Advances in the surgical treatment of esophageal cancer since 1965

Abstract In Japan, the treatment of esophageal cancer has undergone significant development since the Japanese Society for Esophageal Diseases was established in 1965 by Doctors Komei Nakayama, Shigetsugu Katsura, and Ichiro Akakura. When the Society was established, surgery was the first‐line treatment for esophageal cancer. Since then, the Society has been led by three successive chairpersons—Doctors Katsura, Nakayama, and Satoh. Over this time, surgery‐related mortalities declined to 5%‐6% because of the rapid improvements in surgical technique. Beginning in 1980, the bilateral cervical lymph node dissection technique gained attention, and favorable long‐term outcomes were gradually reported. A nationwide questionnaire survey, conducted by the Society in 1990, showed that more favorable long‐term outcomes were achieved by following the three‐field lymph node dissection technique than by following the two‐field lymph node dissection technique. Since then, the three‐field lymph node dissection technique has been recognized and widely used as the standard surgical procedure for treating esophageal cancer. After clinical studies examined the utility of various pre‐ and postoperative adjunctive therapies in outcome improvements, preoperative chemotherapy was recognized as the standard treatment in the therapy guidelines. Additionally, less invasive surgical methods have been developed, including endoscopic and robot‐assisted surgeries, which are applied in general practice now. However, unresectable and recurrent esophageal cancers remain difficult to treat, and additional treatments should be developed.

this disease; the significance of the three-field lymph node dissection technique was recognized and has been widely used. Besides, other relevant developments happened to reduce the invasiveness of surgical treatment. This review describes these milestones in the surgical treatment of esophageal cancer and the advancements thereafter.

| DAWN OF A NE W ER A
The world's first report of a successful thoracic esophageal cancer treatment was published by Torek in 1913. 3 In that report, a patient underwent a two-stage surgery and survived for an additional 13 years. Reconstruction was not performed, but an artificial esophagus, made from a rubber tube, was placed between the cervical esophageal fistula and the gastric fistula. In the same year, Fink attempted to perform antethoracic esophagogastrostomies, although the first successful case was reported 6 years later, in 1920, by Kirschner. 4 In Japan, the reports published by Professors Sadanobu Seo In 1929, Doctor Toru Osawa successfully treated a patient by conducting a total gastrectomy and an intrathoracic esophagojejunal anastomosis, via laparotomy and thoracotomy. 5

| FIF T Y YE AR S OF PROG RE SS S IN CE THE JAPANE S E SO CIE T Y FOR E SOPHAG E AL D IS E A S E S WA S E S TAB LIS HED
After the publication of the assigned reports, the aforementioned advances occurred gradually and were recognized as major developments over the 50 years since the Japanese Society for Esophageal Diseases (predecessor of the current Japan Esophageal Society) was established in 1965 (Table 1). At the time of the establishment of the Society, it was led by Doctors Komei Nakayama, Shigehiro Katsura, and Ichiro Akakura, whose efforts led to surgery becoming the first-line treatment for esophageal cancer.
In addition to the aforementioned antethoracic esophagogastrostomy, Doctor Nakayama also invented a safer three-stage procedure in which a gastrostomy is created to facilitate improving patient nutrition during the first stage. Since this method was introduced, the importance of preoperative nutritional management has been considered. 7    For the 2017 guidelines, a meta-analysis of the effects of preoperative respiratory therapy or rehabilitation was conducted. 13 The findings showed that such therapy led to a significant decrease in the postoperative risk of pneumonitis and respiratory complications.  published, and one extremely interesting finding was that, in middle intrathoracic esophageal cancers, the rate of metastasis to the supraclavicular lymph nodes is higher than the rate of metastasis to the middle mediastinum lymph nodes. 28 Conversely, the 5-year survival rate of patients with supra-clavicular node metastases is higher than that of patients with middle-mediastinal node metastases. Based on those findings, supraclavicular lymph nodes were reclassified into the N2 group in the 11th edition. In addition, according to the 7th edition of the TNM classification of resected esophageal cancers, registered in 2011, the 5-year survival rate for pStage IV disease was 22.8%, but was 14.8% for pStage IIIc disease, showing inverted tendencies. 29 There is a need to universally recognize supraclavicular lymph node metastases as local lymph node metastases and not as distant metastases.
Regardless of the progress made to date, unresectable esophageal cancers and recurrent esophageal cancers remain difficult to treat; therefore, additional new treatments need to be developed.

| CON CLUS IONS
During the past 50 years, the surgical treatment of esophageal cancers has undergone significant progress, thanks to our predecessors' efforts, resulting in improved safety and prognoses compared with earlier techniques. Further, advances in radiation therapy and chemotherapy occurred in addition to recognizing the importance of multidisciplinary treatments and treatment options tailored to individual patients. In the future, more outcome improvements are expected, including in immunotherapy using immune checkpoint inhibitors-a class of therapies that has recently attracted attention as the fourth pillar of cancer therapy.

D I SCLOS U R E
Conflict of Interest: The author declares no Conflict of Interests for this article.