Which of the following statement(s) is/are correct concerning the options for resection of esophageal carcinoma?

d. Radical transthoracic esophagectomy with en bloc dissection of continuous lymph node bearing tissues has not been shown to improve survival over transhiatal esophagectomy

For most patients with localized esophageal carcinoma, resection provides the most effective and reliable palliation of dysphagia. The rational surgical approach to distal esophageal carcinoma has been a left thoracoabdominal incision. Tumors involving the mid-esophagus have been resected either through a thoracoabdominal or separate thoracic and abdominal incision, and a high thoracic esophagogastric anastomosis is performed. The major disadvantages of this technique are the necessity of a thoracotomy in debilitated patients with esophageal obstruction as well as the disastrous complications following intrathoracic esophageal anastomotic leak. Although recent results have shown improved operative mortality rates, the operation can still be associated with significant morbidity and mortality. A further disadvantage of the standard intrathoracic esophagogastric anastomosis is inadequate long-term relief of dysphagia either due to tumor recurrence at the anastomotic suture line or due to the development of reflux esophagitis above the anastomosis. Although it has been long taught that the patient with esophageal carcinoma does not live long enough to develop reflux esophagitis after a low intrathoracic esophagogastric anastomosis, this is clearly not the case, and the development of reflux in these patients can produce not only severe pyrosis and reflux symptoms, but also dysphagia from benign stenosis.

During the last two decades, the technique of transhiatal esophagectomy without thoracotomy has been popularized as an operation that minimizes the factors responsible for poor results from traditional transthoracic esophageal resection and reconstruction. In experienced hands, transhiatal esophagectomy without thoracotomy is possible in over 90% of patients. The survival data is comparable to those obtained in most series of transthoracic resection with results usually demonstrating decreased postoperative morbidity and mortality. Although conceptually radical transthoracic esophagectomy with en bloc dissection of contiguous lymph node bearing tissues would appear to offer a better “cancer operation” than transhiatal esophagectomy with no formal lymph node dissection, current survival results are not statistically different. These data suggest that survival after resection for esophageal carcinoma is more a function of the extent and stage of the tumor rather than the size of the specimen or the number of lymph nodes removed.