Original article Two-®eld radical lymphadenectomy in the treatment of esophageal carcinoma A. J. Torres, A. SaÂnchez-Pernaute, F. Hernando, L. DõÂez Valladares, O. GonzaÂlez LoÂpez, E. PeÂrez Aguirre, A. SuaÂrez, J. L. Balibrea II Department of Surgery, Hospital Universitario San Carlos, Madrid, Spain SUMMARY. This paper retrospectively compares post-operative complications, mortality and long-term survival of patients with esophageal carcinoma who were treated with standard esophagectomy or with extended two-®eld lymph node clearance. Fifty-seven patients with resectable esophageal carcinoma were included in the study. Twenty-eight patients were submitted to a radical two-®eld esophagectomy and lymphadenectomy, while the remaining 29 were submitted to a standard, more conservative, esophagectomy performed mostly through a transhiatal route. The two groups of patients were similar in all clinical, laboratory and pathologic features. There was a signi®cant lower anastomotic leakage rate in the group of patients submitted to a radical lymph node resection; post-operative respiratory complication rate and mortality were similar in both groups. The overall 5-year survival was 20%. When lymph node resection was performed, the 5-year survival rate rose to 36%; it was 44% when nodal involvement was negative and 19% for N1 patients; when standard esophagectomy was the procedure, these ®gures were 9% (p < 0.05), 16% and 6% respectively. INTRODUCTION Surgical resection is the mainstay of curative therapy for carcinoma of the esophagus. Esophagectomy not only provides the best opportunity for cure in patients with limited disease but also oers substan- tial palliation for patients with more advanced disease. The 5-year survival rate associated with other kinds of therapy such as radiotherapy alone or in combination with chemotherapy is less than 10%. 1 However, esophagectomy was until quite recently accompanied by the highest mortality reported for any electively performed surgical procedure. The diculty of the operation and the poor performance status of most patients are responsible for an in-hospital mortality rate that at the beginning of the 1980s was around 30%. 2 The high complication rate and the poor long-term outcome have led some physicians to avoid the transthoracic approach and search for a technique that would have a more benign post-operative course, although survival rates are unlikely to be signi®cantly improved. 3 The aim is to minimize post-operative respiratory problems and avoid cervical anastomosis with its associated dramatic consequences of medias- tinal leakage. The use of the transthoracic technique appears to be a retrograde step: the ®rst documented resection of the thoracic esophagus was performed by Mikulicz in 1900 4 ± although the ®rst mention of the procedure in the literature is usually attributed to Dent in 1913 ± and it was undertaken transhiatally, because the lack of positive-pressure ventilation precluded the transthoracic approach. In the 1970s, the poor results obtained with transthoracic eso- phagectomy and the high rates of post-operative complications led to a resurgence of extrathoracic resections. Recently, a substantial decrease in the post-oper- ative complication rate and an improvement in the long-term survival rate have been reported, mainly from Oriental authors. 5 Both ®ndings are associated with improved perioperative patient care and surgical techniques, which include systematic extensive thor- acic and abdominal lymph node clearances. 6 This aggressive policy is gradually being adopted in Occidental settings, and post-operative complication and survival rates similar to those reported in Japan are being acheived in some European and American centers. 7,8 Correspondence to: A. J. Torres, Servicio de CirugõÂa II (Prof. Balibrea), Hospital Universitario San Carlos, 3 a planta, ala Sur, c/Martin Lagos s/n, Madrid 28040, Spain. Tel. (+34) 91 3303179/34, or 91 33 03444; (+34) 91 3303179 or 91 3941217. *Presented at the VIIth World Congress, International Society for Diseases of the Esophagus, Montreal, September 1998. 137 Diseases of the Esophagus (1999) 12, 137±143 Ó 1999 ISDE/Blackwell Science Asia