Advances in esophageal cancer surgery in Japan: An analysis of 1000 consecutive patients treated at a single institute Masaru Morita, MD, PhD, FACS, a Rintaro Yoshida, MD, a Keisuke Ikeda, MD, a Akinori Egashira, MD, PhD, a Eiji Oki, MD PhD, a Noriaki Sadanaga, MD, PhD, a Yoshihiro Kakeji, MD, PhD, FACS, a Takeharu Yamanaka, PhD, b and Yoshihiko Maehara, MD, PhD, FACS, a Fukuoka, Japan Background. In Japan, most esophageal cancers are squamous cell carcinomas, and the results of esophagectomy have improved remarkably in recent years. The object of this study was to evaluate advances in operative therapy for esophageal cancer in Japan. Method. We evaluated mortality, morbidity, and prognosis in 1000 consecutive patients who underwent esophagectomy for esophageal cancer at a single institution in Japan. The patients were divided into 3 groups according to the period when esophagectomy was performed: Group I (n = 197), 1964--1980; group II (n = 432), 1981--1993; and group III (n = 371), 1993--2006. Results. The incidence of squamous cell carcinoma was 94%. The morbidity rates were 62%, 38%, and 33 %, in groups I, II, and III, respectively (P < 0.01, groups I vs II and III), and the in-hospital mortality rates were 14.2%, 5.1%, and 2.4%, respectively (P < 0.01, between each group). The 5-year overall survival rate was 30% (14%, 27%, and 46% in groups I, II, and III, respectively; P < 0.0001). Multivariate analysis revealed age, gender, depth of invasion, node metastasis, distant metastasis, curability, extent of lymphadenectomy, resectability, and the period when the operation was performed as independent prognostic factors. Conclusion. Generally, esophagectomy has been performed safely without critical complications; however, the prognosis has improved remarkably with advances in surgical techniques and treatment modalities. (Surgery 2008;143:499-508.) From the Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, a and the Cancer Biostatistics Laboratory, Institute for Clinical Research, National Kyushu Cancer Center, b Fukuoka, Japan ESOPHAGEAL CANCER is highly aggressive, and until re- cently, it was almost always associated with a dismal prognosis. 1,2 Esophageal resection remains the gold standard of treatment, providing the optimal chance for cure. 3 In the past, however, this proce- dure was extremely invasive and associated with high mortality and morbidity rates. 1,4 Treatment and perioperative management have evolved in recent years, with dramatic advances in diagnostic techniques, the implementation of radical esopha- gectomy with extensive lymphadenectomy, and the development of combined chemo-radiotherapy. 5,6 Consequently, 5-year survival rates of more than 40% have been reported, with remarkable improve- ments in mortality and morbidity. 7-10 In Western countries, an increasing prevalence of adenocarcinoma of the esophagus exists with a shift in predominance to the lower esophagus or gastro- esophageal junction. 3,5,11 Conversely, in Japan, the incidence of squamous cell carcinoma is still as high as 93%, and 53% of all esophageal carcinomas are located in the mid-thoracic esophagus. 12 The prognosis of patients with squamous cell carcinoma of the esophagus has been reported to be worse than that of those with adenocarcinoma. 5,11 Further- more, carcinomas of the upper- or mid-thoracic Supported in part by a Grant-in-Aid from the Ministry of Educa- tion, Culture, Sport, Science and Technology of Japan. Presented at the 2007 Annual Meeting of the American Society of Clinical Oncology, Chicago, Illinois, June 1-5, 2007. Accepted for publication December 7, 2007. Reprint requests: Yoshihiko Maehara, MD, PhD, FACS, Depart- ment of Surgery and Science, Graduate School of Medical Sci- ences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812- 8582, Japan. E-mail: maehara@surg2.med.kyushu-u.ac.jp. 0039-6060/$ - see front matter Ó 2008 Mosby, Inc. All rights reserved. doi:10.1016/j.surg.2007.12.007 SURGERY 499