Esophageal Resection

Esophageal Resection – Introduction

esophageal resection (surgery to remove all or part of the esophagus) is commonly performed for management of esophageal cancer, but in rare cases may also be indicated for benign conditions refractory to other management methods^(1,2,3,4)
surgery may be performed via an open or laparoscopic approach using transthoracic (Ivor Lewis, McKeown, and left thoracoabdominal) or transhiatal techniques^(1,2,3,4)

Synonyms

Esophagectomy

Definitions

American Joint Committee on Cancer (AJCC) staging for esophageal cancer, eighth edition definitions of staging abbreviations
- primary tumor (T)
  - TX – primary tumor cannot be assessed
  - T0 – no evidence of primary tumor
  - Tis – high-grade dysplasia (malignant cells confined to epithelium by basement membrane)
  - T1 – tumor invades lamina propria, muscularis mucosae, or submucosa
    - T1a – tumor invades lamina propria or muscularis mucosae
    - T1b – tumor invades submucosa
  - T2 – tumor invades muscularis propria
  - T3 – tumor invades adventitia
  - T4 – tumor invades adjacent structures
    - T4a – tumor invades pleura, pericardium, azygos vein, diaphragm, or peritoneum
    - T4b – tumor invades other adjacent structures, such as aorta, vertebral body, or airway
- regional lymph nodes (N)
  - NX – regional lymph nodes cannot be assessed
  - N0 – no regional lymph node metastasis
  - N1 – metastases in 1-2 regional lymph nodes
  - N2 – metastases in 3-6 regional lymph nodes
  - N3 – metastases in ≥ 7 regional lymph nodes
- Used with permission of the American College of Surgeons, Chicago, Illinois. The original source for this information is the AJCC Cancer Staging Manual, Eighth Edition (2017) published by Springer International Publishing.

Incidence/Prevalence

29% rate of esophagectomy in cohort study of 10,364 patients diagnosed with esophageal cancer from 2010 to 2018 in Canada (JAMA Netw Open 2021 Sep 1;4(9):e2126090 full-text)
rates of esophagectomy in patients with benign conditions
- while esophagectomy is rarely required for management of esophageal perforation, urgent esophagectomy reported in 67% of patients who have a perforated esophagus > 5 cm with mediastinal or abdominal contamination and concomitant benign or malignant strictures⁽³⁾
- 48% of adults with esophageal stenosis from ingestion of corrosive substances and who were refractory to endoscopic dilation had esophagectomy and 52% of adults had esophageal bypass in retrospective cohort of 27 adults (J Surg Res 2021 Aug;264:249)
- leiomyomas reported to be the most commonly resected benign neoplasm with 10% of patients reportedly requiring esophagectomy⁽³⁾

Indications

esophagectomy is primarily performed for patients with esophageal cancer, often with associated lymphadenectomy
- consider esophagectomy for patients who are deemed fit to withstand surgery and have resectable tumors (> 5 cm from cricopharyngeus)⁽²⁾
- esophageal resection is indicated for patients with extensive carcinoma in situ (pTis or high-grade dysplasia) or pT1a tumors, especially for nodular disease not adequately removed by ablation alone or endoscopic resection followed by ablation (NCCN Category 2A)⁽²⁾
- esophageal resection can be performed after chemotherapy and radiation therapy
  - consider salvage esophagectomy in patients who develop persistent or progressive localized, resectable esophageal cancer after definitive chemoradiation if no distant recurrence present (ESMO Grade B, Level II) (Ann Oncol 2016 Sep;27(suppl 5):v50)
  - Enhanced Recovery After Surgery (ERAS) recommendations for optimal timing of surgery (ERAS Moderate recommendation, Moderate-quality evidence)⁽⁴⁾
    - 3-6 weeks after completion of chemotherapy (in patients not having radiation therapy)
    - 6-10 weeks after completion of radiation therapy
- surgery alone (without preoperative therapy) is a treatment option for localized disease without suspected lymph node involvement (T1-2, N0, M0) (ESMO Grade B, Level II) (Ann Oncol 2016 Sep;27(suppl 5):v50)
- types of esophageal malignant tumors that may require esophagectomy include⁽²⁾
  - squamous cell carcinoma
    - Tis and T1a tumors
    - T1b tumors
    - cT1b-cT2 tumors
    - N0 tumors; < 3 cm in diameter and well-differentiated if low-risk N0 tumor
  - adenocarcinoma
    - some invasive primary T1b tumors with nodular involvement that may not be treated with resection plus ablation
    - cT1b-cT2 tumors
    - N0 tumors; < 3 cm in diameter and well-differentiated if low-risk N0 tumor
rarely, esophagectomy may be indicated for benign conditions when all other management methods have failed and the esophagus is not salvageable or is causing a poor quality of life; examples of potential indications include
- esophageal strictures associated with caustic ingestion or gastroesophageal reflux disease (GERD)^(1,3)
  - rarely indicated in patients with GERD but may be considered in patients with refractory stricture, severe dysmotility, cancer, or previous complications from fundoplication
  - esophageal resection may be complicated due to presence of scar tissue and a herniated stomach from previous failed fundoplication
- caustic ingestion⁽³⁾
  - esophagectomy typically performed acutely in patients who have ingested alkalotic fluids resulting in full-thickness perforation; the distal esophagus is most commonly affected
  - esophageal resection may be considered for refractory esophageal strictures after several failed serial dilations and is more commonly performed in children
- esophageal perforation for any reason, including in patients with^(1,3)
  - esophageal perforation > 5 cm plus mediastinal or abdominal contamination and sepsis⁽³⁾
  - esophageal necrosis (Surg Clin North Am 2014 Feb;94(1):35)
  - esophageal motility disorder such as achalasia that may lead to poor healing of primary repair (Surg Clin North Am 2014 Feb;94(1):35)
  - previous failed endoscopic treatment or surgical repair⁽³⁾
- Barrett esophagus, primarily for patients with high-grade neoplasia or esophageal adenocarcinoma that has extended into submucosa (Gut 2014 Jan;63(1):7, revised recommendation can be found at BSG 2017 Apr)
- recurrent tracheoesophageal fistula⁽¹⁾
- dysmotility disorders such as⁽³⁾
  - end-stage achalasia^(1,3)
  - esophageal spasm⁽³⁾
  - scleroderma⁽³⁾
- benign neoplasm⁽³⁾
  - consider esophageal resection for patients with symptoms of esophageal obstruction or when the lesion can not be identified as malignant or benign and involves a large portion of the esophagus
  - types of benign neoplasms that may require esophagectomy include
    - leiomyoma that are 8 cm- 10 cm in size, have annual morphology, or diffuse involvement
    - gastrointestinal stromal tumors > 2 cm
    - schwannoma > 2 cm
    - adenoma
    - extra-esophageal tumors invading the esophagus
    - fibrovascular polyp
    - granular cell tumor
    - hemangioma
    - inflammatory pseudotumors
    - papilloma
- blunt or penetrating trauma with severe injury to the esophagus (Injury 2017 Aug;48(8):1735)
- indications in pediatric patients can include
  - caustic ingestion
  - tracheoesophageal fistula
  - esophageal atresia
  - see also
    - Caustic Ingestion and Injury
    - Tracheoesophageal Malformations

Preoperative Evaluation and Management

Prehabilitation

preoperative assessment for all nonemergency patients should establish if patient is able to withstand general anesthesia and major thoracic and/or abdominal surgery⁽²⁾
consider multimodal prehabilitation program prior to esophagectomy (ERAS Moderate recommendation, Low-quality evidence)⁽⁴⁾
prehabilitation aims to address modifiable risk factors prior to surgery, such as physical activity, nutritional status, and psychological well-being⁽⁴⁾
- preoperative exercise may increase functional capacity and reduce risk of perioperative morbidity (preoperative exercise for patients having esophagectomy typically include inspiratory muscle training to reduce risk of pulmonary complications)
- malnutrition is common among patients needing esophagectomy and may lead to postoperative morbidity and mortality; enteral nutrition support with or without feeding tubes may improve functional capacity and quality of life
- psychological prehabilitation aims to reduce psychological distress associated with esophageal cancer and treatments, and improve postoperative outcomes
- Reference – Cancers (Basel) 2022 Apr 22;14(9):2096 full-text
no single prehabilitation program is recommended: both unimodal and multimodal programs are available (Cancers (Basel) 2022 Apr 22;14(9):2096 full-text)
≥ 4 weeks of prehabilitation may be needed to influence postoperative recovery⁽⁴⁾

Preoperative Nutritional Assessment and Support

Enhanced Recovery After Surgery (ERAS) recommendations for preoperative nutritional assessment and support in patients having esophagectomy⁽⁴⁾
- perform preoperative nutritional assessment on all patients prior to esophagectomy to assess nutritional status (ERAS Strong recommendation, Low-quality evidence)
  - assess for significant weight loss (>10% premorbid weight loss associated with increased mortality)
  - assess for malnutrition (common in patients with esophageal cancer), defined as
    - weight loss > 10%-15% of body weight in the last 6 months
    - body mass index (BMI) < 18.5 kg/m²
    - serum albumin < 30 g/L
- optimal preoperative management varies by nutrition status
  - low-risk patients with adequate food intake or minimal weight loss can be managed with dietary education
  - moderate-risk patients with anorexia/dysphagia and/or unintentional weight loss of 5%-9% of total body weight can be managed with protein and energy supplements
  - high-risk patients with severe dysphagia (on a puree/fluid diet only), unintentional weight loss > 10%, and/or BMI < 18 kg/m² should be considered for enteral support, preferably using the gastrointestinal tract with selective use of feeding tubes (ERAS Strong recommendation, Low-quality evidence)
- advise patient to stop smoking and avoid high alcohol consumption ≥ 4 weeks before esophagectomy to limit risk of postoperative complications (ERAS Strong recommendation, Moderate-quality evidence)
for patients who require enteral support, a jejunostomy tube is typically preferred over a gastrostomy tube as placement of a gastrostomy tube in the preoperative setting may compromise the use of a gastric conduit for esophageal reconstruction⁽²⁾

Preoperative Cardiopulmonary Assessment and Management

European Society of Cardiology/European Society of Anesthesiology 2014 classification of cardiovascular risk for noncardiac surgery classifies esophagectomy as a high-risk procedure with > 5% reported risk for 30-day cardiovascular death or myocardial infarction (Minerva Anestesiol 2015 Feb;81(2):226)
cardiovascular risk factors for anesthesia complications should be identified during the preoperative evaluation
- functional capacity through self-reported activities of daily living can be used to assess cardiac reserve and metabolic equivalents (METS) (lower number of METS associated with increased risk of cardiovascular events)
- laboratory values such as either N-terminal pro-brain natriuretic peptide (NT-proBNP) or brain natriuretic peptide (BNP) may be used as adjunct measures of cardiovascular risk, with a normal preoperative value for either of these tests predicting a low likelihood of adverse cardiovascular outcomes
- Reference – J Thorac Dis 2021 Oct;13(10):6037 full-text
preoperative cardiopulmonary testing should be individualized, and may be as involved as formal cardiopulmonary exercise testing (CPET), or depending on history and risk factors, may consist of individual components such as an electrocardiogram (ECG), spirometry, treadmill test, or dobutamine stress test⁽⁴⁾
- routine preoperative ECG may not be necessary for all patients having esophageal resection but should be performed in high-risk patients treated with radiation therapy and/or chemotherapy (J Thorac Dis 2021 Oct;13(10):6037 full-text)
- in patients in whom noninvasive cardiopulmonary testing indicates a high risk for cardiovascular complications, CPET can be performed (J Thorac Dis 2021 Oct;13(10):6037 full-text)
- CPET can be incorporated into preoperative assessment of patients having major surgery to help determine risk for postoperative cardiopulmonary complications; however, evidence for use in patients having esophageal resection is limited (ERAS Moderate recommendation, Low-quality evidence)⁽⁴⁾
- reduced preoperative peak V_O2 and preoperative anaerobic threshold associated with increased 1-year mortality and unplanned intensive care unit (ICU) admissions but not noncardiopulmonary complications in patients undergoing esophagectomy
  - based on systematic review of cohort studies
  - systematic review of 7 studies evaluating association between preoperative CPET markers and postoperative complications in 955 patients undergoing esophagectomy
  - in 4 studies CPET performed before starting neoadjuvant therapy, in 1 study after completion of neoadjuvant therapy, and in 2 studies timing of CPET was not clear
  - comparing patients who experienced event vs. patients who did not experience event
    - death after 1 year associated with
      - lower peak V_O2 (standardized mean difference [SMD] -0.31, 95% CI -0.61 to -0.02) in analysis of 3 studies with 439 patients
      - lower anaerobic threshold (SMD -0.34, 95% CI -0.68 to 0) in analysis of 3 studies with 432 patients
    - unplanned readmission to ICU associated with
      - lower peak V_O2 (SMD -0.34, 95% CI -0.6 to -0.08) in analysis of 3 studies
      - lower anaerobic threshold (SMD -0.34, 95% CI -0.61 to -0.07) in analysis of 3 studies
    - cardiopulmonary complications associated with lower peak V_O2 (SMD -0.43, 95% CI -0.77 to -0.09) in analysis of 7 studies with 923 patients, results limited by significant heterogeneity
  - no significant difference in
    - anaerobic threshold between patients with and without cardiopulmonary complications in analysis of 6 studies, results limited by significant heterogeneity
    - peak V_O2 or anaerobic threshold between patients with and without noncardiopulmonary complications in analysis of 5 studies
  - Reference – Ann Surg Oncol 2020 Oct;27(10):3783
administer antithrombotic prophylaxis (low molecular weight heparin [LMWH]) beginning 2-12 hours preoperatively and continue 4 weeks postoperatively to reduce risk of venous thromboembolism; epidural catheter can be placed ≥ 12 hours after last LMWH dose (ERAS Strong recommendation, High-quality evidence)⁽⁴⁾

Preoperative Imaging Studies and Staging

in patients with esophageal cancer, preoperative imaging and staging are performed to assess the resectability of a tumor⁽²⁾
preoperative imaging studies may include⁽²⁾
- computed tomography (CT) of chest and abdomen
- whole body 18-fluorodeoxyglucose (FDG)-positron emission tomography (PET); combination of FDG-PET/CT is preferred
- endoscopic ultrasound
for additional information on imaging for select esophageal conditions, see
- Esophageal and Esophagogastric Junction Cancer
- Achalasia
- Barrett Esophagus
- Caustic Ingestion and Injury
- Esophageal Strictures
- Gastroesophageal Reflux Disease (GERD)
- Perforated Esophagus
- Tracheoesophageal Malformations

Anesthetic Considerations

Anesthesia Strategies and Airway Management

perioperative anesthetic practices within the purview of an anesthesiologist during esophageal resection include
- preoperative assessment
- selecting appropriate type of anesthesia
- ventilation management
- fluid management
- depth management
- temperature control
- monitoring hemodynamic status and need for blood transfusion
- facilitation of early extubation
- postoperative analgesia pain management
- References – J Thorac Dis 2021 Oct;13(10):6037 full-text, J Thorac Dis 2017 Jul;9(Suppl 8):S705 full-text
prior to surgery; caution should be taken in patients with significant dysphagia or symptoms of obstruction (ERAS Strong recommendation, High-quality evidence)⁽⁴⁾
- prolonged fasting was previously thought to reduce the risk of aspiration at time of induction, but evidence to support this is lacking
- patients presenting with significant obstruction may require prolonged fasting; however, insufficient evidence is available to guide recommendation
placement of nasogastric tube for decompression is recommended for patients having esophageal resection⁽⁴⁾
Enhanced Recovery After Surgery (ERAS) recommendations for anesthetic management in patients having esophagectomy⁽⁴⁾
- anesthetic management aims to minimize pulmonary and systemic responses that could lead to adverse events, and to facilitate early extubation
- volatile or IV anesthetics are equally effective for anesthesia maintenance during esophageal resection (ERAS Strong recommendation, Moderate-quality evidence)
- strategies to facilitate early extubation include
  - use of bispectral index (BIS) monitoring to titrate depth of anesthesia (ERAS Strong recommendation, High-quality evidence)
  - use of intermediate-acting neuromuscular blockers (NMBs) (long-acting NMBs and excessive doses should be avoided) (ERAS Strong recommendation, High-quality evidence)
  - avoid volume overload (ERAS Strong recommendation, Moderate-quality evidence)
airway and ventilator management is the primary concern for patients having esophagectomy
- evidence supporting lung protective measures is strong for two-lung ventilation (TLV), but more limited for one-lung ventilation (OLV)⁽⁴⁾
- OLV is typically needed with open esophagectomy (J Thorac Dis 2021 Oct;13(10):6037 full-text)
- if OLV is required, the lowest allowable fraction of inspired oxygen should be set at oxygen saturation > 94% and ideally < 96% (J Thorac Dis 2021 Oct;13(10):6037 full-text)
Enhanced Recovery After Surgery recommendations for lung protective measures in patients having esophagectomy⁽⁴⁾
- recommended lung protective measures for TLV
  - use low tidal volume (V_t) (6-8 mL/kg predicted body weight [PDW]) (ERAS Strong recommendation, High-quality evidence)
  - routine positive end-expiratory pressure (PEEP) > 2-5 cm H₂O and recruitment maneuvers are not well established (ERAS Strong recommendation, Moderate-quality evidence)
- recommended lung protective measures for OLV
  - avoid hyperoxia but allow mild hypercapnia (ERAS Moderate recommendation, High-quality evidence)
  - use low V_t (4-5 mL/kg PDW) (ERAS Moderate recommendation, Moderate-quality evidence)
  - apply PEEP 5 cm H₂O to ventilated lung (ERAS Strong recommendation, Low-quality evidence)
  - apply continuous positive airway pressure (CPAP) 5 cm H₂O to nonventilated lung (ERAS Moderate recommendation, Low-quality evidence)
double-lumen tubes, bronchial blockers, or single-lumen tube may each be used for lung separation
- single-lumen tube is preferred when OLV is not needed (J Thorac Dis 2021 Oct;13(10):6037 full-text)
- double-lumen tube is preferred when OLV is required due to association with fewer complications; however, conversion to single-lumen tube is needed for patients requiring postoperative ventilation to prevent mucosal necrosis (J Thorac Dis 2021 Oct;13(10):6037 full-text, J Vis Surg 2017;3:108 full-text)
- bronchial blockers may be used for patients with a difficult airway who require OLV after awake intubation with fiber optic bronchoscopy through a single-lumen tube (J Thorac Dis 2021 Oct;13(10):6037 full-text)
maintenance of anesthesia with inhaled sevoflurane or desflurane reduces risk of pulmonary complications at 7 days compared to propofol in adults having minimally invasive esophagectomy for esophageal cancer (level 1 [likely reliable] evidence)
- based on randomized trial
- 558 adults having elective minimally invasive esophagectomy for esophageal cancer were randomized to maintenance of anesthesia with inhaled sevoflurane vs. inhaled desflurane vs. IV propofol and followed for 30 days
  - all patients had induction of anesthesia with midazolam 0.03-0.05 mg/kg, sufentanil 0.3-0.5 mcg/kg, propofol 1.5-2.5 mg/kg, plus cisatracurium 0.2-0.4 mg/kg or rocuronium 0.6-1 mg/kg
  - maintenance of anesthesia targeted bispectral index (BIS) between 40 and 60
  - ventilation was performed using pressure-controlled ventilation volume-guaranteed mode as part of lung-protective ventilation strategy
- key exclusion criteria included American Society of Anesthesiologists (ASA) physical status classification IV; acute lung injury or acute respiratory distress syndrome within past 3 months; serious illness, including severe heart failure, severe renal impairment and severe hepatic dysfunction; and pregnancy or lactation
- primary outcome was composite of pulmonary complications, defined as respiratory infection, pleural effusion, pneumothorax, atelectasis, respiratory failure, bronchospasm, pulmonary embolism, or aspiration pneumonitis within 7 days after surgery
- severity of pulmonary complications graded from 0 to 5 points, with 0 points indicating no symptoms and 5 points indicating death before discharge
- outcome assessors were blinded
- sevoflurane and desflurane groups were pooled (volatile anesthesia) for primary analysis; pairwise comparisons between groups were considered exploratory
- 553 patients (99.1% of randomized; mean age 65 years, 77.6% male) were included in analysis
- all patients had high (≥ 45 points) preoperative Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score at baseline
- comparing volatile anesthesia vs. propofol in primary analysis
  - pulmonary complications within 7 days in 36.5% vs. 47.5% (p = 0.013, NNT 9)
    - respiratory infection in 30% vs. 38.8% (p = 0.038, NNT 12)
    - pleural effusion in 6.8% vs. 10.4% (not significant)
    - pneumothorax in 1.1% vs. 1.6% (not significant)
    - atelectasis in 7.3% vs. 8.7% (not significant)
    - respiratory failure in 2.2% vs. 2.2% (not significant)
    - bronchospasm in 1.1% vs. 0% (not significant)
    - pulmonary embolism in 0% vs. 0.5% (not significant)
    - aspiration pneumonitis in 0% vs. 0%
  - pulmonary complication severity score ≥ 3 points in 33.8% vs. 44.8% (p = 0.012, NNT 9)
  - surgery-related complications (Clavien-Dindo grade ≥ 2) within 7 days in 57.6% vs. 63.4% (not significant)
  - 30-day mortality 2.2% vs. 2.2% (not significant)
- consistent results for pulmonary complications within 7 days in analysis adjusted for baseline differences in intubation strategy, surgery time, and total fluids
- no significant differences in quality of recovery, length of hospital stay, and unplanned intensive care unit admission
- in exploratory analysis of pairwise comparisons
  - pulmonary complications within 7 days
    - 31.9% with desflurane (p = 0.002 vs. propofol, NNT 7; p = 0.066 vs. sevoflurane)
    - 41.1% with sevoflurane (not significant vs. propofol)
    - 47.5% with propofol
  - respiratory infection within 7 days
    - 23.8% with desflurane (p = 0.002 vs. propofol, NNT 7; p = 0.009 vs. sevoflurane NNT 8)
    - 36.2% with sevoflurane (not significant vs. propofol)
    - 38.8% with propofol
- Reference – Anesth Analg 2024 Jan 9 early online

Fluids and Monitoring

fluid levels should be monitored during the entire perioperative period as fluid administration with esophageal resection is a complex process
- esophageal resection is a combination of gastrointestinal surgery (typically requiring large quantities of fluid) and thoracic surgery (typically requiring fluid restriction)
- close observation of in/out fluid balances and maintenance of vital signs is preferred over dynamic indices (systolic pressure, pulse pressure, and stroke volume variations) to guide fluid administration in cases of open esophagectomy
- fluid administration is only needed if the patient is losing fluid
- intraoperative fluid > 4 L and increased fluid levels on postoperative day 1 are each associated with increased risk of pulmonary complications
- Reference – J Thorac Dis 2021 Oct;13(10):6037 full-text
optimal fluid balance is achieved with consideration of all contributory factors; avoid positive fluid balance leading to > 2 kg/day weight gain (ERAS Strong recommendation, High-quality evidence)⁽⁴⁾
fluid administration methods
- zero-balance approach is suggested for low-risk patients with maintenance infusion rate of 1-3 mL/kg/hour (J Thorac Dis 2021 Oct;13(10):6037 full-text)
- goal-directed fluid therapy may be considered for high-risk patients (ERAS Weak recommendation, Moderate-quality evidence)⁽⁴⁾
- consider balanced crystalloids for fluid replacement (ERAS Moderate recommendation, Moderate-quality evidence)⁽⁴⁾
- for patients having epidural analgesia who are hypotensive but normovolemic, vasopressors may be initiated⁽⁴⁾
  - norepinephrine is reported to be the preferred vasopressor for patients in septic shock or cardiogenic shock and may decrease the need of fluid replacement (Ann Transl Med 2018 Nov;6(Suppl 1):S25 full-text)
  - 16% of 327 patients who had Ivor Lewis esophagectomy reported to develop anastomotic leak in retrospective cohort study; use of vasopressors or the amount of IV fluid given were not significantly associated with risk of anastomotic leak (Dis Esophagus 2021 Apr 7;34(4):doaa090 full-text)
  - CLINICIANS’ PRACTICE POINT: Some surgeons are concerned that vasopressors might cause excessive vasoconstriction of the blood vessels supplying the esophageal anastomosis, which may increase the risk of tissue ischemia, necrosis, and anastomotic leak. Trying to reduce the frequency of anastomotic leaks is an area of ongoing research.

Prophylaxis for Postoperative Nausea and Vomiting

in high-risk patients, prophylaxis can reduce the risk for postoperative nausea and vomiting (PONV) (ERAS Strong recommendation, Low-quality evidence)⁽⁴⁾
- combination therapy is preferred for PONV prophylaxis
- in patients who develop PONV, treatment with 5-hydroxytryptamine receptor antagonists (such as ondansetron) is suggested
use a multimodal treatment strategy combining pharmacologic and nonpharmacologic prophylaxis when possible to reduce risk for PONV in addition to anxiety and pain, including
- reduction of procedure-related risk factors for PONV
  - avoid nitrous oxide and volatile anesthetics
  - provide adequate hydration
  - follow fasting guidelines preoperatively
- preoperative anxiolysis (often with midazolam)
- prophylactic antiemetics (such as droperidol at induction and ondansetron at end of surgery)
- total IV anesthesia (TIVA) with propofol
- Reference – Anesth Essays Res 2016 Sep;10(3):388

Surgical Techniques

Overview of Surgical Techniques

a wide variety of esophageal resection techniques are available; however, minimally-invasive and robotic-assisted approaches are becoming more commonly used⁽¹⁾
a hybrid surgical technique, combining laparoscopic and open surgical techniques (laparoscopy and thoracotomy or laparotomy and thoracoscopy) has also been utilized (BMC Cancer 2011 Jul 23;11:310 full-text)
factors influencing selection of surgical approach include
- location of tumor⁽¹⁾
- potential for metastases along the esophagus or stomach⁽¹⁾
- potential for lymphatic compromise⁽¹⁾
- patient physiologic state⁽¹⁾
- surgeon preference⁽¹⁾
- etiology of benign conditions requiring esophageal resection⁽³⁾
esophageal resection can be performed using a transthoracic or transhiatal approach
- transthoracic approach provides enhanced visualization and exposure, allowing for wider tumor resection margins and greater nodal dissection (examples include the Ivor Lewis, McKeown, and left thoracoabdominal techniques)⁽¹⁾
- transhiatal approach is typically performed for patients with tumors of the lower third of the esophagus or gastric cardia, and in patients with benign conditions requiring esophagectomy⁽¹⁾
  - possibly associated with reduced risk of respiratory complications as it avoids the need for a thoracotomy or intrathoracic anastomosis
  - may be associated with increased risk for anastomotic leak from the cervical anastomosis, subsequent stricture formation, and recurrent laryngeal nerve injury
- other reports suggest that the transhiatal and transthoracic approaches have comparable risks of pulmonary complications, and that the universal application of Enhanced Recovery After Surgery (ERAS) and other clinical pathways may have one of the most important roles in preventing pulmonary complications (Dis Esophagus 2017 Nov 1;11(1):43, BMC Surg 2020 Jan 3;20(1):3 full-text)
- either approach may be used in patients with benign conditions; however, the transthoracic approach is typically reserved for more complex cases⁽³⁾
nasogastric decompression (with nasogastric tube placement) at the time of esophageal resection is recommended but consider early removal (on postoperative day 2) when clinically indicated (ERAS Strong recommendation, Moderate-quality evidence)⁽⁴⁾
- use of nasogastric tube is routinely used in patients having esophagectomy; however, its use to prevent some complications (such as anastomosis leak and pneumonia) is controversial (J Thorac Dis 2019 Apr;11(Suppl 5):S819 full-text)
- insufficient evidence to inform recommendations on intraoperative insertion of retrograde jejunogastric decompression and pharyngostomy tubes in patients having esophagectomy⁽⁴⁾

Open vs. Laparoscopic and/or Robotic-assisted Procedures

both open and minimally-invasive (or hybrid) approaches to esophagectomy can be used with good outcomes, but minimally-invasive (laparoscopic) procedures may be associated with less perioperative blood loss, reduced incidence of pulmonary infection, and shorter hospital stay compared to open approaches (ERAS Moderate recommendation, Moderate-quality evidence)⁽⁴⁾
a hybrid approach incorporates both open and laparoscopic techniques, such as laparoscopy and thoracotomy or laparotomy and thoracoscopy (BMC Cancer 2011 Jul 23;11:310 full-text)
open procedure may be more appropriate for patients with⁽²⁾
- history of previous abdominal surgery
- large and/or bulky tumors
- unusable gastric conduit
- difficulty with lymph node dissection
robotic-assisted esophagectomy is a newer minimally invasive technique that allows for three-dimensional views for dissection, but it requires special training and equipment and is associated with a longer operating time⁽²⁾
EVIDENCE SYNOPSIS: Laparoscopic and open esophagectomy are associated with similar overall survival and recurrence rates, but the laparoscopic approach may reduce risk for serious adverse events and pulmonary complications.
- laparoscopic transhiatal esophagectomy associated with similar mortality and recurrence and reduced risk of serious adverse events compared to open transhiatal esophagectomy in patients with esophageal cancer (level 2 [mid-level] evidence)
  - based on Cochrane review of observational studies
  - systematic review of 6 observational studies comparing laparoscopic vs. open transhiatal esophagectomy in 334 patients with esophageal cancer
  - no significant differences in
    - short-term mortality in analysis of 5 studies with 326 patients
    - long-term mortality in analysis of 2 studies with 193 patients
    - recurrence in analysis of 2 trials with 173 patients
  - laparoscopic transhiatal esophagectomy associated with
    - lower risk of serious adverse events (risk ratio 0.49, 95% CI 0.24-0.99) in analysis of 3 studies with 213 patients
    - shorter duration of hospital stay in 3 studies with 266 patients
  - Reference – Cochrane Database Syst Rev 2016 Mar 31;3:CD011390 full-text
- minimally invasive transthoracic esophagectomy may reduce postoperative pulmonary infection compared to open transthoracic esophagectomy in patients with resectable cancer of intrathoracic esophagus or gastroesophageal junction (level 2 [mid-level] evidence)
  - based on randomized trial without blinding of outcome assessors
  - 115 patients aged 18-75 years with resectable cancer of intrathoracic esophagus or gastroesophageal junction (adenocarcinoma, squamous cell carcinoma, or undifferentiated) randomized to minimally invasive transthoracic esophagectomy vs. open transthoracic esophagectomy
  - patients followed for 12 months
  - comparing minimally invasive vs. open transthoracic esophagectomy
    - pulmonary infection within 2 weeks in 9% vs. 29% (p = 0.005, NNT 5)
    - pulmonary infection in-hospital in 12% vs. 34% (p = 0.005, NNT 5)
    - median hospital stay of 11 days vs. 14 days (p = 0.044)
    - mortality in-hospital 3% vs. 2% (no p value reported)
    - 30-day mortality 1% vs. 0% (no p value reported)
  - Reference – TIME trial (Lancet 2012 May 19;379(9829):1887, editorial can be found in Lancet 2012 May 19;379(9829):1856)
  - minimally invasive and open transthoracic esophagectomy may be associated with similar 3-year overall and disease-free survival in patients with resectable cancer of intrathoracic esophagus or gastroesophageal junction (level 2 [mid-level] evidence)
    - based on follow-up of TIME trial with wide confidence intervals
    - 115 patients (100%) included in 3-year follow-up
    - comparing minimally invasive vs. open transthoracic esophagectomy at 3 years
      - overall survival 50.5% vs. 40.4% (hazard ratio 0.88, 95% CI 0.54-1.44), not significant, but CI includes possibility of benefit or harm
      - disease-free survival 40.2% vs. 35.9% (hazard ratio 0.69, 95% CI 0.39-1.24), not significant, but CI includes possibility of benefit or harm
    - Reference – TIME trial (Ann Surg 2017 Aug;266(2):232, commentary can be found in Ann Transl Med 2018 Feb;6(4):85)
- hybrid minimally invasive esophagectomy reduces risk of intraoperative and postoperative major complications (level 1 [likely reliable] evidence) and might increase survival at 3 years (level 2 [mid-level] evidence) compared to transthoracic open esophagectomy in adults with resectable esophageal cancer
  - based on randomized trial with confidence interval that includes differences that are not clinically important for survival at 3 years
  - 207 patients aged 18-75 years (85% male) with resectable squamous-cell carcinoma or adenocarcinoma of middle or lower third of esophagus were randomized to hybrid minimally invasive esophagectomy vs. transthoracic open esophagectomy and followed for 3 years
    - hybrid minimally invasive surgery or Ivor Lewis procedure included 2-field abdominal-thoracic surgery with laparoscopic gastric mobilization and open right thoracotomy
    - all patients had World Health Organization performance status score 0-2 points on 5-point scale, with higher scores indicating greater disability
  - primary outcome assessed at 30 days was intraoperative or postoperative complication of grade II or higher based on Clavien-Dindo classification (major complication leading to intervention)
  - 99% had esophagectomies, 100% included in analysis
  - comparing hybrid minimally invasive esophagectomy vs. transthoracic open esophagectomy
    - primary outcome in 36% vs. 64% (p < 0.001, NNT 4)
    - major pulmonary complications in 18% vs. 30% (no p value reported)
    - 3-year overall survival 67% vs. 55% (hazard ratio for death 0.67, 95% CI 0.44-1.01), not significant, but CI includes both clinically important and unimportant differences
    - 3-year disease-free survival 57% vs. 48% (hazard ratio for first tumor recurrence, second cancer, or death 0.76, 95% CI 0.52-1.11), not significant, but CI includes possibility of benefit or harm
  - operative times, median length of hospital stay, postoperative mortality at 30 days, and major/minor intraoperative and postoperative overall morbidity at 30 days were similar in both groups
  - Reference – MIRO trial (N Engl J Med 2019 Jan 10;380(2):152)
  - hybrid minimally invasive esophagectomy might increase survival at 5 years compared to transthoracic open esophagectomy in adults with resectable esophageal cancer (level 2 [mid-level] evidence)
    - based on post hoc follow-up of MIRO trial with confidence interval that includes differences that are not clinically important
    - 100% were included in analysis at median 58.2 months
    - comparing hybrid minimally invasive esophagectomy vs. transthoracic open esophagectomy
      - 5-year overall survival 59% vs. 47% (hazard ratio for death 0.71, 95% CI 0.48-1.06), not significant, but CI includes both clinically important and unimportant differences
      - 5-year disease-free survival 52% vs. 44% (hazard ratio for recurrence or death 0.81, 95% CI 0.55-1.17)
      - recurrent disease in 40% vs. 44% (not significant)
    - Reference – MIRO trial (JAMA Surg 2021 Apr 1;156(4):323 full-text, editorial can be found in JAMA Surg 2021 Apr 1;156(4):332)
- minimally invasive esophagectomy associated with similar overall survival, decreased risk of pulmonary complications, and shorter length of hospital stay compared to open esophagectomy in patients with esophageal squamous cell carcinoma having McKeown esophagectomy (level 2 [mid-level] evidence)
  - based on retrospective cohort study
  - 917 patients with esophageal squamous cell carcinoma who had McKeown esophagectomy at a single center between 2011 and 2016 were included in analysis
    - 67% had total minimally invasive esophagectomy
    - 33% had open esophagectomy
  - propensity score for likelihood of having total minimally invasive esophagectomy or open esophagectomy was calculated for each patient based on demographic and clinical factors
  - 288 patients who had total minimally invasive esophagectomy (mean age 59 years, 98% male patients) and 288 patients who had open esophagectomy (mean age 60 years, 74% male patients) were included in propensity-matched analysis
  - comparing total minimally invasive esophagectomy vs. open esophagectomy in propensity-matched analysis
    - median overall survival 61.4 months vs. 61.1 months (not significant)
    - postoperative complications in 49.7% vs. 58.7% (p = 0.03)
      - pneumonia in 7.6% vs. 14.9% (p = 0.006)
      - respiratory insufficiency in 4.9% vs. 11.8% (p = 0.003)
      - cervical anastomotic leakage in 14.2% vs. 27.8% (p < 0.001)
      - wound infection in 0.7% vs. 3.5% (p = 0.02)
      - pleural effusion in 19.1% vs. 13.5% (p = 0.071)
      - pneumothorax in 4.9% vs. 2.1% (p = 0.069)
      - use of intubation ventilator for > 2 days in 9.7% vs. 17.7% (p = 0.005)
    - mean length of postoperative hospital stay 18.2 days vs. 23.2 days (p = 0.002)
    - mean length of intensive care unit stay 2.4 days vs. 3.6 days (p = 0.007)
    - 30-day mortality 0% vs. 2.8% (p = 0.004)
    - 90-day mortality 0.7% vs. 5.9% (p < 0.001)
  - no significant differences in intraoperative blood loss, operative duration, R0 resection rate, number of lymph nodes harvested, or reoperation rate
  - Reference – Ann Thorac Surg 2022 Feb;113(2):473
- robot-assisted minimally invasive esophagectomy associated with similar mortality but reduced risk of pulmonary complications, atrial fibrillation, and wound infection compared to open esophagectomy in patients with esophageal cancer (level 2 [mid-level] evidence)
  - based on systematic review of mostly observational studies
  - systematic review of 1 randomized trial and 9 cohort studies comparing robot-assisted minimally invasive esophagectomy vs. open esophagectomy in 1,977 patients having esophagectomy for esophageal cancer
  - no significant differences in
    - 30-day mortality in analysis of 3 studies with 650 patients
    - 90-day mortality in analysis of 6 studies with 1,229 patients
    - anastomotic leakage in analysis of 10 studies with 1,977 patients
    - total number of lymph nodes resected in analysis of 8 studies
    - R0 resection rate in analysis of 6 studies with 1,741 patients
  - robot-assisted minimally invasive esophagectomy associated with
    - decreased risk of overall pulmonary complications (odds ratio [OR] 0.38, 95% CI 0.26-0.56) in analysis of 6 studies with 1,030 patients
    - decreased risk of pneumonia (OR 0.39, 95% CI 0.26-0.57) in analysis of 6 studies with 1,675 patients
    - decreased risk of atrial fibrillation (OR 0.53, 95% CI 0.29-0.98) in analysis of 5 studies with 1,065 patients
    - decreased risk of wound infection (OR 0.2, 95% CI 0.07-0.57) in analysis of 4 studies with 956 patients
    - less blood loss (weighted mean difference -187.08 mL, 95% CI -283.81 to -90.35 mL) in analysis of 8 studies
    - shorter length of hospital stay (weighted mean difference -9.22 days, 95% CI -14.39 to -4.06 days) in analysis of 9 studies
    - longer operating time (weighted mean difference 69.45 minutes, 95% CI 34.39-104.42 minutes) in analysis of 8 studies
    - nonsignificant decrease in risk of overall complications (OR 0.66, 95% CI 0.42-1.05) in analysis of 5 studies with 1,284 patients
  - Reference – Cancers (Basel) 2022 Jun 29;14(13):3177 full-text
6.3% conversion rate from minimally invasive esophagectomy to open esophagectomy in patients with esophageal cancer (level 3 [lacking direct] evidence)
- based on retrospective cohort study
- 2,616 patients with esophageal cancer who had esophagectomy from 2016 to 2018 from American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database were evaluated
  - 55% (1,439) had successfully completed minimally invasive esophagectomy
  - 3.7% (97) had converted minimally invasive esophagectomy to open esophagectomy
  - 41.3% (1,080) had planned open esophagectomy
- 6.3% overall conversion rate for minimally invasive esophagectomy
- 30-day mortality
  - 5.2% with converted minimally invasive esophagectomy (p = 0.06 vs. completed minimally invasive esophagectomy, not significant vs. open esophagectomy)
  - 2% with completed minimally invasive esophagectomy (no p value reported vs. open esophagectomy)
  - 3% with open esophagectomy
- compared to completed minimally invasive esophagectomy, converted minimally invasive esophagectomy associated with
  - increased risks of superficial surgical site infection (SSI), organ space SSI, sepsis, pneumonia, anastomotic leak, ventilation > 48 hours, bleeding requiring transfusion, and unplanned reoperation
  - nonsignificant increase in risks of deep venous thrombosis and unplanned readmission
- compared to open esophagectomy, converted minimally invasive esophagectomy associated with
  - increased risks of organ space SSI, anastomotic leak, bleeding requiring transfusion, unplanned reoperation, and unplanned readmission
  - nonsignificant increase in risks of superficial SSI and sepsis
- Reference – Ann Thorac Surg 2021 Nov;112(5):1593

Transthoracic Approach

Ivor Lewis Technique

Ivor Lewis technique is reported to be the most commonly used transthoracic technique for resection of the middle and lower third esophagus⁽¹⁾
description of procedure⁽¹⁾
- laparotomy (or laparoscopy) is performed to first mobilize the stomach to create a conduit and then mobilize the esophagus within the hiatus
  - a gastric tube may be created, after which an upper abdominal lymphadenectomy is performed with resection of lymph nodes on celiac trunk, splenic, and common hepatic arteries
  - traditionally, a pyloric drainage procedure (such as pyloroplasty, pyloromyotomy, pyloromyomectomy, or botulinum toxin injection into the pyloric muscle) is performed prior to the thoracotomy, but evidence to support the necessity and value of this step is limited
- right thoracotomy is performed with patient placed in the left lateral decubitus position
  - azygos vein can be divided, followed by en bloc resection of the esophagus and adjacent mediastinal lymphatic tissue
    - the thoracic duct and distal portion of the pericardial vein or other mediastinal structures can be included in the resection as needed
    - lymphadenectomy can assist with staging and reduce risk for local recurrence
  - gastric tube or whole stomach conduit is pulled into the chest where the stomach is then divided at the cardia
  - an end-to-end anastomotic stapler is then used to create an intrathoracic anastomosis between the remaining esophagus and the gastric conduit
  - when possible, the esophagogastric anastomosis should be placed as high as possible in the chest (above the azygos vein) for best surgical margin and to decrease reflux
  - in most cases the conduit is placed in the paravertebral space, but it can alternatively be placed in the substernal or right paratracheal position
jejunostomy is typically needed with the Ivor Lewis technique to maintain adequate nutrition⁽¹⁾
in adults with esophageal cancer having hybrid or totally minimally invasive esophagectomy, intrathoracic anastomosis may be associated with decreased risk of anastomotic leakage and other postoperative complications compared to cervical anastomosis (level 2 [mid-level] evidence)
- based on randomized trial with differences in closure technique of anastomosis
- 262 adults with primary esophageal adenocarcinoma or squamous cell carcinoma (cT1b-4a, NO-3, M0) located from mid-to-distal esophagus or at gastroesophageal junction having hybrid or totally minimally invasive esophagectomy were randomized to intrathoracic anastomosis vs. cervical anastomosis (all with omental wrap) and followed for 90 days
- all patients (51) having hybrid minimally invasive approach were treated at single center
- 245 adults (median age 67 years, 78% male) who had minimally invasive esophagectomy and did not withdraw consent were included in analysis
- 2 patients from cervical anastomosis group crossed over to transthoracic anastomosis group
- at surgery, comparing intrathoracic anastomosis group vs. cervical anastomosis group
  - handsewn anastomosis in 3.3% vs. 87.8%
  - end-to-end anastomosis in 2.5% vs. 37.4%
  - end-to-side anastomosis in 34.4% vs. 1.6%
- primary outcome was anastomotic leakage needing endoscopic, radiologic, or surgical intervention within 30 days
- comparing intrathoracic anastomosis vs. cervical anastomosis
  - primary outcome in 12.3% vs. 31.7% (p < 0.001, NNT 6)
  - any anastomotic leakage in 12.3% vs. 34.1% (p < 0.001, NNT 5)
  - Clavien-Dindo level ≥ 3b complication in 10.7% vs. 22% (p = 0.02, NNT 9)
  - pleural effusion needing drainage in 9.8% vs. 21.1% (p = 0.01, NNT 9)
  - recurrent laryngeal nerve palsy in 0% vs. 7.3% (p = 0.003, NNT 14)
  - intensive care unit (ICU) readmission in 9% vs. 17.9% (p = 0.04, NNT 12)
  - median hospital stay 10 days vs. 11.5 (p = 0.003)
  - conversion to laparotomy in 0% vs. 5.7% (p = 0.01, NNT 18)
- no significant differences in other postoperative complications, length of ICU stay, or mortality up to 90 days
- intrathoracic anastomosis reported to be associated with improved quality of life scores for dysphagia, choking when swallowing, and trouble talking (no p values reported)
- Reference – JAMA Surg 2021 Jul 1;156(7):601 full-text, editorial can be found in JAMA Surg 2021 Jul 1;156(7):610

McKeown Technique

McKeown (tri-incisional) technique may be considered for patients with a tumor superior to the gastroesophageal junction and inferior to the clavicle⁽¹⁾
the surgical procedure is similar to the Ivor Lewis technique entailing a right thoracotomy and laparotomy (or laparoscopy); however, addition of a left neck incision with cervical anastomosis makes the McKeown technique more appropriate for proximal esophageal tumors⁽¹⁾
- McKeown technique begins with the patient in the left lateral decubitus position
- while leaving the esophagus intact, a right thoracotomy through the fifth intercostal space is performed to remove compromised portions of the esophagus, adjacent nodules, and mediastinal tissue from noncompromised structures
  - ligation of the thoracic duct may be performed to decrease risk of postoperative chylothorax
  - chest closure begins with placement of surgical drains and positioning the patient supine prior to performing a laparotomy
- midline laparotomy is performed to mobilize the stomach and necessary lymphatic tissue to create a conduit
- a gastric conduit (whole stomach or gastric tube) with or without additional pyloric drainage procedures is placed in the neck through a left cervical incision
- cervical anastomosis is performed after removal of the esophagus; method of removal may vary based on size of lesion but can be through the left neck incision or upper midline incision
jejunostomy typically needed with McKeown technique to maintain adequate nutrition⁽¹⁾

Left Thoracoabdominal Technique

the left thoracoabdominal approach is predominantly used in patients with bulky, distal esophageal or gastroesophageal junction tumors⁽¹⁾
the benefit of this procedure is that it enables exposure of the superior abdominal and posterior mediastinal compartments using a single incision, and allows for extensive lymphadenectomy in the abdomen and posterior mediastinum⁽¹⁾
a thoracoabdominal incision may not be well tolerated and can lead to significant debility in some patients⁽¹⁾

Transhiatal Approach

the transhiatal approach (laparotomy or laparoscopy plus cervical anastomosis) is primarily performed for resection of tumors in the lower third of the esophagus or gastric cardia and for patients with benign conditions requiring esophageal resection⁽¹⁾
- the main benefit of this procedure is that it can reduce risk for respiratory complications by avoiding a thoracotomy and an intrathoracic anastomosis with the potential for an intrathoracic anastomotic leak
- limitations include an increased rate of anastomotic leak for a cervical anastomosis and increased risk of stricture formation and recurrent laryngeal nerve injury
the transhiatal approach is a 3-phase procedure⁽¹⁾
- in the first phase, a supraumbilical incision is used to allow for resection of the distal esophagus
- in the second phase (cervical phase), an incision is made adjacent to the left sternocleidomastoid muscle for dissection of the proximal esophagus
- in the third phase, blunt dissection of the esophagus in the mediastinum is performed transhiatally through the abdominal incision
  - following mobilization of the entire esophagus, the cervical esophagus is transected
  - partial gastrectomy is then performed with removal of the esophagus through the abdominal incision
  - a cervical esophagogastric anastomosis is then created by bringing the gastric conduit up to the neck through the posterior mediastinum
laparoscopic transhiatal esophagectomy associated with similar mortality and recurrence but may reduce risk of serious adverse events compared to open transhiatal esophagectomy in patients with esophageal cancer (level 2 [mid-level] evidence)
- based on Cochrane review of observational studies
- systematic review of 6 observational studies comparing laparoscopic vs. open transhiatal esophagectomy in 334 patients with esophageal cancer
- no significant differences in
  - short-term mortality in analysis of 5 studies with 326 patients
  - long-term mortality in analysis of 2 studies with 193 patients
  - recurrence in analysis of 2 trials with 173 patients
- laparoscopic transhiatal esophagectomy associated with
  - lower risk of serious adverse events (risk ratio 0.49, 95% CI 0.24-0.99) in analysis of 3 studies with 213 patients
  - shorter duration of hospital stay in 3 studies with 266 patients
- Reference – Cochrane Database Syst Rev 2016 Mar 31;3:CD011390 full-text

Selection of Conduit

a gastric tube is the preferred conduit for esophageal reconstruction due to its reliable vascularity and simplicity, but the colon or jejunum can be used as an alternative in cases such as^(1,2,4)
- if the stomach is not available (such as in patients with previous or synchronous gastrectomy)^(1,2,4)
- history of abdominal surgery that has compromised the gastroepiploic artery (main blood supply to a gastric conduit) inhibiting gastric pull-up (Ann Cardiothorac Surg 2017 Mar;6(2):137 full-text)
a colon conduit (typically left colon) is primarily used for patients with benign conditions and a long life expectancy⁽¹⁾
- potential indications include surgery for caustic/peptic strictures, Barrett esophagus, advanced functional disorders, congenital atresia, achalasia, scleroderma, or esophageal varices
- the left colon is preferred because of its relatively smaller diameter, better vasculature, and ability to peristalse more solid boluses
- the colon conduit is placed below the upper esophageal sphincter with cervical esophagocolonic anastomosis, then the distal end is either connected to the posterior of the gastric antrum, or the jejunum (preferred) or duodenum
- integrity of the remaining colon is maintained with ileocolostomy or colocolostomy
- colon conduits are associated with reduced risk for anastomotic leaks compared to gastric conduits
- disadvantages include the more technically challenging procedure, increased morbidity/mortality, and longer operating times compared to gastric conduit
a jejunum conduit is typically reserved for cases where neither the stomach nor colon are available⁽¹⁾
- the portion of jejunum used for a conduit is selected based on vascularity⁽¹⁾
- adequate length is needed to create a pedicled or free graft to replace the esophagus; division of the jejunum mesentery is needed to straighten the segment used for a conduit to limit redundancy (Ann Cardiothorac Surg 2017 Mar;6(2):137 full-text, J Thorac Dis 2014 May;6 Suppl 3:S333 full-text)
- the jejunum conduit is placed in the thoracic cavity in retrogastric position⁽¹⁾
- esophagojejunal anastomosis may be to the intrathoracic or cervical esophagus, and jejunogastric and jejunojejunal anastomoses are then created to establish intestinal continuity⁽¹⁾
- benefits of the jejunum conduit include increased resistance to bile and acid, reduced risk of intrinsic disease, increased peristalsis, better postoperative body weight maintenance, and decreases incidence of gastroparesis⁽¹⁾
- the main limitation is that the procedure requires the creation of at least 3 anastomoses, increasing the potential for complications⁽¹⁾
Enhanced Recovery After Surgery (ERAS) recommendations for selection of conduit⁽⁴⁾
- the stomach, colon, and jejunum are all options for conduit reconstruction after an esophageal resection; the decision for which conduit to use should consider the patient, circumstances, and benefits and limitations of each organ as an esophageal substitute (ERAS Strong recommendation, Low-quality evidence)
- the tubularized gastric (stomach) conduit is recommended as the first-line option for conduit reconstruction due to its reliable vascularity and simplicity (ERAS Strong recommendation, Low-quality evidence)
- routine mechanical bowel preparation is not recommended before esophagectomy with gastric reconstruction as it does not reduce the rate of postoperative complications, however, mechanical bowel preparation is typically performed for planned colonic reconstruction (ERAS Strong recommendation, Moderate-quality evidence)

Lymphadenectomy

Enhanced Recovery After Surgery (ERAS) recommendations for lymphadenectomy in patients having esophageal resection for management of esophageal malignancy⁽⁴⁾
- 2-field lymphadenectomy recommended for middle and lower-third esophageal adenocarcinoma T1b-T3/4 (does not include dissection of recurrent laryngeal nerve nodes) (ERAS Strong recommendation, Moderate-quality evidence)
- 3-field lymphadenectomy recommended for upper third esophageal squamous cell carcinoma (ERAS Strong recommendation, Moderate-quality evidence)
either standard or extended (en-bloc) lymph node dissection can be performed (NCCN Category 2A)⁽²⁾
- in patients without preoperative chemoradiation, ≥ 15 lymph nodes should be removed and evaluated for adequate nodal staging
- in patients with preoperative chemoradiation, the ideal number of lymph nodes requiring removal is unknown, but similar lymph node resection as in patients without preoperative chemoradiation is recommended
removal of ≥ 20 lymph nodes during surgery associated with improved 3-year survival in adults with esophageal cancer who had neoadjuvant chemoradiation therapy (level 2 [mid-level] evidence)
- based on cohort analysis of data from randomized trial
- 182 adults (median age 56 years, 84.6% male) with locally advanced esophageal squamous cell carcinoma who had neoadjuvant chemoradiotherapy and systemic lymph node dissection and achieved R0 resection in NEOCRTEC5010 trial were assessed at 3 years
- 53.3% had removal of ≥ 20 lymph nodes and 46.7% had removal of < 20 lymph nodes
- comparing removal of ≥ 20 lymph nodes vs. < 20 lymph nodes
  - 3-year overall survival 84.3% vs. 64.6% (adjusted hazard ratio [HR] 0.36, 95% CI 0.21-0.63)
  - 3-year disease-free survival 79% vs. 61.1% (adjusted HR 0.42, 95% CI 0.25-0.68)
  - local recurrence in 5.5% vs. 18.8% (p = 0.004)
  - total recurrence in 25.8% vs. 41.2% (p = 0.027)
  - postoperative complications in 41.2% vs. 41.2% (not significant)
- complications occurring in > 5% in both groups were arrythmia in 12.6%, pulmonary infection in 11%, and anastomotic leakage in 8.8%
- Reference – Ann Surg 2023 Feb 1;277(2):259
3-field lymphadenectomy may improve overall survival compared to 2-field lymphadenectomy in adults with resectable esophageal squamous cell carcinoma (level 2 [mid-level] evidence)
- based on systematic review of mostly observational studies
- systematic review of 14 studies (3 randomized trials and 11 retrospective cohort studies) comparing 3-field vs. 2-field lymphadenectomy in 3,431 adults with resectable esophageal squamous cell carcinoma
  - 2 field defined as dissection of abdominal and mediastinal lymph nodes stations
  - 3 field defined as 2 field plus bilateral cervical lymph node dissection (with removal of paraesophageal, deep cervical, and supraclavicular stations)
- tumor characteristics
  - tumors were located in upper (7.7%), middle (65%), and lower (27%) esophagus and tumor size reported in 4 studies ranged from 3 cm to 5.7 cm
  - American Joint Committee on Cancer (AJCC) tumor staging was reported in 9 studies (stage 0-I in 17%, stage II in 33%, stage III in 37%, and stage IV in 12.6%)
- minimum follow-up 5 years
- 3-field lymphadenectomy associated with
  - improved overall survival (hazard ratio for death 0.8, 95% CI 0.71-0.9) in analysis of all studies
  - increased total number of harvested lymph nodes (weighted mean difference 2, 95% CI 1-3) in analysis of 7 studies with 1,561 patients
- difference in mean survival time
  - 1.6 months up to 48 months of follow-up (p = 0.04)
  - 1.2 months up to 60 months of follow-up (not significant)
- no significant differences in 30- or 90-day mortality, anastomotic leak, pulmonary complications, chylothorax, or recurrent nerve palsy in analysis of 7-10 studies
- Reference – Surgery 2022 Apr;171(4):940

Surgical Drainage

Enhanced Recovery After Surgery (ERAS) recommendations for surgical drainage⁽⁴⁾
- evidence for pyloroplasty or other pyloric drainage procedures is limited with no specific recommendation (ERAS Strong recommendation, Low-quality evidence)
- avoid using perianastomotic drains with cervical anastomosis due to lack of proven benefit (ERAS Moderate recommendation, Moderate-quality evidence)
- consider minimizing the use and duration of chest drains following esophagectomy (ERAS Moderate recommendation, Weak-quality evidence)
  - if air and chyle leaks are not present the chest drain may be removed
  - 1 mid-positioned drain is reported to be as effective as 2 drains and associated with less pain
  - passive drainage is reported to be as effective as active drainage

Intraoperative Feeding Tube Placement

lack of feeding jejunostomy tube (J-tube) insertion during esophagectomy associated with increased 30-day all-cause mortality
- based on systematic review of cohort studies and trials with methodologic limitations
- systematic review of 10 cohort studies and 2 randomized trials comparing feeding J-tube insertion vs. no J-tube insertion in 36,284 patients having esophagectomy
  - in J-tube insertion groups, J-tube inserted at time of esophagectomy in 99% of patients and feeding initiated within 48 hours
  - in no J-tube insertion groups, feeding regimens varied and included early oral feeding on day of surgery, postesophagectomy diets starting on fifth postoperative day, and parenteral nutrition before initiation of oral feeding
- methodologic limitations in the 2 randomized trials included small study size (1 trial) and lack of blinding (1 trial)
- comparing no J-tube insertion to feeding J-tube insertion
  - no J-tube insertion associated with increased 30-day all-cause mortality (risk ratio 1.53, 95% CI 1.37-1.7) in analysis of 6 cohort studies with 35,414 patients (63% of patients in 1 cohort study)
  - no significant differences in
    - anastomotic leakage in analysis of 8 studies with 2,450 patients
    - length of hospital stay in analysis of 9 studies with 27,369 patients
    - readmission in analysis of 6 studies with 24,571 patients
    - sepsis in analysis of 4 studies with 24,375 patients
    - pneumonia in analysis of 7 studies with 24,703 patients
    - chyle leakage in analysis of 5 studies with 592 patients
- mortality not reported in randomized trials
- Reference – J Thorac Cardiovasc Surg 2022 Aug;164(2):422

Postoperative Evaluation and Management

Intensive Care Unit (ICU) Admission

historically, patients were routinely admitted to the ICU after esophageal resection, but current guidance suggests postoperative management should be individualized and does not necessarily require routine ICU admittance (ERAS Strong recommendation, Moderate-quality evidence)⁽⁴⁾
high-risk patients who are on pressor support or hypothermic may require extended intubation with monitoring in the ICU while low-risk patients are typically extubated immediately after surgery and monitored in a progressive care unit (Surg Today 2020 Apr;50(4):323 full-text)
intubation and ventilation with sedation may be needed in some patients for up to 48 hours⁽⁴⁾

Postoperative Pain Management

proper pain management should be implemented for
- patient comfort
- enhancing early recovery
- decreasing surgical morbidity
- decreasing hospitalization time
- Reference – J Thorac Dis 2021 Oct;13(10):6037 full-text
thoracic epidural analgesia (TEA) is the preferred type of anesthesia for postoperative pain management following esophagectomy
- associated with reduced risk of respiratory complications and postoperative mechanical ventilation and a shorter hospital stay
- may also reduce risk of anastomotic leakage
- Reference – J Thorac Dis 2017 Jul;9(Suppl 8):S705 full-text
Enhanced Recovery After Surgery (ERAS) recommendations for pain management in patients having esophagectomy⁽⁴⁾
- pain management should include a multimodal approach with regional and local anesthetics to minimize opiate use
- TEA should be considered as the first-line option for postoperative analgesia following esophagectomy (ERAS Strong recommendation, Moderate-quality evidence)
- paravertebral analgesia can be used as an alternative to TEA following esophagectomy (ERAS Strong recommendation, Moderate-quality evidence)
  - may be preferred over TEA when the abdominal surgery portion of an esophagectomy is performed laparoscopically
  - reported to be associated with fewer complications compared to TEA
- regular dosing of acetaminophen should be considered following esophagectomy (ERAS Strong recommendation, Moderate-quality evidence)
  - do not exceed 4 g in 24 hours
  - may be administered orally, IV, or rectally
- the decision to use nonsteroidal anti-inflammatory drugs (NSAIDs) should be made on an individualized basis, taking into account the difficulty and complexity of surgery, patient age, and renal function (ERAS Strong recommendation, Moderate-quality evidence)
  - common adverse effects associated with NSAIDs include gastric irritation/erosion, platelet dysfunction, and renal dysfunction
  - esophageal resection is associated with increased risk of renal dysfunction; consider delaying administration of NSAIDs until confirmation of adequate renal function
- medications which may be options for postesophagectomy pain but have limited evidence to support their use include
  - gabapentinoids (ERAS Weak recommendation, Low-quality evidence)
  - ketamine (ERAS Weak recommendation, Moderate-quality evidence)
  - magnesium (ERAS Weak recommendation, Moderate-quality evidence)
  - lidocaine infusions (ERAS Weak recommendation, Moderate-quality evidence)
patient-controlled intermittent epidural analgesia may reduce rescue analgesic use and hypotension compared to continuous epidural infusion plus patient-controlled epidural analgesia in adults having thoracoscopic-laparoscopic esophagectomy (level 2 [mid-level] evidence)
- based on small randomized trial
- 60 adults aged 18-80 years with American Society of Anesthesiologists class I-III having thoracoscopic-laparoscopic esophagectomy were randomized to 1 of 2 regimens for patient-controlled epidural analgesia
  - ropivacaine 0.3% plus fentanyl 1.5 mcg/mL patient-controlled intermittent epidural boluses (6 mL, lockout time 30 minutes)
  - ropivacaine 0.3% plus fentanyl 1.5 mcg/mL continuous epidural infusion (6 mL/hour) plus patient-controlled additional epidural boluses of 3 mL each (lockout time 15 minutes)
- primary outcome was total consumption of fentanyl and ropivacaine during postoperative period
- 91.7% of patients completed study and were included in analysis
- comparing intermittent epidural boluses vs. continuous epidural infusion
  - rescue analgesic use for breakthrough pain in 14.8% vs. 42.9% (p = 0.02, NNT 4)
  - hypotension in 18.5% vs. 53.6% (p = 0.006, NNT 3)
  - mean total fentanyl dose 279.4 mcg vs. 490.7 mcg (p = 0.001)
  - mean total ropivacaine dose 39.4 mg vs. 60.3 mg (p = 0.001)
  - median intensive care unit (ICU) length of stay 2.5 days vs. 4 days (p = 0.06)
  - median time to hospital discharge 16 days vs. 18 days (not significant)
- no significant differences in pneumonia, atelectasis, anastomotic leakage, or nausea and vomiting
- Reference – J Pain Res 2019;12:29 full-text

Postoperative Foley Catheter Management

Enhanced Recovery After Surgery (ERAS) recommendations for postoperative Foley catheter management after esophagectomy⁽⁴⁾
- in patients that have had a thoracotomy and who have an epidural catheter, removal of the urinary catheter before the epidural catheter is associated with increased risk for urinary catheter replacement, particularly in male patients (ERAS Strong recommendation, High-quality evidence)
- early removal of urinary catheters can be considered assuming there are clear protocols in place for patient bladder monitoring to assess the need for catheter reinsertion (catheter removal within 48 hours of surgery is associated with increased risk for reinsertion for urinary retention) (ERAS Strong recommendation, High-quality evidence)
- if urinary drainage is required > 4 day, suprapubic catheters are associated with reduced urinary infection rates (ERAS Moderate recommendation, High-quality evidence)

Postoperative Nutritional Support, Fluid Management, Glycemic Control, and Bowel Stimulation

patients having surgery for esophageal cancer or other esophageal conditions are at increased risk for malnutrition due to decreased oral intake preoperatively, adverse effects of medications and esophageal surgery, and the physiological impact of a reconstructed upper gastrointestinal tract^(3,4)
- gastrointestinal dysfunction may occur after esophagectomy leading to deficiencies in vitamin and minerals such as⁽²⁾
  - vitamin B12
  - folic acid
  - vitamin D
  - calcium
- in some patients, nutritional support may be needed for months after esophagectomy⁽⁴⁾
Enhanced Recovery After Surgery (ERAS) recommendations for nutritional support, fluid management, glycemic control, and bowel stimulation in the early postoperative period⁽⁴⁾
- optimal fluid balance is achieved with consideration of all contributory factors; avoid positive fluid balance leading to > 2 kg/day weight gain (ERAS Strong recommendation, High-quality evidence)⁽⁴⁾
- nasogastric decompression at the time of esophageal resection is recommended but consider early removal (on postoperative day 2) when clinically indicated (ERAS Strong recommendation, Moderate-quality evidence)
- early introduction of enteral nutrition can improve outcomes in patients having surgery for esophageal cancer (ERAS Strong recommendation, Moderate-quality evidence)
- strongly consider early introduction of enteral feeding with target nutritional rate on day 3-6 after esophagectomy (ERAS Moderate recommendation, Moderate-quality evidence)
  - optimal route of enteral nutrition administration in the early postoperative period is unclear
  - jejunostomy or nasojejunal/nasoduodenal tubes may be used
- recommendations for glycemic control
  - reducing insulin resistance and treatment of excessive hyperglycemia can improve patient outcomes, so a multimodal approach designed to minimize the metabolic stress of surgery is recommended (ERAS Strong recommendation, Moderate-quality evidence)
  - multimodal approach should include preoperative carbohydrate treatment, epidural anesthesia, minimally invasive surgical techniques, and early enteral nutrition (ERAS Strong recommendation, Moderate-quality evidence)
  - blood glucose levels > 10 mmol/L (180 mg/dL) require treatment (ERAS Strong recommendation, Moderate-quality evidence)
- recommendations for bowel stimulation
  - use a multimodal approach with epidural analgesia and near zero fluid balance (ERAS Weak recommendation, Low-quality evidence)
  - postoperative administration of oral laxatives and chewing gum is reported to be safe and can improve intestinal motility (ERAS Weak recommendation, Low-quality evidence)
when the patient resumes oral intake, eating small, frequent meals (5 small meals/day) and minimizing fat and fiber consumption is recommended⁽²⁾
CLINICIANS’ PRACTICE POINT: After esophagectomy with a gastric conduit or partial gastrectomy, patients may not have the stomach capacity to tolerate larger meals.
regularly monitor for malnutrition and weight loss after esophagectomy; progressive weight loss within the first 6 months after surgery is expected in patients with esophageal cancer⁽²⁾

Postoperative Imaging

postoperative imaging such as chest x-ray, esophagram, and chest computed tomography (CT) can be used to screen for postoperative complications⁽¹⁾
single-contrast esophagram may be taken between postoperative days 6-10 based on patient status to asses for leaks, obstruction, and delayed gastric emptying⁽¹⁾
chest CT is typically performed along with the esophagram for unstable or complex patients, including those with⁽¹⁾
- redundant fundal tissue at anastomosis
- revision surgeries with side-to-side anastomosis
- contained extravasations

Early Mobilization

early mobilization after esophageal resection may be challenging due to pain and presence of feeding tubes, pumps, or drains⁽⁴⁾
- early mobilization should be started as soon as possible and follow a standardized, structured approach with daily targets (ERAS Strong recommendation, Moderate-quality evidence)
- general characteristics of a postoperative mobilization plan include
  - early mobilization on either postoperative day 1 or as soon as possible
  - incremental increase in activity each day to reach predetermined targets
  - written material and guides with pictures for patient explaining importance of mobilization and goals
early mobilization is necessary as prolonged bed rest can lead to⁽⁴⁾
- muscle loss/weakness
- impaired lung function and tissue oxygenation
- insulin resistance
- increased risk of thromboembolic/respiratory complications

Complications and Prognosis

Mortality

esophageal resection reported to have the highest mortality of all elective gastrointestinal surgeries⁽¹⁾
- 3%-22% overall reported mortality
- pulmonary complications reported to account for 66% of deaths
- anastomotic leaks reported to account for up to 40% of deaths
no significant difference in postoperative morbidity or mortality comparing transthoracic (Ivor Lewis or McKeown approach) and transhiatal techniques in 1,568 patients who had esophagectomy for malignant or benign indications (JAMA Surg 2013 Aug;148(8):733)
acute respiratory distress syndrome, reintubation, new renal failure, new central neurological event, myocardial infarction, ventricular arrhythmia, atrial arrhythmia, sepsis, and reoperation each associated with increased in-hospital or 30-day mortality after esophagectomy
- based on retrospective cohort study
- 11,943 patients with esophageal cancer who had esophagectomy between 2009 and 2017 from Society of Thoracic Surgery database were assessed
  - esophagectomy techniques included open Ivor Lewis in 34%, minimally invasive Ivor Lewis in 23%, transhiatal in 21%, open 3-hole in 9%, minimally invasive 3-hole in 6%, minimally invasive transhiatal in 4%, and thoracoabdominal in 3%
  - 49% of patients had ≥ 1 of 23 postoperative events analyzed in this study
- 3.3% overall in-hospital or 30-day mortality
- in multivariable analysis, postoperative events associated with increased in-hospital or 30-day mortality included
  - acute respiratory distress syndrome (adjusted odds ratio [OR] 8.17, 95% CI 5.61-11.9)
  - reintubation (adjusted OR 6.39, 95% CI 4.5-9.06)
  - new renal failure (adjusted OR 6.18, 95% CI 4.2-9.09)
  - new central neurological event (adjusted OR 4.79, 95% CI 2.05-11.2)
  - myocardial infarction (adjusted OR 4.71, 95% CI 2.26-9.8)
  - ventricular arrhythmia (adjusted OR 4.02, 95% CI 2.32-6.98)
  - atrial arrhythmia (adjusted OR 1.39, 95% CI 1.06-1.82)
  - sepsis (adjusted OR 2.41, 95% CI 1.62-3.59)
  - reoperation for
    - bleeding (adjusted OR 4.63, 95% CI 2.22-9.68)
    - chylothorax (adjusted OR 2.55, 95% CI 1.53-4.23)
    - anastomotic leak (adjusted OR 1.65, 95% CI 1.15-2.39)
    - other reason (adjusted OR 1.54, 95% CI 1.05-2.26)
- Reference – J Gastrointest Surg 2020 Sep;24(9):1948

Procedural Complications

procedural complications associated with esophageal resection may include⁽¹⁾
- recurrent laryngeal nerve injury
  - reported in 10%-20% of patients after cervical anastomosis
  - may increase risk of aspiration
- chylothorax due to thoracic duct injury
  - reported in 1%-5% of patients
  - associated with nutritional deficiencies, reduced immunity, and increased risk of systemic infection
- hemorrhage due to injury during retraction or dissection
- tracheobronchial injury
- diaphragmatic hernia (may occur in early or late postoperative period)

Pulmonary Complications

pulmonary complications reported to be the most common complication after esophagectomy⁽¹⁾
- in some studies, pulmonary complications are reported to be more common with a transthoracic esophagectomy and may lead to mediastinitis and/or sepsis⁽¹⁾
- in other studies, pulmonary complications are reported to be equally as common in transhiatal as transthoracic esophagectomy, and some complications, such as pleural effusion and atelectasis, may be more common, while others, such as pneumothorax, may be less common (Dis Esophagus 2017 Nov 1;11(1):43)
types of pulmonary complications include⁽¹⁾
- aspiration
- acute respiratory distress syndrome
- pleural effusion
- pneumonia
- pneumothorax
- prolonged ventilator dependence
- pulmonary edema
- pulmonary embolism
- reintubation
- tracheobronchial injury
pneumonia appears to be the most common postoperative complications in adults treated with esophagectomy for cancer
- based on noncomparative data from retrospective population-based cohort study
- 2,545 adults (99% ≥ 41 years old) who had esophagectomy (63%) or gastrectomy (37%) for cancer between 2016 and 2017 from random sample of hospitals in Dutch Upper Gastrointestinal Cancer Audit were assessed for 30 days
- postoperative outcomes were defined according to Esophagectomy Complications Consensus Group
- in patients who had esophagectomy
  - overall postoperative complication rate 65%
  - most common complications included
    - pneumonia in 21%
    - esophago-enteric leak from anastomosis, staple line, or localized conduit necrosis in 19%
    - atrial dysrhythmia in 15%
  - 30-day mortality 1.7%
  - reintervention in 26%
  - readmission in 15%
  - median hospital stay 11 days
- Reference – Ann Surg 2020 Jun;271(6):1095

Atrial Fibrillation

atrial fibrillation (AF) reported to be a common complication of esophageal resection for patients with cancer, with new-onset reported in 12%-37% of patients
- due to hemodynamic instability and organ hypoperfusion, AF may increase the risk of other complications, such as thromboembolic events
- AF may be associated with
  - increased postoperative infectious complications
  - longer hospital stay
  - need for reoperation
  - increased postoperative mortality
- exact mechanism of AF is unclear, proposed mechanisms include
  - trauma to the atrium or autonomic nerve fibers, particularly during transthoracic esophagectomy
  - alterations to adenosine triphosphate (ATP) production and use due to oxidative stress associated with one-lung ventilation or infection
  - postoperative hypovolemia and hypervolemia
  - concomitant cardiac condition
- Reference – J Thorac Dis 2019 Apr;11(Suppl 5):S831 full-text

Anastomotic Leaks

10%-44% of patients reported to develop anastomotic leaks following esophageal resection, and up to 40% of postoperative mortality is associated with anastomotic leaks⁽¹⁾
- most leaks occur within the first 10 days postoperatively due to inappropriate tension at the anastomosis
  - insufficient tension may result in poor tissue apposition with extravasation and impaired healing
  - excessive tension may lead to ischemia and necrosis (severe ischemia may lead to conduit necrosis)
- leaks are most commonly located at the site of the anastomosis but can develop at any resection site
- procedural factors associated with increased risk for anastomotic leaks include
  - gastric conduits compared to colon conduits
  - cervical anastomosis compared to thoracic anastomosis
- anastomotic leaks may lead to increased risk of subsequent anastomotic strictures; complications of anastomotic strictures include
  - persistent dysphagia
  - odynophagia
  - poor oral intake or nutrition (potentially requiring placement of feeding tubes)
  - food impaction
  - complete esophageal obstruction
  - complications of treatment (particularly with dilation or stenting)
patients may be asymptomatic or present with symptoms of shock or other severe, life-threatening symptoms⁽¹⁾
gross anastomotic leak may be diagnosed by physical exam showing saliva leaking from neck incision or gastric fluids leaking from the chest tube⁽¹⁾
management varies by clinical presentation and can range from close observation in asymptomatic patients to antibiotics and emergent revision surgery in unstable patients with severe sepsis (Clin Colon Rectal Surg 2016 Jun;29(2):138 full-text)
anastomotic leak associated with reduced survival in patients having esophagectomy
- based on systematic review of observational studies
- systematic review of 13 observational studies evaluating effects of anastomotic leak on long-term survival in 7,118 patients after having esophagectomy
- 10.2% of patients had anastomotic leak
- anastomotic leak associated with reduced survival compared to patients without anastomotic leak
  - restricted mean survival time difference (RMSTD) -0.7 months (95% CI -1.2 to -0.2 months) at 12 months in analysis of 13 studies
  - RMSTD -2.6 months (95% CI -3.7 to -1.6 months) lower with anastomotic leak at 36 months in analysis of 11 studies
  - RMSTD -4.2 months (95% CI -6.4 to -2.1 months) at 60 months in analysis of 10 studies
- Reference – Ann Surg Oncol 2023 Sep;30(9):5564, commentary can be found in Ann Surg Oncol 2023 Sep;30(9):5573

Functional Complications

complications related to esophageal function after esophageal resection may include
- delayed gastric emptying
  - reported in 10% of patients, typically with the Ivor Lewis technique due to vagotomy and anatomic rearrangement (pyloric drainage procedures often performed to reduce risk)⁽¹⁾
  - reported in up to 37% of patients who had esophageal reconstruction with gastric conduit⁽²⁾
- dumping syndrome, reported in up to 50% of patients from rapid transit time of hyperosmolar gastric substrates to the small intestine⁽¹⁾
- esophageal reflux, reported to be more common after pyloroplasty and associated with subsequent ulceration and stricture⁽¹⁾

Delayed Complications

delayed complications associated with esophageal resection typically include anastomotic stricture and disease recurrence, both of which are commonly associated with dysphagia⁽¹⁾
- anastomotic strictures reported in 9%-48% of patients
- risk for anastomotic strictures include anastomotic leaks, stapled anastomosis, poorly vascularized conduit, comorbid cardiac disease, and diabetes
functional complications such has anastomotic leak, fistula, and diaphragmatic hernia may have delayed presentation postoperatively⁽¹⁾
patients with history of esophageal/esophagogastric junction cancers and esophagectomy have an increased risk for long-term gastrointestinal issues that may decrease quality of life⁽²⁾

Guidelines and Resources

Guidelines

International Guidelines

Enhanced Recovery After Surgery (ERAS) Society guideline on perioperative care in esophagectomy can be found in World J Surg 2019 Feb;43(2):299

United States Guidelines

National Comprehensive Cancer Network (NCCN) guidelines on
- esophageal and esophagogastric junction can be found at NCCN website (free registration required)
- diagnosis and treatment of esophageal cancer can be found at NCCN website (free registration required)
American College of Gastroenterology (ACG) clinical guideline on diagnosis and management of Barrett esophagus can be found in Am J Gastroenterol 2016 Jan;111(1):30, correction can be found in Am J Gastroenterol 2016 Jul;111(7):1077, commentary can be found in Am J Gastroenterol 2016 Jun;111(6):899
National Cancer Institute (NCI) guidance on treatment option overview for esophageal cancer can be found at NIH NCI 2022 Oct 14

United Kingdom Guidelines

British Society of Gastroenterology (BSG) guideline on diagnosis and management of Barrett’s columnar-lined oesophagus can be found in Gut 2014 Jan;63(1):7, commentary can be found in Gut 2015 Jul;64(7):1184, revised recommendations can be found at BSG 2017 Apr 7 PDF

European Guidelines

European Society of Gastrointestinal Endoscopy (ESGE) guideline on endoscopic submucosal dissection for superficial gastrointestinal lesions can be found in Endoscopy 2022 Jun;54(6):591 PDF
European Society of Medical Oncology (ESMO) clinical practice guideline on diagnosis, treatment, and follow-up of esophageal cancer can be found in Ann Oncol 2016 Sep;27(suppl 5):v50

Review Articles

review of prehabilitation for esophagogastric cancer surgery can be found in Cancers (Basel) 2022 Apr 22;14(9) full-text
review of perioperative esophagectomy approach for the anesthesiologist can be found in J Thorac Dis 2021 Oct;13(10):6037 full-text
review of esophagectomy for benign conditions can be found in J Thorac Dis 2018 Mar;10(3):2026 full-text
review of anesthesia during esophagectomy can be found in J Thorac Dis 2017 Jul;9(Suppl 8):S705 full-text
review of esophagectomy and gastric pull through procedures can be found in Radiographics 2016 Jan;36(1):107
review of salvage esophagectomy can be found in J Thorac Dis 2014 May;6 Suppl 3:S341 full-text
review of complications with esophagectomy can be found in J Thorac Dis 2014 May;6 Suppl 3:S355 full-text

MEDLINE Search

to search MEDLINE for (Esophageal Resection) with targeted search (Clinical Queries), click therapy, diagnosis, or prognosis

Patient Information

information on esophageal cancer treatment (adult) from National Cancer Institute or in Spanish

References

Flanagan JC, Batz R, Saboo SS, et al. Esophagectomy and Gastric Pull-through Procedures: Surgical Techniques, Imaging Features, and Potential Complications. Radiographics. 2016 Jan;36(1):107-21.
Ajani JA, D’Amico TA, Bentrem DJ, et al. Esophageal and Esophagogastric Junction Cancers. Version 2.2022 In: National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology (NCCN Guidelines). NCCN 2022 Feb from NCCN website (free registration required).
Mormando J, Barbetta A, Molena D. Esophagectomy for benign disease. J Thorac Dis. 2018 Mar;10(3):2026-2033 full-text.
Low DE, Allum W, De Manzoni G, et al. Guidelines for Perioperative Care in Esophagectomy: Enhanced Recovery After Surgery (ERAS) Society Recommendations. World J Surg. 2019 Feb;43(2):299-330.

Esophageal Resection – Introduction

Synonyms

Definitions

Incidence/Prevalence

Indications

Preoperative Evaluation and Management

Prehabilitation

Preoperative Nutritional Assessment and Support

Preoperative Cardiopulmonary Assessment and Management

Preoperative Imaging Studies and Staging

Anesthetic Considerations

Anesthesia Strategies and Airway Management

Fluids and Monitoring

Prophylaxis for Postoperative Nausea and Vomiting

Surgical Techniques

Overview of Surgical Techniques

Open vs. Laparoscopic and/or Robotic-assisted Procedures

Transthoracic Approach

Ivor Lewis Technique

McKeown Technique

Left Thoracoabdominal Technique

Transhiatal Approach

Selection of Conduit

Lymphadenectomy

Surgical Drainage

Intraoperative Feeding Tube Placement

Postoperative Evaluation and Management

Intensive Care Unit (ICU) Admission

Postoperative Pain Management

Postoperative Foley Catheter Management

Postoperative Nutritional Support, Fluid Management, Glycemic Control, and Bowel Stimulation

Postoperative Imaging

Early Mobilization

Complications and Prognosis

Mortality

Procedural Complications

Pulmonary Complications

Atrial Fibrillation

Anastomotic Leaks

Functional Complications

Delayed Complications

Guidelines and Resources

Guidelines

International Guidelines

United States Guidelines

United Kingdom Guidelines

European Guidelines

Review Articles

MEDLINE Search

Patient Information

References

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