The 105 years since the first successful thoracic oesophagectomy was performed saw initially slow progress in terms of operative mortality, morbidity and oncological outcomes. Even until the late 1990’s, operative mortality figures of 15-20% were commonplace and long term survival was poor, as low as 12%1. The last 20 years has seen a major change in these outcomes both within Australia and overseas. These improvements have been based on the bed rocks of improved surgical techniques, improved peri operative care, changes in the distribution of the pathophysiology of the disease, improved patient selection through better staging, Development of endoscopic techniques for early tumours, development of effective neo adjuvant regimes and the development of “high” volume centres have all contributed to the current figures of 4% preoperative mortality and overall 5 year survivals in the post surgical patient of 40%. Better understanding of the nutritional issues involved has led to an emphasis on better quality of life issues in both the curative and palliative settings. This talk outlines the forces that have brought about the changes including outlining the modern treatment algorithm and discussing the volume effects of surgery in the Australian context 1. Earlam R, Cunha-Melo JR. Oesophageal squamous cell carcinoma: I. A critical review of surgery. Br J Surg 1980;67: 381-90

1. Professor Neil Merrett
Discipline of Surgery, School of Medicine Western Sydney University, Sydney, NSW,
Australia
Department of Upper GI Surgery, Bankstown & Liverpool Hospitals
CICM :Sydney May 2017

5. NSW :
17% 5 YEAR SURVIVAL OVERALL
2.6% OF ALL CANCERS
500 CASES PER YEAR
OVERALL NUMBERS UNCHANGED

6. For no field in surgery presented more dangers and
difficulties; in none was the challenge taken up with more
persistent endeavour in the face of repeated failures
Ifor Lewis BJS 1946:34;18-31

7.  Carcinoma of the esophagus is one of the
most difficult malignancies to manage,
principally because of
 its late presentation in an elderly population,
 its unrelenting progression,
 its inaccessible location,
 the inexact preoperative staging,
 and the uncertainty as to the appropriate therapy
.Ifor Lewis

8.  Removal of the diseased organ or part thereof
 Removal of associated regional lymph nodes if
involved
 Reconstruction of the alimentary tract to allow
comfortable food intake
“To cure the disease while rendering the patients life
useful – or at least bearable”
Ifor Lewis Hunterian lecture10/01/1946

9.  Edwin Smith Papyrus:
 Gaping wound of throat penetrating the gullet
 1868: Kussmaul diagnosed tumour with a rigid tube
 1871: Billroth first successful cervical oesophagectomy
in dogs
 1877: Czerny first human cervical oesophageal
segmental resection
 1908: Voellcker resection of cardia and anastamosis

10. 1913: Franz Torek first successful
transthoracic oesophagectomy
for mid oesophageal SCC
 A cervical oesophagostomy
connected by a rubber tube to a
gastrostomy
 Pt lived 13 years to age 80
Torek F, JAMA 1913;60:1533
1925: Torek 92.3% mortality
Torek F, Annals surg 1929 90; 496-506
“The Torek type of operation will
possibly prolong the patients life
and will certainly prolong their
misery” Ifor Lewis BJS 1946:34;18-31

11.  1933: Grey Turner “pull through”
 1938: First successful transpleural oesophagectomy and anastamosis
Adams et al. J Thorac surg
1938;7;605
 1940: 191 reported oesophagectomies - 72% op mortality
Oschner A et al J Thorac Surg 1940; 10; 401
 1945: US operative mortality to 29% Garlock JH Surg. Gynec. Obstet 1945;66;534
 1946: Ifor Lewis oesophagogastrectomy Ifor Lewis BJS 1946:34;18-31

12.  Overall 5 year survival remains 17%
 Rates of resection have remained stable
 Operative mortality rates have fallen 15% to 3%

14.  The good physician
treats the disease:
the great physician
treats the patient
with the disease.
William Osler
 Staging permits individualisation based on best
outcomes with the pathology of the tumour allied
with the co morbidity of the patient

15. “The Great Questions Of The Day Will Not Be Decided
By Speeches And Discussion - That Was The Mistake Of
1848 - The Great Matters Will Be Decided By Blood And
Iron.”

17.  Fit the therapies and the disease to minimise
morbidities but optimise cure
 These principles frequently conflict and must
be balanced
 Accepting higher morbidity without improving
outcomes and Quality of life is not acceptable

18.  Right treatment
 Right patient
 Right place
 Right time

20.  Palliative and curative
 Surgery
 Radiotherapy
 Oncology
 Gastroenterology
 Palliative care
 Anaesthetic/ respiratory/ cardiology
 Allied health

21.  Treatment no longer
as per Bismark
NOW just as
 War is the
continuation of
diplomacy
Karl von Clauswitz
so
 Multimodality
therapy - Surgery is
part of the spectrum
of treatment

22.  Change in pathology
 From SCC to Adeno ca

25. In general in Australia
 SCC
 treated with Definitive Chemoradiation
 Surgery for salvage or failure of treatment
 Adenocarcinoma
 Treated with surgery +/- chemotherapy +/-
radiotherapy depending on staging
There is no role for palliative surgery in
oesophageal surgery

26.  In western society,
adenocarcinoma in
Barretts more
common than SCC
 Holy grail of
elimination of Barretts
with minimal or
endoscopic surgery

27. Invasive
Adenocarcinoma
High-grade
dysplasia
Low-grade
dysplasia
Barrett's
metaplasia
Chronic
inflammation
Squamous
esophagus
Accumulate
Genetic
Changes
Injury
Acid & bile reflux
nitrous oxide
Genetics
Gender, race,
? other factors (cox-2)
Evolution of Barrett’s and Cancer

28.  Malignancy risk
 Barretts 600/100 000
 dysplasia 1700/100 000
 Severe 6600/100 000
 Colonic polyps 580/100 00
http://www.seer.cancer.gov/ (accessed Dec 10, 2011)
Surveillance, Epidemiology and End Results (SEER)
Wani S, et al. Am J Gastroenterol 2009
Winawer SJ, et al. N Engl J Med 1993

29. “what physicians say about
disease is applicable here: at
the beginning a disease is
easy to cure, but difficult to
diagnose; but as time
passes, not having been
recognised or treated at the
outset, it becomes easy to
diagnose but difficult to
treat”
Niccolo Machiavelli
In “The Prince”: Chapter III

34. Siewert JR, Hölscher AH, Becker K, Gössner W (1987)
Kardiakarzinom: Versuch einer therapeutisch
relevanten Klassifikation. Chirurg 58: 25–32

35.  Siewert 1: transthoracic oesophagectomy
 Siewert 3: Total Gastrectomy
 Siewert 2: ?? Adequate clearance is determinant
Asia; Radical Total Gastrectomy,
Western Trans thoracic oesophagectomy
Huscher et al Ann Surg 2007;246:992
Barbour et al Ann Surg 2007;246:1-8

37.  Endoscopy
 EUS (T stage)
 CT (chest and abdo) T4 N&M
 Laparoscopy (small volume peritoneal0
 PET Scan
 Cardiorespiratory review
 Dietician
 Minimise futile surgery (R2/1 resections)

38.  Minimise R2/R1
 No role for palliative resections
 Magic study. 30%R2 resection rate
 Bankstown study 2008 & 2014
 Oesophageal cancer 5% R2 (2008) 212 consecutive gastric and
oesophageal resections for cancer D. K. Chang, A. V. Biankin and N. D. Merrett ANZ J.
Surg. 2008; 78: 77
 Oesophagogastrectomy 4% R2 (2016) Chen Y, Awan N, Haveman JW, Apostolou C,
Chang DK, Merrett ND. Gastric cancer: Australian outcomes of multi-modality treatment with curative intent ANZ J Surg.
2016 May;86(5):386-90. doi: 10.1111/ans.12693. Epub 2014 May 21

40.  Volume effects

41.  Overall operative mortality
of 14%
 Operative mortality
decreases as volume
increases (30% difference if
volume increases 10 cases)
 Open and close laparotomies
less common (p<.02)
 Overall outcomes better in high
volume Centres (not doctors)
passive v active ix and rx

42.  Volume-outcome relationship in
surgery for esophageal
malignancy: systematic review
and meta-analysis 2000-2011.
Markar et al. J Gastrointest Surg.
(2012 )16(5):1055-63
Low volume (<6) vs high volume
(>9 to >346)
In hospital mortality:
8.5% v 2.8%
The volume-outcome relation in
the surgical treatment of
esophageal cancer: a systematic
review and meta-analysis.
Wouters MW et al Cancer. 2012 Apr
1;118(7):1754-63.
 Higher procedural volume is
associated with less
postoperative mortality and
better survival
 Hospitals annual volume seems
more important than surgeons
individual volume.

43. BANKSTOWN:. MED F/U 30MTHS
3 YR DSS: 46% 5YR DSS: 38%
3 YR DFS: 43% 5YR DSS: 37%
•
NSW 5YR SURVIVAL FOR OPERABLE OESOPHAGEAL CANCER: 24%
 78 oesophagectomy
with curative intent.
 4%operative mortality
 LN yield 17 nodes
 R0 resection 85%

44. ANZ J Surg. 2014 May 21. Doi: 10.1111/ans.12693
 Predictors of outcome after surgery for gastric cancer in a Western cohort
Pattison S, Mann GB, Crosthwaite G. et al
ANZ J Surg. 2016 Jun;86(6):469-74. doi: 10.1111/ans.12915.
Med J Aust 2014;
200 (7): 408-413.doi:10.5694/mja13.11182
Internationally comparable outcomes in international low volume
centres, but high volume specialised in Aus context

45.  Low incidence cancers
 Tyranny of distance
 Australian centres low volume by international
definition
 Where should it be performed
 Balance between care as close as possible and
volume effects

51.  EOI
 Mentor and formal buddying up with regional
centres
 Consolidation within metropolitan Sydney

52.  Concern that patients
would not have
treatment locally
 40% increase in
numbers of cases

53.  90 day survial  1 year survival

55.  Multimodality
 SCC
 Chemoradiotherapy standard of care
 Trimodality with salvage oesophagectomy

57.  OE5
 Increased chemo increased treatment mortality (2%)
 Chemomortality higher than surgery mortality
 No improvement in survival
 ST03
 Addition on biological agent (VEGF inhibitor)
 Tripled anastamotic leak rate
 No improvement in survival

58.  Cross study (van Hagen 2012)
 Included SCC and Adeno
 Significant improvement of SCC
 Just reached significance in adenoca
 Siewert 2 and 3
 Magic chemotherapy
 Siewert 1

61. Good Judgement comes from
experience;
Experience comes from poor
judgement.
Simon Bolivar
