Salvage esophagectomy: safe therapeutic strategy?

Abstract

The objectives of this review were to assess both the short- and long-term clinical outcomes in patients managed with definitive chemoradiotherapy, and salvage esophagectomy subsequently in comparison to those neoadjuvant chemoradiotherapy followed by planned esophagectomy (NCRS) for esophageal cancer from published literature. Eleven studies comprising 1,906 patients were included, 563 in the salvage group and 1,343 in the NCRS group. Pooled analysis showed no significant difference between salvage and NCRS groups in overall survival [hazard ratio (HR) =1.17; 95% confidence interval (95% CI), 0.94-1.46, P=0.148], postoperative mortality [pooled odds ratios (POR) =1.12; 95% CI, 0.52-2.41, P=0.775], pulmonary complications (POR =1.24; 95% CI, 0.83-1.86, P=0.292) and positive resection margin incidence (POR =1.29; 95% CI, 0.94-1.76, P=0.114). However, within the salvage group there were increases in postoperative morbidity (POR =1.30; 95% CI, 1.00-1.67, P=0.046) and anastomotic leak (POR =1.88; 95% CI, 1.41-2.51, P<0.001). Herein we found that salvage esophagectomy has similar short- and long-term mortality in comparison to planned esophagectomy following neoadjuvant chemoradiotherapy. However, anastomotic leak is increased following salvage esophagectomy suggesting the need for this practice to be reserved for high volume surgeons within high volume centers.

Keywords: Esophageal cancer; chemotherapy; definitive chemotherapy; neoadjuvant chemotherapy; salvage esophagectomy.

Figure 1

PRISMA search strategy.

Figure 2

Forrest plot showing no significant difference between the groups in overall survival (HR =1.17; 95% CI, 0.94–1.46, P=0.148). HR, hazard ratio.

Figure 3

Forrest plot showing no significant difference between the groups in postoperative mortality (POR =1.12; 95% CI, 0.52–2.41, P=0.775). POR, pooled odds ratios.

Figure 4

Forrest plot showing an increase in postoperative morbidity following salvage esophagectomy (POR =1.30, 95% CI, 1.00–1.67, P=0.046). POR, pooled odds ratios.

Figure 5

Forrest plot showing an increase in anastomotic leak following salvage esophagectomy (POR =1.88; 95% CI, 1.41–2.51, P<0.001). POR, pooled odds ratios.

Figure 6

Forrest plot showing no significant difference between the groups in pulmonary complications (POR =1.24; 95% CI, 0.83–1.86, P=0.292). POR, pooled odds ratios.

Figure 7

Forrest plot showing no significant difference between the groups in positive resection margin incidence (POR =1.29; 95% CI, 0.94–1.76, P=0.114). POR, pooled odds ratios.