This document discusses surgical approaches for esophageal cancer. It covers: - Esophageal anatomy, blood supply, lymph drainage - Staging of esophageal cancer and criteria for resection - Preoperative evaluation including imaging, biopsy, and laparoscopy - Surgical procedures for cervical, thoracic, and esophagogastric junction cancers including transhiatal esophagectomy, Ivor-Lewis procedure, and tri-incisional esophagectomy - Oncologic principles for lymphadenectomy and margins during resection

1. ESOPHAGECTOMY : SURGICAL
APPROACHES AND CURRENT
EVIDENCE
DR AMIT DANGI

2. • Localized disease : 22 percent of all cases.
• Regional disease : 30 percent of patients.
• Goal of surgical management is curative.
• Surgical resection is the traditional mainstay of multidisciplinary
therapy for patients with localized disease.
• The clinical spectrum of esophageal cancer has changed over the last
few decades, with an increase in incidence of adenocarcinoma and a
decrease of squamous cell carcinoma.
• Surgical management is independent of histology.

3. ANATOMY
• 25 to 30 cm in length
• Posterior mediastinum.
• C6-T11

5. Anatomy of esophageal cancer primary
site, including typical endoscopic
measurements of each region
measured from the incisors.
Exact measurements depend on body
size and height. For tumors of the EGJ
and cardia, location of cancer primary
site (ie, esophagus, stomach) is defined
by cancer epicenter.
Divided into 4 anatomic areas
• Cervical
• Thoracic
• Lower thoracic/Esophagogastric
junction
• Abdominal esophagus.

7. • The esophagus is composed of
the mucosa, submucosa,
muscularis externa, and
adventitia.
• There are three critical
anatomic points of narrowing:
Cricopharyngeus ,
Broncho-aortic
constriction,
Esophagogastric junction.
• These are also the most
common sites of iatrogenic
and mechanical perforation.

8. BLOOD SUPPLY
Arterial supply:
• Inferior thyroid artery (cervical
esophagus),
• Bronchial arteries, and the aorta (thoracic
esophagus)
• Branches of the LGA and inferior phrenic
artery (abdominal esophagus).
Venous drainage:
• Inferior thyroid vein (cervical esophagus);
• Aygous vein, the hemiazygous vein, or the
bronchial veins (thoracic esophagus);
• Coronary vein (abdominal esophagus)

9. LYMPHATIC SUPPLY
• Rich network of submucosal lymphatic
that facilitate the longitudinal spread
of neoplastic cells along the
esophageal wall.
• Lymphatic drainage is to cervical
nodes, tracheobronchial and
mediastinal nodes, and gastric and
celiac nodes.
• An important point is that the regional
lymph nodes for all locations in the
esophagus, including the cervical
esophagus and esophagogastric
junction, extend from the
periesophageal cervical nodes to celiac
nodes.

10. HISTOLOGY OF ESOPHAGEAL CANCER
SQUAMOUS CELL CARCINOMA
• SCC arises from the cells that line the upper part of
esophagus.
• Smoking and alcohol
• Dietary factors : Alfatoxin, hot beverages, N nitroso
compounds, areca nut, red meat, low selenium,
zinc deficiency
• Underlying disease: Achalasia : 16 fold
Corrosive ingestion
• Prior gastrectomy or Atrophic gastritis
• HPV
• Tylosis
• Oral bisphosphonates
• Poor oral hygiene
ADENOCARCINOMA
• Adenocarcinoma arises from glandular cells
that are present at the GEJ.
• Barrett Metaplasia : 30 fold
• GERD
• Obesity and metabolic syndrome
• Smoking
• No association with alcohol

12. TNM STAGING (8th edition 2017)
• Recognizes biologic heterogeneity and provides separate stage groupings
for adenocarcinoma and SCC.
• Tumors involving the EGJ with the tumor epicenter no more than 2 cm into
the proximal stomach are staged as esophageal cancers.
• In contrast, EGJ tumors with their epicenters located more than 2 cm into
the proximal stomach are staged as stomach cancers, as are all cardia
cancers not involving the EGJ, even if they are within 2 cm of the EGJ.
• Thus, regardless of histology and Siewert type, esophageal tumors arising
in the cervical, thoracic esophagus or abdominal esophagus, and those
involving the EGJ that have an epicenter within 2 cm of the EGJ share the
same criteria for T stage, N stage, and M stage designation

15. PRETREATMENT EVALUATION
Endoscopic biopsy : 98% diagnosis with 7 biopsies
(100% if brush cytology added)
Computed tomography (CT) of the neck, chest and
abdomen.
Endoscopic ultrasound (EUS) : Preferred for loco-
regional staging.
Positron emission tomography (PET): Detect occult
mets in 20%
Diagnostic laparoscopy and thoracoscopy : Selective
use, invasive, more accurate than CT or EUS alone,
no comparison with EUS + PET/CT
Brochoscopy and VDL.

16. SUV which reflects the metabolic activity of the tumor may also serve as a prognostic factor.
A high SUV predicted a worse survival.
However, some studies suggested a better response to NACRT in this group, but is uncertain.
Suspicious PET findings should be confirmed with biopsy before excluding a patient from
surgical consideration, given the high rate of false-positive findings.
Detect occult mets after CRT or induction CT in approx 8% of patients.

17. Role of Diagnostic laparoscopy
NCCN
Consider DL to be "optional" for patients with EGJ
tumors and no evidence of metastatic disease.
ESMO
Advocate DL for all patients with locally advanced
(T3/T4) adenocarcinomas of the EGJ infiltrating the
gastric cardia.
SAGES
Early stage esophageal cancer with no evidence of
distant or LN metastases on high- quality
preoperative imaging), who are considered for
curative resection may benefit from staging
laparoscopy (grade B).
The need for diagnostic laparoscopy for patients who appear to have potentially resectable distal esophageal and EGJ
adenocarcinomas is controversial.

18. IMPORTANCE OF PRE-TREATMENT STAGING
ASSESSMENT
• T1N0 : High cure rate from surgical or endoscopic therapy alone.
• Surgery: Primary curative modality for both esophageal and EGJ cancers
that have invaded through the esophageal wall or are node positive : Poor
long-term outcome with resection alone (even R0).
• T3 or N+ tumors: NACRT is generally preferred over initial surgery.
• Optimal approach to clinical T2N0 disease is debated.
• NCCN suggest NACRT for clinical T2N0 adenocarcinomas of the distal
esophagus and EGJ, and initial resection for clinical T2N0 SCC if they are <2
cm and well differentiated.
• Regardless of histology, between 50 and 80 percent of patients with
esophageal and EGJ cancers present with incurable, locally advanced
unresectable or metastatic disease.

19. Criteria for resection
Esophagectomy as first line of
therapy
● cT1N0M0 lesions
● cT2N0M0 lesions are candidates in
many medical centers
Esophagectomy following
NACT/NACRT
● Patients with thoracic esophageal
or EGJ tumors and full-thickness (T3)
involvement of the esophagus
with/without nodal disease.
● cT4a disease with invasion of
local structures (pericardium, pleura,
and/or diaphragm only) that can be
resected en bloc, and who are
without evidence of metastatic
disease to other organs (eg, liver,
colon).

20. cPR
• Surgical resection is recommended.
• cPR seen in 20-25% of patients.
• However, it is not possible to reliably identify these patients either by
EUS or repeat PET scan.
• The recommendation is to proceed with resection if the patient is fit
for surgery and has not progressed during chemoradiotherapy

21. Surgery after NACRT
• The impact of NACT/NACRT on perioperative morbidity and mortality
was addressed in a meta-analysis of 23 randomized trials comparing
neoadjuvant therapy versus surgery alone or NACT versus CRT.
• Neither NACT/NACRT increased the risk of total postoperative
mortality or morbidity.
• However, subgroup analysis suggested that patients undergoing
NACRT for SCC might be at an elevated risk for postoperative
mortality relative to those treated by surgery alone (risk ratio 1.95,
95% CI 1.06-3.6).

22. Relative contraindications
● Advanced age
● Comorbid illness
Indicators of unresectability —
• Metastatic disease
• Extra-regional LN spread (eg,
paraaortic or mesenteric
lymphadenopathy).
• The regional lymph nodes for
all locations in the esophagus,
including the cervical and
EGJ, extend from the
periesophageal cervical nodes
to celiac nodes.
• Celiac nodal metastases and
mediastinal/supraclavicular
nodes are scored as regional
nodal disease TNM staging
system, regardless of the
primary tumor location.
• Number rather than location
of involved LN determines
the N stage

23. (A-C) Lymph node maps for esophageal cancer. Regional lymph node stations for staging esophageal cancer from left (A),
right (B), and anterior (C).

24. PREOPERATIVE OPTIMIZATION
• PREOPERATIVE RESPIRATORY REHABILITATION —A retrospective
cohort study of 100 patients undergoing an esophagectomy found
that patients managed with preoperative respiratory rehabilitation (n
= 63) for seven days had a lower rate of postoperative pulmonary
complications (6 versus 24 percent) [18].
• NUTRITION AND IMMUNONUTRITION-

25. OPERATIVE PROCEDURES

26. Cervical esophageal cancer resection
• CRT : Primary modality
• Surgical resection : Patients who fail CRT, or who opt for a surgical resection.
• Resection usually requires removal of portions of the pharynx, the larynx, the
thyroid gland, and portions of the proximal esophagus.
• Single stage, three-phase operation requires cervical, abdominal, and thoracic
incisions.
• Permanent terminal tracheostomy.
• Bilateral radical neck dissections are generally performed [19-29].
• Restoration of GIT continuity with a gastric pull-up and anastomosis to the
pharynx.
• Free jejunal interposition graft or a deltopectoral or pectoralis major
myocutaneous flap are alternative reconstructive options.

27. Thoracic cancer resection
• EAC and SCC involving the middle or lower third of the esophagus (except GEJ
cancers), generally requires total esophagectomy (submucosal skip lesions).
• In selected superficial or early invasive esophageal cancer arising distally in the
setting of BE, a more limited resection can be performed.
• Optimal surgical approach : Unknown
• Choice of surgical approach depends upon many factors:
● Tumor location, length, submucosal extension, and adherence to surrounding
structures
● The type or extent of lymphadenectomy desired
● The conduit to be used to restore GIT
● Postoperative bile reflux
● The preference of the surgeon

28. • The THE, Ivor-Lewis (TTE), and tri-incisional esophagectomy
(McKeown) procedures are the most commonly performed
esophagectomies in North America.
• Extended (three-field) lymphadenectomy is commonly performed in
Asia.
• Gastric interposition: preferred conduit
• Jejunum or the colon can also be used as the conduit.
• These conduits are resistant to the effects of gastric acid, and they
have a shape similar to the native esophagus.

29. Transhiatal esophagectomy
• Cervical, thoracic, and EGJ cancers.
• Upper midline laparotomy incision and a left neck incision.
• Blunt dissection of thoracic esophagus.
• Cervical anastomosis with a gastric pull-up.
• Disadvantages: Limited thoracic lymphadenectomy and blind midthoracic dissection.
• In the largest prospective database series of 2007 patients, the in-hospital mortality rate
decreased in the 1998 to 2006 cohort (n = 944 patients) compared with the 1976 to 1998 cohort
(1 versus 4 percent).
• The anastomotic leak rate was also lower in the 1998 to 2006 cohort (9 versus 14 percent).
• Other postoperative complications included atelectasis and pneumonia (2 percent), and
intrathoracic hemorrhage, RLN paralysis, chylothorax, and tracheal laceration in <1 percent each.
Orringer MB, et al. Ann Surg. 2007

30. Ivor-Lewis transthoracic esophagectomy
• Lower third of the esophagus.
• Not the optimal approach for cancers located in the middle third because of the limited
proximal margin that can be achieved.
• Combines a laparotomy with a right thoracotomy and an intrathoracic anastomosis.
• Direct visualization of the thoracic esophagus & allows a full thoracic lymphadenectomy.
• Minimally invasive Ivor-Lewis approach to a thoracotomy.
• Disadvantages :
Limited length of proximal esophagus that can be resected to achieve a R0,
Intrathoracic anastomosis.
3 to 20 percent risk of severe bile reflux.
Higher morbidity (64%) and mortality associated with leak.
With current technique, mortality rates are substantially lower.

31. Modified Ivor-Lewis transthoracic
esophagectomy
Left thoracoabdominal incision (single incision)
Gastric pull-up and an esophagogastric anastomosis in the left chest.
Most useful for tumors involving the GEJ.
Disadvantages include a high incidence of complications such as
postoperative reflux and limitation of the proximal esophageal margin
by the aortic arch.

32. Tri-incisional esophagectomy
• Combines the THE and TTE approaches (MIS can be perfomed)
• Transthoracic total esophagectomy with a thoracic lymphadenectomy and
cervical anastomosis.
• Allows a complete 2-field (mediastinal and upper abdominal)
lymphadenectomy under direct vision.
• Advantages of a neck anastomosis :
Easier management of a possible leak
Lower reflux
More extensive proximal resection margin
Location outside of radiation ports if administered preoperatively.

33. Oncological principles
1. Thoracotomy
A right posterolateral thoracotomy or a thoracoscopy is performed to assess
resectability and exclude local invasion of contiguous structures.
En bloc resection is performed
2. Laparotomy
Metastatic disease is excluded, and the stomach is mobilized with
construction of conduit.
3. Neck incision –
Left neck exposure preferred.
Left RLN recurs lower (around the aortic arch) than the right RLN, which recurs
around the subclavian artery and is therefore more likely to be injured from a right
neck approach.

35. Annals RCT

36. EGJ cancer resection
• Surgical management is standard of care
includes either an esophagectomy with partial
or extended gastrectomy, with/out
thoracotomy.
• Principles:
R0 resection,
4-cm (distal) gastric margin,
5-cm esophageal margin, and
Resection of at least 15 nodes in
basins appropriate for the primary tumor.
• Solely transabdominal approach without
thoracoabdominal incision or THE is not
acceptable for tumors that involve the distal
esophagus.
Siewert JR, et al. Chirurg 1987

37. • The contemporary operative approach for EGJ cancer is based upon
findings of 2 phase III trials.
● A Japanese trial (JCOG 9502)
Compared THE vs extended esophagectomy using a left
thoracoabdominal approach (LTA) for patients with Sievert
type II or III adenocarcinoma.
THE gp: Received a total gastrectomy plus a D2
lymphadenectomy (including splenectomy) and PALND.
LTA gp: Underwent thorough mediastinal nodal dissection
below the left IPV + D2 abdominal LAD.
The trial closed prematurely when a planned interim
analysis concluded that it was unlikely that LTA would be
significantly better than TH.
• 5 yr OS was lower in the LTA group (38 vs 52 %, p>0.05),
• 10 yr OS: 24 versus 37 percent (p>0.05)[89].
• More complications and mortality in LTA gp.
• Conclusion: LTA could not be recommended for type II/III
tumors.
● A phase III Dutch trial
N=220 patients with Siewert type I or II adenocarcinoma
Assigned to
a. THE
b. Extended thoracic resection (TTE) with an extended en
bloc lymphadenectomy via the right thoracic approach
[RTA]) [73,86].
• Similar In-hospital mortality.
• More pulmonary complications and postoperative
chylous leakage after RTA.
• More ICU and total hospital stays in RTA group [86].
• Similar 5 yr OS (36 versus 34 percent for RTA and THE)
• Better survival with extended thoracic resection in the
patients with a type I tumor (five-year survival 51
versus 37 percent, p = 0.33).
• Conclusions : Given the greater hazards a/w with
extended transthoracic resection, it could only be
recommended for patients with type I and not type II
tumors.

38. SIEWERT CLASSIFICATION AND THE EXTENT OF THE
SURGICAL RESECTION.
.
Based on information from: Mariette C, Piessen G, Briez N, Gronnier C, Triboulet JP.
Oesphagogastric junction adenocarcinoma: which therapeutic approach? Lancet Oncol
2011; 12:296.
Type II
Arises from the cardia or the EGJ.
Resected by a total gastrectomy, distal
esophagectomy, and regional lymphadenectomy.
Type I
Located in the distal esophagus.
Resected by a subtotal gastrectomy, subtotal
esophagectomy, and regional lymphadenectomy.
Type III
Originates in the subcardial gastric location,
infiltrates the EGJ and distal esophagus from
below.
Resected by a total gastrectomy, distal
esophagectomy, and regional lymphadenectomy

39. Open versus minimally invasive
Advantages of MIS include :
● Smaller incisions
● Less blood loss
● Fewer postop complications
● Shorter ICU and hospital stay
● Better preservation of
postoperative pulmonary function
Areas of uncertainty include:
● Optimal minimally invasive
procedure
● Adequacy of the esophageal and
gastric surgical margins
● Extent of LN dissection
● Safety of minimally invasive
esophagectomy in patients who have
undergone preoperative radiation
therapy
● Long-term oncologic outcomes

40. Safety of MIS Esophagectomy
• No consensus that MIE is associated with a decrease in 30-day
mortality and overall morbidity, as found in many retrospective and
prospective studies:

41. n=75,502 Esophagectomy
n = 1155 : MIE
• No significant benefits as defined by a decrease in 30-day mortality
and overall morbidity (4.3 versus 4.0 percent and 38.0 versus 39.2
percent, respectively).
• The re-intervention rate was significantly higher for patients
undergoing an MIE compared with an open esophagectomy (21.0
versus 17.6 percent).

42. A prospective TIME trial found that patients undergoing an MIE have a better
perioperative hospital course.
N=115
Patients undergoing an MIE had
• Lower rate of in hospital pulmonary infections (12 vs 34%)
• Lower perioperative (within 2 weeks) pulmonary infections (9 vs 29%).
• Similar DFS (36 versus 40 percent) and 3 yr OS (40 versus 51 percent)

43. 12 studies
N = 672 MIE or hybrid minimally invasive esophagectomy (HMIE)
N = 612 Open esophagectomy
No significant difference in
• 30-day mortality.
• Frequency of anastomotic leak
MIS procedures were associated with
• Significantly lower blood loss
• Shorter ICU and hospital stay
• Fewer respiratory complications.
• 50 % reduction in total morbidity.
• Total morbidity was similar for HMIE
procedure and open esophagectomy.

44. • Lap THE was associated with
Fewer overall complications (risk ratio 0.64, 95% CI 0.48-0.86)
Fewer serious complications (risk ratio 0.49, 95% CI 0.24-0.99)
Shorter hospital stays (by three days).
However, RCTs are needed to determine the optimal approach to THE.

45. Total MIE approach
• Limited data for oncologic outcomes.
• In the largest series with oncologic outcomes, 70 of 77 attempts to perform a total MIE were successful.
2 yr OS and DFS were 81 and 74 %, respectively.
Recurrence was documented in 14 patients, 11 of which were distant recurrences.
• No RCTs comparing any form of MIE to an open procedure.
• However, a retrospective Australian series compared outcomes among
• 114 patients : open esophagectomy,
• 309 patients; Thoracoscopic-assisted surgery (TAS)
• 23 patients : Total MIE
While the data suggest potential for a total MIE approach, this cannot be considered a
standard approach.
Berrisford RG, et al; Br J Surg 2008; 95:602.
Smithers BM, et al.. Ann Surg 2007; 245:232.
No differences in the rate of margin positivity or
the no of LN retrieved,
No difference in the time to recurrence or
median or 3 yr OS (compared stage for stage).

46. Combined approach
• Thoracoscopic mobilization of the esophagus + node dissection combined with open laparotomy.
• Most popular MIE technique with the most extensive published experience.
• Relative C/I to thoracoscopic surgery include
Inadequate pulmonary function,
Extensive pleural adhesions,
Prior pneumonectomy,
Bulky tumors,
Locally infiltrative tumors, particularly those with airway involvement
Santillan AA, et l. J Natl Compr Canc Netw 2008; 6:879
Wang H, et al. J Thorac Cardiovasc Surg 2015; 149:1006.

47. Circumferential resection margin
• Unclear prognostic role till recently
• The College of American Pathologists (CAP) defines a positive CRM as the
presence of esophageal cancer at the resection margin.
• The United Kingdom Royal College of Pathologists (RCP) defines a positive
CRM as the presence of esophageal cancer within 1 mm of the resection
margin.
• CAP criteria differentiate a higher-risk group of patients with resectable
esophageal cancer than the RCP criteria.
• Meta- analysis (14 cohort studies including 3566 patients)
5 yr mortality rates were higher for patients with a + CRM
Chan DS, et al. Br J Surg. 2013

48. Extent of lymphadenectomy
• Debated.
• The minimum number of LN that should be removed has not been established.
• However, as many LN should be removed as is feasible, since more extensive
lymphadenectomy has been associated with better survival.
• In a retrospective review of 972 patients with node-negative esophageal cancer:
5 yr DSS : 55 percent when fewer than 11 nodes were resected,
5 yr DSS : 66 percent for 11 to 17 nodes resected
5 yr DSS : 75 percent for 18 or more nodes resected.
The data suggest that the higher number of nodes retrieved correspond to a more
extensive resection.
Greenstein AJ, et al. Cancer 2008

49. Definitions

50. • Many high-volume surgical centers routinely perform en bloc esophagectomy
with a two-field (mediastinal, upper abdomen) LN dissection.
• 3 field lymphadenectomy of the mediastinal, abdominal, and cervical nodes, is
commonly practiced in Asian countries for upper thoracic esophageal cancers.
• In a retrospective review of 1361 patients with SCC of the thoracic esophagus, the
frequency of nodal metastasis was
Neck (9.8 percent)
Upper mediastinum (18.0 percent)
Middle mediastinum (18.9 percent)
Lower mediastinum (11.8 percent)
Upper abdomen (28.4 percent)
Li B, Chen H, et al. J Thorac Cardiovasc Surg. 2012

51. • Proponents of extended lymphadenectomy emphasize the relationship between
total LN count and prognosis and quote long-term OS as evidence of its
therapeutic benefit.
• Atorki et al: 80 patients underwent 3 field LAD.
5 yr OS was 51 % (88 % for node-negative and 33% for node-positive).
• Unsuspected metastases in the RLN or cervical nodes were detected in 36 % of
pts.
• The location of the tumor (upper versus middle to lower-third) may have an
influence on the frequency of finding cervical nodal metastases.
• At least two randomized trials have compared different extents of
lymphadenectomy during esophageal cancer surgery.
Neither provided a conclusive result as to the benefit of 3 field LAD.
• In the US, en bloc resection of the mediastinal and upper abdominal lymph nodes
is considered a standard component of transthoracic esophagectomy.
Altorki N, et al Ann Surg 2002
Hulscher JB, et al. N Engl J Med. 2002
Nishihira T, et al. Am J Surg. 1998

52. 2 field vs 3 field

53. Hand-sewn versus stapled anastomosis
• Hand-sewn (single versus double layer) vs Stapled (circular versus
side-to-side linear) vs Hybrid linear stapled technique,
• Surgeon experience : most important determinant at present.
Meta-analysis (12 RCTs with 1407 patients):
(Circular stapled vs hand sewn)
• Similar rate of anastomotic leak.
• More strictures with circular stapler.
A hybrid linear stapled technique (modified Collard
technique)
65 % increase in the anastomotic cross-sectional area
Reduced morbidity.
In a review of 274 patients (Hybrid i.e modified Collard
technique vs hand sewn), the pts with hybrid
anastomosis had:
Less cervical wound infections (8 versus 29 percent) .
Similar leak rate
Fewer anastomotic dilatations (4 versus 11%,
mean 2.4 versus 4.1 per patient, respectively).
Honda M, et al. Ann Surg. 2013
Collard JM, et al. Ann Thorac Surg
Ercan S, et al. J Thorac Cardiovasc Surg.
2005

54. Cervical versus thoracic anastomosis
• Equally safe when performed using standardized techniques.
• At present, the choice of anastomotic location remains clinician
dependent.
• A cervical anastomosis has a higher leak rate and risk of injury to the
RLN.
• However, the anatomic confines of the neck and thoracic inlet limit
surrounding tissue contamination and, thus, limit morbidity.

55. • 4 clinical trials (267 patients) : 132 cervical anastomosis vs thoracic
anastomosis
Cervical anastomosis were associated
• Higher rate of anastomotic leak (18 versus 4 %).
• Significantly higher rate of RLN injury (OR 7.14, 95% CI 1.75-29.14)
• No difference in rate of pulmonary complications, perioperative
mortality, benign stricture formation, or tumor recurrence at the
anastomotic site.

56. Orthotopic placement
• Orthotopic placement is generally preferred.
• A meta-analysis of trials comparing the posterior mediastinal route
and the retrosternal route was unable to demonstrate any difference
in postoperative morbidity .
• Other series revealed a higher anastomotic leak rate in the
retrosternal route, likely due to increased length requirements for the
conduit as well as compression.
Urschel JD, Urschel DM, Miller JD, et al. Am J Surg 2001
Collard JM, Tinton N, Malaise J, et al. Ann Thorac Surg 1995
Ngan SY, Wong J. J Thorac Cardiovasc Surg 1986

57. Role of pyloroplasty or pyloromyotomy
Meta-analysis:
9 trials and 553 esophagectomy patients
Randomized to pyloromyotomy vs none
Lower risk of GOO for patients with a
pyloromyotomy (p <0.046).
No difference for:
Operative mortality
Anastomotic leaks
Pulmonary morbidity
Fatal pulmonary aspiration.
Urschel JD, et al. Dig Surg. 2002
Prospective study :
N = 242 patients
Group A : No pyloromyotomy (n = 83)
Group B : Pyloromyotomy (n = 159)
Results:
Pyloromyotomy does not reduce the
incidence of symptomatic DGE.
(Group A 9.6% vs Group B 18.2%, p=0.078).
Post-operative GOO can be effectively
managed with endoscopic pyloric dilatation.
Lanuti M, et al. Eur J Cardiothorac Surg. 2007

58. Recurrent laryngeal nerve identification
• Injury can occur during cervical or upper thoracic dissection.
• Incidence: 2-17 %
• More common when a cervical approach is utilized.
• Principles
Precise knowledge of cervical esophageal
anatomy.
Plane of dissection should be as close as possible to
the esophagus.
Avoidance of metal or rigid retractors along the TE
groove.
Orringer MB, et al. Ann Surg. 2007

59. Jejunal feeding tube placement
• A feeding jejunostomy tube is inserted at the time of the surgical
resection for all patients undergoing an esophagectomy and for select
patients who require nutritional support during induction
chemotherapy and/or radiation therapy.
• The jejunostomy tube is inserted 40 cm distal to the ligament of
Treitz, using either a laparoscopic approach if technically feasible or
through a small laparotomy incision.

60. POSTOPERATIVE MANAGEMENT
• Enteral feedings are started on POD 2 and slowly advanced.
• OGS is performed on POD 7 to evaluate for leak and emptying of the conduit.
• The NG tube generally remains in place until OGS is performed and demonstrates no leak.
• Minimal liquid diet for approximately 2 weeks.
• Postoperative thromboprophylaxis : Controversial
High risk procedure :Postoperative thromboprophylaxis is recommended (The American College of
Chest Physicians Guidelines on the Prevention of VTE)
High risk of bleeding : Especially in the setting of blunt mediastinal dissection, and thus argue for less
aggressive prophylaxis.
Frequent use of neuraxial anesthesia, which further limits the use of perioperative anticoagulants for
thromboprophylaxis .
Unfortunately, a paucity of data exists to help clarify these issues, and, therefore, clinical practice
varies.
Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical
Practice Guidelines (8th Edition). Chest 2008; 133:381S.
Horlocker TT, Vandermeuelen E, Kopp SL, et al. Reg Anesth Pain Med 2018; 43:263.

61. Early Feeding after Esophagectomy

62. MORBIDITY AND MORTALITY
• The overall incidence of postoperative complications varies widely
between 20 and 80 percent
• Includes systemic complications (eg, pneumonia, myocardial
infarction) and complications specific to the surgical procedure (eg,
anastomotic leaks, recurrent laryngeal nerve injury).
• Pulmonary complications : mc (16 – 67%), mc of mortality.
• Anastomotic leak is the most dreaded (0-40%)
• The overall in-hospital mortality rates range from 0 to 22 percent.
• The overall 30-day mortality rates (excluding in-hospital deaths) is <1
to 6 percent.

63. Systemic complaints
Pulmonary
MC (16 to 67%)
60% of mortality
Cardiac
AF: 20%
MI: 1.1-3.8%
Anastomotic leak — 5-40 %,
Mortality a/w with leaks: 2-12 %.
Factors affecting leaks:
Anastomotic technique
Location (neck vs chest)
Type of conduit (stomach vs colon vs small bowel)
Location of the conduit (orthotopic vs heterotopic)
Other Risk Factors:
Conduit ischemia
Neoadjuvant therapy
Comorbid conditions like heart failure,
hypertension, renal insufficiency.
Type of procedure
M/M
Neck leaks : Wound m/m
Thoracic leaks: Re-exploration, Endoscopic
stenting or clips, transluminal vacuum therapy
Conduit ischemia — 9%
Minor leak to, rarely, complete loss of the
conduit.
Rate of ischemia similar for gastric pull-up &
colonic interposition graft (10.4 vs 7.4 %).
Total conduit ischemia: Rapidly deteriorating
course with septic shock.
Mandates aggressive resuscitation, surgical
removal, drainage and proximal esophageal
diversion, broad-spectrum antibiotic
coverage.
Anastomotic stricture : 9 to 40 %
Linked to conduit malperfusion/ischemia or
surgical technique. Endoscopic dilatation.
RLN injury — Hoarseness, dyspnea, and/or
aspiration pneumonia.
Laryngoscopy and esophageal swallow
evaluation.
More common in cervical anastomosis and
3-field lymphadenectomy.
Management of a laterally paralyzed cord
requires vocal cord injection or temporary
vocal cord medialization.
Chylothorax — 0 to
8% . 18% mortality
rates and 85% major
30-day complication.
Diagnosis : High
chest tube output
(milky)
TGs >110,
chylomicrons +
M/M: Parenteral nutrition +octreotide + fluid resuscitation.
Early surgical intervention (within 14 days from diagnosis) is favored if it
persists (>10 mL/kg for 5 days)
If the site of the leak is not identified, ligation of all tissue between the spine
and the aorta is performed as caudal as possible in the right hemithorax.

64. QUALITY OF LIFE
• Temporary and long-term detrimental impacts on HR-QOL.
• Recovery seems to occur within 12 to 24 months.
• Long-term survivors still report residual problems with eating,
breathlessness, diarrhea, reflux, fatigue, and odynophagia even after 3-4
years.
• Recovery of HR-QOL may be to the occurrence of postoperative
complications.
• Patients who sustained a major postoperative complication (eg,
pneumonia, anastomotic leak) had significant more dyspnea, fatigue and
eating restrictions.
Derogar M,et al. Influence of major postoperative complications on health-related quality of life among long-term survivors of esophageal
cancer surgery. J Clin Oncol. 2012

65. Centralization of Esophageal surgery
• Lower mortality rates and better clinical outcomes in large volume
centres compared with lower-volume institutions.
• The definition of low versus high volume is variable, with most studies
defining "low volume" as <4 to <10 procedures and "high volume" as
>9 to >40 procedures.
• As an example, in one report that used Medicare claims data, the
mortality following esophagectomy at the highest-volume hospitals
(>19 procedures annually) was significantly lower compared with the
lowest-volume hospitals (<2 procedures annually)
Birkmeyer et al. Engl J Med. 2002