1. History Of Oesophageal Surgery
Mr Dipankar Mukherjee
Consultant Upper GI & Laparoscopic surgeon
QUEENS UNIVERSITY HOSPITAL UK

2. This talk is not about Basic science Non surgical treatment
Benign surgery unless relevant
Endoscopic therapy

3. Wide geographical variation
United States
5 cases per
United Kingdom
7-10 cases per
Iran, China, and Russia
over 500 cases per
Blot WJ. Epidemiology of esophageal cancer. In Roth JA, RuckdeschelJC, Weisenburger TH, eds. Thoracic oncology. Philadelphia: WBSaunders, 1989;295

4. Rise of adenocarcinoma in Barretts…
30 years ago 10% of oesophageal cancers, it now represents
approximately 50% to 70% in the western world

5. Edwin Smith papyrus 3000 to 2500 BC ….The first report
1862
Edwin Smith papyrus 3000 to 2500 BC
….The first report
Case 28 of the 48 cases described in this work was entitled "A Gaping Wound of the Throat Penetrating the Gullet"
"...if thou examinest a man having a gaping wound in his throat, piercing through to his gullet; if he drinks water he ‘chokes’ (and) it comes out of the mouth of his wound; if it is greatly inflamed so that he develops fever from it, thou shouldst draw together that wound with stitching..."

6. Greece
Rome
Dark age
Islam

7. Paul of Aegina (about 620-690)Alexandrian school
Byzantine Era
Paul of Aegina (about )Alexandrian school
amputation of the breast for cancer, extirpation of the uterus
Tonsillectomy
tracheotomy
Removal of foreign body from oesophagus
some of his descriptions of complicated and difficult operations have been little improved upon even in modern times

8. Challenges:
The anatomic remoteness of the thoracic oesophagus
Physiologic challenge of intraoperative control of respiration h
The history of oesophageal surgery is the tale of men repeatedly losing to a stronger adversary yet persisting in this unequal struggle until the nature of the problems became apparent and the war was won.
Emslie 1988
Perspectives in the Development of Oesophageal Surgery

9. 1633 Ambrose Pare
when the oesophagus was being sutured great care should be taken.

10. Cervical oesophagotomy for FB removal
Hermann Boerhaave ( )
post-mortem examinations to find the cause of fatal illnesses
use of the Fahrenheit thermometer
The syndrome that is named after him he described in 1724
when Grand Admiral of the Dutch Fleet and Prefect of Rhineland Baron J van Wassenaer died soon after developing chest and abdominal pain after vomiting on a full meal.
Boerhaave performed a post-mortem and identified an oesophageal rupture with spillage of gastric contents into the mediastinum (Boerhaave's syndrome
1738 Goursaud and Roland
Cervical oesophagotomy for FB removal

11. Leeuwen howek1670 microscope

12. Ignaz Semmelweis Vienna1848
Observation:Friend died of autopsy wound
Measurement:Physicians 10%
Midwives 3%
Hypothesis :"cadaveric particles."
Smell not removed by hand washing, but calcium hypochlorite:
Result:Ca(OCl)2 reduced puerperal fever death rate 12.4% to 1.27%.

13. Joseph Lister 1860 antisepsis

14. Late 19th century Age of the German Titans ……Charite ` Berlin lineage
Anesthesia 1846
Langenbeck,
Billroth, Kocher
Czerny,
Polya, Mikulicz, Sauerbruch
The pleasure of a physician is little, the gratitude of patients is rare and even rarer is material reward, but, these things never deter the student who feels the call within him"

15. Bernhard Rudolf Konrad von Langenbeck (1810 – 1887):Father of surgical residency
Franko Prussian war of 1870–71
Militär-ärztliche Gesellschaft
A forum of military surgeons of all nationality
"father of the surgical residency". Berlin
a system whereby new medical graduates would live at the hospital as they gradually assumed a greater role in the day-to-day care and supervision of surgical patients.
Among his most well-known "house staff" were such illustrious surgeons as Billroth and  Emil theodore Kocher

16. …..And the great nephew of Langenbeck Theodor Billroth (1829-1894)
First oesophagectomy in animal
Adenoma carcinoma sequence 1855
First laryngectomy1874
Billroth I gasrectomy1881
Prolonged apprenticeship
Animal and cadaveric dissection
Study of surgical literature
Polya
Czerny
Mikulicz
sauerbruch
Halstead

17. Theodor Kocher ( )
Vincenz Czerny (1842 – 1916)
1877,
first “surgeon” to successfully resect a cervical oesophageal cancer

18. Johann von Mikulicz-Radecki 1850-1905
Skin tube 1886 oesophagoscope
Listerism
Respiratory studies

19. (Ernst) Ferdinand Sauerbruch..The Dark Lord..
 German surgeon, Marburg, Zürich, München, Berlin , born in Bremen, died in Berlin
Sauerbruchs chamber 1904
Limb prosthesis
Tuberculosis diet

20. William Halstead (1852-1922) John Hopkins
William Halstead ( ) John Hopkins.. Brings experimental surgery and apprenticeship to America
Student of
John Dalton a pioneering experimental physiologist
Theodore billroth
1889 technique of inguinal hernia repair
early 1890s radical mastectomy for breast cancer
1892 he described ligation of the subclavian artery.
Early 1900s he published on autotransplantation
of the parathyroid gland..
Fallen Hero

21. Story of anaesthesia AD 220 the Chinese surgeon Hua
surgical anaesthesia.
In 1526 Paracelsus
ether (which he knew as oleum vitreoli dulce) could quieten chickens and
relieve pain.
In Birmingham in 1772 Priestley, a Unitarian
minister, discovered nitrous oxide
1825Charles Waterton
Published wanderings in South America
accurate account of curare.

22. 1677 Robert hooke maintained life in dogs by bellows
1775 John Hunter two way air flow
1846 Morton
1853 simpson
Magill & Rowbotham
Sauerbruch
Negative pressure airtight chamber
Brauer and Peterson
CPAP Positive pressure chamber
Endotracheal anaesthesia

23. …Penicillin saga
Fleming A. On the antibacterial action of cultures of a
penicillium with special reference to their use in the
isolation ofB influenzae. BrJExp Pathol 1929;10:
Chain E, Florey HW, Gardner AD, Heatley NG, Jennings
MA, Orr-EwingJ, Sanders AG. Penicillinasa chemotherapeutic
agent. Lancet 1940;ii:226-8.

24. FirstTransthoracic resection Endotracheal anaesthsia Oesophagectomy
Franz Torek 1913
FirstTransthoracic resection
Endotracheal anaesthsia
Oesophagectomy
without reconstruction
12 year survival
Torek F. The first successful case of resection of the thoracic portion of
the esophagus for carcinoma. Surg Gynecol Obstet, 1913;16:614

25. Attempts at Reconstruction
1907 Dr. Cesar Roux (famous for the Roux-Y operation)
use of jejunum as a substitute for the esophagus
1911, Kelling
fi rst successful case of cervical oesophagocolostomy usimg transverse colon
1920, Kirschner
successful oesophago gastrostomy in the neck,
pulling up a gastric pedicle through a subcutaneous route. in a patient who had swallowed lye and had a stricture

26. Between the great wars Ohsawa 1933
series of resections with immediate
anastomosis‘
Over a period of seven years, in a series of 101
cases, he found 18 in which the growth involved the lower oesophagus
or cardia and in which he was able to carry out resection and oesophago gastric
anastomosis.
Eight of these patients survived.

27. Between the great wars…..
Grey Turner 1933: prodigious writer and a lone Ranger
Transhiatal Resection
Vice-President
Royal College of Surgeons of England,
HunterianOrator and Hunterian Trustee.
President of the Association of Surgeons
United States :
Murphy Oration
Balfour Oration
Only British surgeon to be awarded the Bigelow Medal.
GREY TURNER AND THE EVOLUTIONOF OESOPHAGEAL SURGERY R. H. FRANKLIN F.R.!C.S. Ann. Roy. Coll. Surg. Engl. 1971, vol. 49)

28. End of the old era and the opening of a new one.
'Finally came the great day of my long-looked-for pilgrimage to Glasgow. In
1901 my appendix had to be removed, As soon as I entered the operating theatre where Macewen was about to start work, it seemed like a new world to me;
and I have never forgotten the tall, handsome figure standing by the basin washing his hands
with the most punctilious care. To me it seemed wonderful that in those days
someone should come in and inoculate culture media from beneath the surgeon'sthe surgeon's
nails.
'It was not that the work in Newcastle-upon-Tyne was of a poor standard, for
I yield to no one in my esteem for Rutherford Morison. But our theatre was not a sacred place, withoutany of the ritual associated with a surgical operation as we know it to-day, or
as Macewen knew it and practised it in those days. All our sterilisation was by
immersion in strong antiseptics, nothing was boiled and the arrangements were
of the simplest.

30. Grey Turner 1933 successful Transhiatal resection
Radicalism
'better todo too much than too little'
care
Better a living
problem than a dead certainty
Patient focus
'Gentlemen, you are probably saying to yourselves this is only anAppendicectomy -but I can assure you that this is the most important operation being carried out to-day-for this particular patient.‘
decimalization and metrication.
vision
'One day they will operate on the heart-mark my words';
'We shall never overcome cancer by surgery, it will be by something we shall inject
Grey Turner successful Transhiatal resection

31. Following Grey turner & Ohsawa
1938, Adams and Phemister
lower oesophagectomy and immediate oesophagogastrostomy through open thoracotomy1933,Osawa at Kyoto University
First successful cases worldwide of the same procedure
Garlock 1944
Sweet1948
worldwide leaders of oesophageal surgery in the middle of the twentieth century, succeeded in oesophago gastrostomy in the thoracic cavity
Oshawas left thoracoabdominal technique remained a dangerous procedure for mid oesophageal tumoursGARLOCK, J. H. (1944) Surg. Gynec. Obstet. 78, 23.

32. Status of surgical treatment for esophageal cancer worldwide, 1965
T. Kakegawa, MD · H, Fujita, Gen Thorac Cardiovasc Surg (2009) 57:55–63
Cases of resection (%) Operative mortality (%) Cases of 5-year survival (%)
Garlock (39.6%) % (21.2%)
Sweet (52.1%) % (12.1%)
Ellis (27.0%) % (17.2%)
Logan (59.7%) % (23.0%)
Petrov (19.0%) % (11.5%)
Berezov (29.2%) %
Wu (40.1%) % (23.7%)
Kuo (12.7%) %
Lortat-Jacob 308 (54.8%) % (6.2%)

33. …..Joining up the gullet : the War years folowers of ohsawa and Grey Turner
1937 Nissen First successful anastomosis
reported a case of transthoracic cardio-oesophageal
resection for penetrating ulcer, and this was probably the first successful
anastomosis in Europe and the Americas.
1938 Adams and Phemister : First one stage resection
but most oesophageal surgeons continued to practise the twostage
procedure,
ADAMS, W. E., and PHEMISTER, D. B. (1938) J. thorac. Surg. 7, 621.
1942 Brock: The first follower
carried out a successful
one-stage resection and anastomosis for a patient with a large myoma.
BROCK, R. C. (1942) Brit. J. Surg. 30, 146.
1945 Vernon Thompson: First UK success
The first patient with a carcinoma to be treated successfully in this way in the UK
THOMPSON, V. C. (1945) Brit. J. Surg. 32, 377.

34. Post war years

35. 1946, The watershed: Transthoracic resection
Lewis I. Hunterian lecture
The surgical treatment of carcinoma of the oesophagus with
special reference to a new operation for growths of the
middle third.
Br J Surg, 1946;34:18
Inspiration to be a doctor severe attack
of acute appendicitis at the age of I2-being
operated upon by David Ellis of Aberystwyth
1939First successful pulmonary embolectomy in the UK

36. Olympus: Going Where no Camera has Gone Before
The Pain in the Butt Camera
Olympus gastrocamera 1960

37. Ronald Belsey TO Fistula Zenkers Diverticulum Antireflux procedure
Belsey R. Reconstruction of the esophagus with left colon. J Thorac Cardiovasc Surg 1965;49:33-55.
Zenkers Diverticulum
The American Association for Thoracic Surgery in 1966, emphasized a dysfunction of the cricopharyngeal muscle as the underlying cause series of 45 patients, the majority of them treated with myotomy and diverticulopexy
Antireflux procedure
Belsey Mark IV
Cancer “cure is an accident"

38. 1976 :Total oesophagectomy
McKeown KC. Total three stage oesophagectomy for cancer of the oesophagus. Br J Surg, 1976;63:259

39. Poor results :
Earlam R, Cunha-Melo Jr. Oesophageal squamous cell carcinoma. 1.
A critical review of surgery. Br J Surg, 1980;67:381
Muller JM, Erasmi H, Stelzner M, Zieren U, Pichlmaier H. Surgi cal
Therapy of Oesophageal Carcinoma. Br J Surg, 1990;77:845

40. Rt Vs Left Thoracotomy Similar results mortality and survival
Launois P, Lygidakis C, Malledant G. Results of the surgical treatment
of carcinoma of the esophagus. Surg Gynecol Obtet, 1983;156:753
Similar results mortality and survival
reflux more in left

41. Total vs Subtotal stricture more in cervical anastomosis
Chasseray VM, Kiroff GK, Buard JL, Launois B. Cervical or thoracic
anastomosis for esophagectomy for carcinoma. Surg Gynecol Obstet,
1989;169:55
stricture more in cervical anastomosis

42. Which conduit?
Gastric
Colon
Greater curve tube

43. Anastomosis:Staples or handsewn
Stricture more in stapled

44. How radical is radical? Skinner DB, Dowlatashy KD, DeMeester TR.
80 patients
radical Enbloc resection
9 (11%) 30 day mortality
Potentially curablecancer of the esophagus. Cancer, 1982;50:2571
Wong J.
Esophageal resection for cancer: the rationale of current
practice. Am J Surg, 1987;153:18

45. 20 years in Chiba University
Seo and OsawaJapan surgical society 1932
Review of world literature before 1942
worldwide incidence of operative mortality up to 1932
144 (95.4%) of the 155 patients
No sucessful reconstruction
Hiroshi Akiyama
Nakayama Japan Surgical Society 1951
incidence of operative mortality
was only 5 (16.6%) of 30 patients who underwent subtotal
esophagectomy followed by esophagogastrostomy
through a subcutaneous route for cancer in the upperor middle thoracic esophagus .

46. Three Japanese masters 1951-1966
Nakayama and Sato Chiba University : Multistage procedure
The operativemortality rate oesophagectomy
% of 30 patients
% of 2053 patients
Katsura at Tohoku University
8/15 55% mortality using positive pressure
0/21 0% using endotrachaeal anaesthesia
Akakura at Keio University, 1966 JATS presidential lecture :
average operative mortality rate in Japan was 15.6% ,861 of 5327
average 5-year survival rate was 12%

47. Problems to be resolved in oesophageal surgery
Akakura keio University :
Problems to be resolved in oesophageal surgery
1. Causes of short-term mortality
1) Incorrect indication for surgery
2) Incorrect adoption of surgical procedures
3) Incorrect surgical maneuver
Postoperative complications
a. Anastomotic leakage
b. Pulmonary complication(s)
c. Circulatory failure
2. Causes of long-term mortality
1) Non-curative surgery
a. Incomplete resection of a local tumor
b. Lymph node metastasis
c. Distant organ metastasis
2) Malnutrition
3) Diseases of the elderly

48. Specialisation
JSED : oesophageal Registry
5-year survival rate %
41.9%
10-yearsurvival rate 1994:
31.0 %
operative mortality 1994:
2% of 7539 patients

50. Early Vs
Advanced:
Lymph
Nodal spread
Recurrent laryngeal and paracardiac sentinel nodes?
Kakegawa 1994

51. Lymphadenectomy Recurrent laryngeal chain

54. Transhiatal Resection
Denk in 1913,
Refined by Turner in 1931
Popularised by Orringer 1978

55. Transhiatal oesophgectomy
University of Michigan Hospitals,Ann Arbor, MI.
1.Orringer MB, Sloan H: Esophagectomy without thoracotomy.
J Thorac Cardiovasc Surg 76:643, 1978
2. Orringer MB, Orringer JS: Esophagectomy without thoracotomy:
a dangerous operation? J Thorac Cardiovasc Surg
85:72, 1983
3. Omnger MB: Transhiatal blunt esophagectomy without thoracotomy.
In Cohn LH (ed): Modem Technics in Surgery:
Cardio-Thoracic Surgery. Mt. Kisco, NY, Futura, 1983, vol
62, installment 9
4. Omnger MB: Partial median sternotomy: anterior approach
to the upper thoracic esophagus. J Thorac Cardiovasc Surg
87:124, 1984
Mark Orringer

56. Orringer MB, Orringer JS: Esophagectomy without thoracotomy:
a dangerous operation? J Thorac Cardiovasc Surg
85:72, 198

57. Orringer MB, Orringer JS: Esophagectomy without thoracotomy:
a dangerous operation? J Thorac Cardiovasc Surg
85:72, 198

58. 200 patients
AverageBlood loss
<1000 ml
Hospital mortality 6%.

59. 11 years of Laparoscopic oesophageal surgery
1991, Dallemagne et al and Geagea Laparoscopic fundoplication
1991 Shimi et al 
Laparoscopic esophageal myotomy.
1993, Cuschieri et al
outcome of Laparoscopic fundoplication
> 100 patients multicenter study

60. Antoon Lerut Leuven
Student of
Ronald Belsey Bristol
James Luketich philadelphia

61. Staging : Evolution in the west
CT and EUS
Tio TL, Cohen P, Coene PP.
Endosonography and computed tomographyof esophageal carcinoma.
Gastroenterology, 1989;96:1478
Grimm H, Soehendra N, Hamper K.
Contribution of endosonographyto preoperative staging in esophageal
and stomach cancer. Chirurg,
1989;60:684 Gastroenterology, 1989;96:1478
Rankin SC, Taylor H, Cook GJ, Mason R.
Computed tomographyand positron emission tomography in the pre-operative staging of oesophageal carcinoma. Clin Radiol, 1998;53:659
Thoracoscopy
Krasna MJ, Reed CE, Jaklitsch MT. Thoracoscopic staging of esophageal cancer: a prospective, multiinstitutional trial. Cancer and Leukemia
Group B Thoracic Surgeons. Ann Thorac Surg, 1995;60:1337

62. MDT
Ajani JA. Current status of new drugs and multidisciplinary approaches
in patients in patients with carcinoma of the esophagus.
Chest, 1998;113:112S

63. Collaboration not competition
Ando N, Iizuka T, Kakegawa T.
A randomized trial of surgery wit hand without chemotherapy for localized squamous carcinoma of the thoracic esophagus. J Thorac Cardiovasc Surg, 1997;114:205
Teniere P, Hay JM, Fingerhut A.
Postoperative Radiation does no t increase survival after curative resection for squamous cell cancer ofthe middle and lower oesophagus as shown by a multicenter controlled trial. Surg Gynecol Obstet, 1991;173:123
Leprise E, Etienne PL, Meunier B. A randomized study of chemotherapy, radiation therapy, and surgery versus surgery for localizedsquamous cell carcinoma of the esophagus. Cancer, 1994;73:1779

64. Chemoradiation increased survival
Walsh TN, Noonan N, Hollywood D.
A comparison of multimodaltherapy and surgery for esophageal adenocarcinoma.
N Engl J Med 1996;335:462
Forastiere AA, Orringer MB, Perez-Tamayo C, Urba SG, ZahurakM. Preoperative chemoradiation followed by transhiatal esophagectomy for carcinoma of the esophagus: final report.
J ClinOncol, 1993;11:1118

65. Junctional tumour:
Siewert Type

66. Today Minimal access EMR ESD PDT Chemoradiation Biological therapy
Multimodality treatment
New treatments?

67. Please do not walk away when you stumble onto it…
Introduction of modern surgical techniques should lead to a paradigm shift in the mindset of the referring clinicians
Things do not change; we change