave the hospital sooner and recover faster. This approach is used most often for early and small cancers.

Clinical outcomes
During the first two years of the Robotic program, twenty seven patients underwent robotic esophagogastrectomy (Ivor Lewis technique) with intrathoracic esophagogastrostomy at our institution. A summary of this experience follows:

• Eighteen men, nine women
• Mean age of 67 +/- five years.
• Twenty three of the twenty seven patients had preoperative neoadjuvant therapy.
• The average operating time (mean) was 8.6 hours; with a range of 8-17 hours.
• There were two non-emergent conversions to a thoracotomy due to difficulty with the anastamosis.
• All tumors were in the distal esophagus.
• The average number of nodes was 16 +/- 3.
• The median intensive care unit stay was one day with a range of 1-7 days.
• The median hospitalization was 9 days with a range of 8-12 days.
• There were no anastomotic leaks.
• The major complications was pneumonia in 3% of the patients.
• There were no in-hospital deaths.
• At a median follow-up of 18 months, the overall survival rate was 97%.