Version July 2025
INTRODUCTION —
For patients with locoregional esophageal cancer, standard multimodal treatments include surgery, radiation therapy, and systemic therapy [1-3]. The selection criteria and surgical management of patients with esophageal cancer are discussed in this topic. Neoadjuvant and adjuvant therapy and radiation therapy, as well as the management of patients with unresectable esophageal cancer, are reviewed separately.
●(See "Neoadjuvant and adjuvant therapy for locally advanced resectable thoracic esophageal cancer".)
●(See "Management of locally advanced unresectable or inoperable esophageal cancer".)
ANATOMY —
The esophagus, which is approximately 25 to 30 cm in length, is located in the posterior mediastinum and extends from the level of the 7th cervical vertebra to the 11th thoracic vertebra (figure 1 and figure 2 and figure 3). It is divided into four anatomic areas including the cervical, thoracic, and lower thoracic/esophagogastric junction (EGJ) and the abdominal esophagus (figure 4 and figure 5 and figure 6). The esophagus is composed of the mucosa, submucosa, muscularis externa, and adventitia (image 1). There are three critical anatomic points of narrowing: the cricopharyngeus muscle, the bronchoaortic constriction, and the EGJ, which are also the most common sites of iatrogenic and mechanical perforation (figure 7 and figure 8) [4].
The arterial supply includes the inferior thyroid artery (cervical esophagus), bronchial arteries, and the aorta (thoracic esophagus) and branches of the left gastric artery and inferior phrenic artery (abdominal esophagus) (figure 9). The venous drainage is through the inferior thyroid vein (cervical esophagus); the azygous vein, the hemiazygous vein, or the bronchial veins (thoracic esophagus); and the coronary vein (abdominal esophagus) (figure 10).
The esophagus has a rich network of lymphatic channels in the submucosa that can facilitate the longitudinal spread of neoplastic cells along the esophageal wall including skip lesions, thereby necessitating generous surgical margins for resections. Lymphatic drainage is to cervical nodes, tracheobronchial and mediastinal nodes, and gastric and celiac nodes (figure 11). An important point is that the regional lymph nodes for all locations in the esophagus, including the cervical esophagus and EGJ, extend from the periesophageal cervical nodes to celiac nodes (figure 12) [5]. Thus, the regional lymph nodes for all locations in the esophagus extend from the periesophageal cervical nodes to the celiac nodes. Celiac nodal metastases and mediastinal/supraclavicular nodes are scored as regional nodal disease in the tumor, node, metastasis (TNM) staging system, regardless of the primary tumor location (figure 12) [5]; it is the number of involved nodes rather than location that determines the N stage (table 1) [5]. (See "Management of locally advanced unresectable or inoperable esophageal cancer" and "Clinical manifestations, diagnosis, and staging of esophageal cancer".)
However, para-aortic and mesenteric lymph nodes are not classified as regional nodes for esophageal cancer, and their involvement indicates distant metastasis. (See 'Local versus metastatic disease' below.)
HISTOLOGY OF ESOPHAGEAL CANCER —
The two most common histologic types of esophageal cancer are squamous cell carcinoma and adenocarcinoma (see "Epidemiology and risk factors for esophageal cancer"):
●Squamous cell carcinoma arises from the cells that line the esophagus and is usually located in the upper and middle third of the esophagus. Squamous cell carcinoma is mainly caused by smoking and alcohol consumption.
●Adenocarcinoma arises from glandular cells that are mostly located at the lower third of the esophagus or the junction of the esophagus and stomach and is mostly caused by gastroesophageal reflux disease, Barrett's metaplasia, and obesity [6].
Globally, squamous cell carcinoma of the esophagus is significantly more prevalent than adenocarcinoma, with most studies reporting that around 85 percent of esophageal cancers are squamous cell carcinomas while adenocarcinoma accounts for roughly 15 percent of cases [7]; however, in Western countries and some Asian countries, the incidence of adenocarcinoma has been rising, making it the dominant subtype in those regions [8].
TNM STAGING —
The tumor, node, metastasis (TNM) staging system of the American Joint Committee on Cancer (AJCC) and the Union for International Cancer Control (UICC) for esophageal cancer is used universally. The current AJCC TNM staging system (eighth edition, 2017) recognizes the biologic heterogeneity of the disease and provides separate stage groupings for adenocarcinoma and squamous cell carcinoma (table 1) [5]. (See "Clinical manifestations, diagnosis, and staging of esophageal cancer".)
Tumors involving the esophagogastric junction (EGJ) are classified according to the Siewert classification (figure 13). Tumors with the tumor epicenter no more than 2 cm into the proximal stomach are staged as esophageal cancers (table 2). 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, 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 (table 1).
The TNM and Siewert classifications are reviewed separately. (See "Neoadjuvant and adjuvant therapy for locally advanced resectable esophagogastric junction and gastric cardia adenocarcinoma", section on 'Definition and classification' and "Clinical manifestations, diagnosis, and staging of esophageal cancer".)
PRETREATMENT EVALUATION —
Precise pretreatment staging guides multidisciplinary management decisions, including surgical resection [9]. Pretreatment evaluation, including endoscopic biopsy, computed tomography of the chest and abdomen, endoscopic ultrasound, positron emission tomography, and diagnostic laparoscopy and thoracoscopy, is reviewed separately. (See "Clinical manifestations, diagnosis, and staging of esophageal cancer", section on 'Pretreatment staging evaluation'.)
WHO SHOULD UNDERGO ESOPHAGECTOMY? —
Esophagectomy is a potentially curative treatment for esophageal cancer that should be offered to medically fit patients who have localized or locoregional disease (ie, no distant metastases).
Fitness for surgery — Esophagectomy is a major oncologic surgery that is associated with relatively high mortality and morbidities. The relative contraindications to an esophagectomy include:
●Advanced age – Advanced age is associated with greater morbidity following esophagectomy. However, chronologic age alone should not determine operability, as selected older patients have similar outcomes to younger patients, thereby emphasizing the importance of assessing "biologic age."
●Comorbid illness – Comorbid illnesses increase the risk of postoperative complications (eg, cardiorespiratory complications, anastomotic leakage, reoperation rates, wound infection) and death following esophagectomy. Obesity is not associated with any increase in overall morbidity following esophagectomy and should not be a contraindication for esophagectomy [10].
Intensive preoperative respiratory rehabilitation and nutritional support reduce postoperative pulmonary complications after an esophagectomy [11-13]. (See "Overview of prehabilitation for surgical patients".)
Patients who are poor surgical candidates may be offered definitive chemoradiation in lieu of surgery. This is discussed separately. (See "Neoadjuvant and adjuvant therapy for locally advanced resectable thoracic esophageal cancer", section on 'Overview of our suggested initial approach' and "Neoadjuvant and adjuvant therapy for locally advanced resectable esophagogastric junction and gastric cardia adenocarcinoma", section on 'Definitive CRT' and "Management of locally advanced unresectable or inoperable esophageal cancer".)
Local versus metastatic disease — The presence of metastatic disease, such as peritoneal, lung, bone, adrenal, brain, or liver metastases, or extraregional lymph node spread (eg, para-aortic, mesenteric, or supraclavicular lymphadenopathy) precludes an attempt at resection. Instead, such patients should be treated with systemic therapy. (See "Initial systemic therapy for metastatic esophageal and gastric cancer" and "Second- and later-line systemic therapy for metastatic gastric and esophageal cancer".)
WHEN SHOULD ESOPHAGECTOMY BE PERFORMED? —
Surgery plays a vital role in the multimodal therapy for esophageal cancer, with the treatment sequence largely determined by the disease stage. For early-stage esophageal cancer (T1 to T2 and node-negative), upfront resection is typically the standard approach. By contrast, for locally advanced patients (T3 to T4a or node-positive) who are candidates for esophagectomy, surgery is conducted after administering neoadjuvant chemotherapy or chemoradiation therapy (CRT). For patients receiving definitive CRT or those on active surveillance following neoadjuvant therapy, salvage esophagectomy may be necessary for managing persistent or recurrent disease.
The role of neoadjuvant therapy and radiation therapy as components of multimodality management is reviewed separately. (See "Neoadjuvant and adjuvant therapy for locally advanced resectable thoracic esophageal cancer" and "Neoadjuvant and adjuvant therapy for locally advanced resectable esophagogastric junction and gastric cardia adenocarcinoma".)
Early esophageal cancer — High-grade dysplasia (Tis) and mucosal cancer (T1a) of the esophagus can generally be treated endoscopically. The risk of lymph node metastasis is very low. Submucosal cancer (T1b), however, should be treated surgically, as well as any superficial cancer with high-risk features (eg, size >2 cm, positive margin, lymphovascular invasion, poorly differentiated histology). Patients with early esophageal cancer can be treated with upfront resection without any neoadjuvant therapy. (See "Management of superficial esophageal cancer", section on 'Esophagectomy'.)
The optimal approach for managing clinical T2N0M0 disease is debated, with expert groups offering differing guidelines on when to use upfront resection versus neoadjuvant therapy [14]. UpToDate contributors suggest an approach based on tumor histology (squamous cell carcinoma versus adenocarcinoma) and high-risk features (tumor size >2 cm, lymphovascular invasion, poor differentiation), which is detailed separately. (See "Neoadjuvant and adjuvant therapy for locally advanced resectable thoracic esophageal cancer", section on 'Clinical T2N0 disease' and "Neoadjuvant and adjuvant therapy for locally advanced resectable esophagogastric junction and gastric cardia adenocarcinoma", section on 'Clinical T2N0 disease'.)
Locally advanced esophageal cancer — All patients with locally advanced esophageal cancer (clinical T3 to T4a or node-positive) should receive neoadjuvant therapy rather than upfront esophagectomy. Neoadjuvant treatment may be chemotherapy alone or CRT, depending on the location of the tumor, patient age, performance status and comorbidities, nodal status, and the desire for adjuvant immune therapy with the goal of preparing the patient for esophagectomy. (See "Neoadjuvant and adjuvant therapy for locally advanced resectable esophagogastric junction and gastric cardia adenocarcinoma", section on 'Perioperative chemotherapy versus surgery alone'.)
Patients with T4b disease (invasion of the aorta, vertebral body, or airway) are considered unresectable and are treated with either definitive CRT or palliative systemic therapy. (See "Management of locally advanced unresectable or inoperable esophageal cancer", section on 'Criteria for unresectable disease'.)
For patients undergoing neoadjuvant therapy for potentially resectable disease, the necessity of subsequent surgery depends on the clinical response and histology (squamous cell carcinoma versus adenocarcinoma) [1] (see "Neoadjuvant and adjuvant therapy for locally advanced resectable thoracic esophageal cancer", section on 'Necessity for surgery'):
●Surgery after neoadjuvant therapy is the standard of care in patients with adenocarcinoma.
●For those with squamous cell carcinoma, surgery is recommended when a complete clinical response is not achieved after neoadjuvant therapy but may be omitted (and the patient observed) when a complete clinical response has been achieved.
Patients who are resectable according to radiographic restaging and endoscopic evaluation generally undergo resection four to eight weeks following completion of chemotherapy or CRT [15,16]. We generally do not repeat endoscopic ultrasound for reevaluation of T and N staging prior to surgery unless specific clinical questions need to be addressed, but repeat upper endoscopy can provide information [17]. (See "Clinical manifestations, diagnosis, and staging of esophageal cancer".)
Persistent or recurrent disease after chemoradiation — Salvage esophagectomy is a feasible therapeutic option for carefully selected patients who have persistent or recurrent disease following [18]:
●Neoadjuvant therapy and active surveillance
●Definitive CRT
Surgery should only be attempted if an R0 resection is technically feasible and after distant metastatic disease has been carefully ruled out. The surgical techniques are the same for salvage, as opposed to non-salvage esophagectomy. However, the morbidity rates are higher due to radiation to the operative field. Thus, salvage surgery is typically performed several months after definitive CRT, allowing time for the effects of radiation to subside and for tissues to recover enough for surgery. (See "Management of locally advanced unresectable or inoperable esophageal cancer".)
WHAT TYPE OF ESOPHAGECTOMY SHOULD BE PERFORMED?
Available esophagectomy techniques — Esophagectomy can be performed transhiatally or transthoracically. Regardless of the approach, we prefer a minimally invasive technique to a thoracotomy or laparotomy whenever feasible. (See 'Open versus minimally invasive surgery' below.)
●A transhiatal esophagectomy can be performed to resect cervical, thoracic, and esophagogastric junction (EGJ) esophageal cancers; it is performed either laparoscopically or open through an upper midline laparotomy incision and a left neck incision [19,20]. The thoracic esophagus is bluntly dissected through the diaphragmatic hiatus superiorly and via the neck inferiorly. A cervical anastomosis is created most often with a gastric pull-up approach. The major advantage of transhiatal esophagectomy is that it avoids a thoracotomy. Disadvantages include the inability to perform a full thoracic lymphadenectomy and the lack of visualization of the midthoracic dissection (figure 11). (See "Minimally invasive esophagectomy", section on 'Minimally invasive transhiatal esophagectomy'.)
●The transthoracic approaches offer great exposure for lymphadenectomy, especially in the mediastinum, but the thoracotomy incision adds to the morbidity of the procedure, though less so if performed minimally invasively. Transthoracic esophagectomy is most commonly performed with two (Ivor-Lewis) or three (McKeown) incisions. Robotic, thoracoscopic, and laparoscopic techniques are more frequently used to accomplish a tri-incisional esophagectomy in various combinations (ie, hybrid techniques). Totally minimally invasive esophagectomy, which uses only minimally invasive techniques to perform the entire operation, are increasing in frequency as skill and knowledge evolve. (See "Minimally invasive esophagectomy".)
•The Ivor-Lewis transthoracic esophagectomy combines a laparotomy with a right thoracotomy and an intrathoracic esophagogastric anastomosis. This approach permits direct visualization of the thoracic esophagus and allows the surgeon to perform a full thoracic lymphadenectomy. However, Ivor-Lewis is not an optimal approach for proximal cancer because of the limited proximal margin that can be achieved. Additional disadvantages of Ivor-Lewis esophagectomy include an intrathoracic location of the esophagogastric anastomosis and a 3 to 20 percent risk of severe bile reflux [21,22]. A leak occurring at the intrathoracic anastomosis had been associated with morbidity and mortality rates as high as 64 percent [23-28], although with current techniques, the leak rate has been lowered to 11 to 13 percent [29-31].
•The tri-incisional (McKeown) esophagectomy combines the transhiatal and transthoracic approaches into a transthoracic total esophagectomy with a thoracic lymphadenectomy and cervical esophagogastric anastomosis [32-36]. The tri-incisional technique allows the surgeon to perform a complete two-field (mediastinal and upper abdominal) lymphadenectomy under direct vision and a cervical esophagogastric anastomosis. The following surgical oncology principles are used to perform an open, tri-incisional esophagectomy:
-Chest – Right posterolateral thoracotomy or thoracoscopy is performed first to assess resectability and exclude local invasion of contiguous structures. An en bloc resection is performed that includes the esophagus and mediastinal (figure 14) and upper abdominal lymph nodes (figure 15), including the right paratracheal, subcarinal, periesophageal, and celiac axis lymph nodes.
-Abdomen – The abdomen is explored by laparotomy or laparoscopy to exclude metastatic disease, and the stomach is mobilized in preparation for the construction of the gastric conduit.
-Neck incision – A left neck exposure is preferred for the esophagogastric anastomosis since this approach reduces the risk of injury to the recurrent laryngeal nerve (RLN) (figure 16) [21,32,37-39]. The 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.
The advantages of neck anastomosis include easier management of a possible anastomotic leak, lower incidence of reflux, more extensive proximal resection margin, and location outside of radiation ports if administered preoperatively. Disadvantages include the need for a longer conduit, thus more risk of ischemia and injury to the left RLN. (See "Complications of esophageal resection", section on 'Conduit complications'.)
•Esophagectomy can also be performed through a left thoracoabdominal incision with a gastric pull-up and an esophagogastric anastomosis in the left chest [40]. This approach is most useful for tumors involving the gastroesophageal junction. Only one incision is required, but disadvantages include a high incidence of complications such as postoperative reflux and limitation of the proximal esophageal margin by the aortic arch.
Choice of a technique based on tumor location — Esophagectomy is a technically difficult operation, and the complication rate is high due to the anatomic challenges of the procedure. The choice of surgical approach depends upon many factors, including [2]:
●Tumor location, length, submucosal extension, and adherence to surrounding structures
●The type or extent of lymphadenectomy desired
●The conduit to be used to restore gastrointestinal continuity
●Postoperative bile reflux
●The preference of the surgeon
Cervical esophageal cancer — Most patients with carcinoma of the cervical esophagus <5 cm from the cricopharyngeus are treated primarily by chemoradiation (CRT) [3]. (See "Neoadjuvant and adjuvant therapy for locally advanced resectable thoracic esophageal cancer", section on 'Cervical esophagus tumors'.)
For patients who fail CRT or who opt for a surgical resection rather than CRT, a surgical resection usually requires the removal of portions of the pharynx, the larynx, the thyroid gland, and portions of the proximal esophagus. A permanent tracheostomy and bilateral neck dissection are also performed [41-51]. This procedure is also called a cervical exenteration [52].
If there is sufficient margin on the upper esophageal sphincter (figure 6), we perform a tri-incisional McKeown esophagectomy with a hand-sewn anastomosis to preserve esophageal length. Alternatively, a transhiatal approach is reasonable.
Restoration of gastrointestinal tract continuity can be accomplished with a gastric pull-up and anastomosis to the pharynx. For tumors confined to the proximal portion of the cervical esophagus, with a sufficient distal resection margin, a free jejunal interposition graft or a deltopectoral or pectoralis major myocutaneous flap are alternative reconstructive options. Free jejunal grafts are advantageous because this approach avoids mediastinal dissection, although expertise in performing microvascular anastomosis is required. Graft necrosis, fistula formation, and later graft strictures are specific problems. When compared with gastric pull-up procedures, graft survival and leakage rates are similar. (See "Complications of esophageal resection", section on 'Conduit complications'.)
Thoracic cancer resection — Patients with either adenocarcinoma or squamous cell carcinoma involving the middle or lower third of the esophagus, except for gastroesophageal junction cancers, generally undergo either a McKeown or an Ivor-Lewis esophagectomy based on tumor location and surgeon preference.
●A proximal tumor would preclude a thoracic anastomosis, and thus, an Ivor-Lewis esophagectomy. How proximal a tumor needs to be to preclude an Ivor-Lewis esophagectomy, however, is determined variably by different surgeons:
•Some surgeons believe that the McKeown procedure is oncologically necessary for tumors located above the carina to dissect upper mediastinal and cervical lymph nodes while the Ivor-Lewis procedure offers perioperative and oncological safety for tumors located below the carina [53].
•Other surgeons perform the McKeown procedure for tumors higher than the azygous vein.
•Other surgeons perform the McKeown procedure for proximal tumors above 18 cm [54].
•Other surgeons only perform the McKeown procedure for cervical esophageal cancers [2].
•The author of this topic performs an Ivor-Lewis esophagectomy for all esophageal cancers below 25 cm from the incisors whereby he can obtain an adequate margin from the chest approach of at least 4 to 5 cm unless there is significant Barrett's dysplasia extending above this, in which case a McKeown is probably best to eradicate all dysplastic endothelium.
●When both procedures are feasible, some surgeons prefer the McKeon procedure, a total esophagectomy, because it minimizes the risk of submucosal skip lesions, and a leak in the neck is easier to treat than one in the chest [55-57]. In selected cases, such as a superficial or early invasive esophageal cancer arising distally in the setting of Barrett's esophagus, a more limited resection (eg, an anastomosis in the thorax or a less radical resection such as a transhiatal resection) can be performed. (See "Management of superficial esophageal cancer".)
●When both procedures are feasible, other surgeons prefer the Ivor-Lewis procedure because most thoracic surgeons do not operate in the neck frequently and are less comfortable with neck incisions. In addition, a recurrent nerve injury is only due to the cervical dissection. The author of this topic prefers an Ivor-Lewis esophagectomy for any tumor located in the lower two-thirds of the esophagus and EGJ since it will provide adequate margins and allow the appropriate node dissection.
The transhiatal, Ivor-Lewis, and tri-incisional esophagectomy procedures are the most commonly performed esophagectomies in North America [58-60], while an esophagectomy and an extended (three-field) lymphadenectomy is commonly performed in Asia [61-67].
Although the gastric interposition is most commonly used as a conduit for reconstruction following esophagectomy, the jejunum or the colon can also be used as the conduit [68-72]. These conduits are resistant to the effects of gastric acid, and they have a shape similar to that of the native esophagus. However, their use requires two additional anastomoses, and in the case of the jejunal interposition, the fixed mesenteric length limits transposition to the proximal esophagus unless supercharged.
Esophagogastric junction cancer resection — Esophageal cancers at the EGJ or intra-abdominal esophagus have been traditionally managed surgically with either an esophagectomy with partial gastrectomy or an extended gastrectomy, with or without thoracotomy (figure 3).
Based on findings from two phase III trials [73,74], which randomly assigned patients to the operative procedure on the basis of the Siewert classification of EGJ adenocarcinoma (figure 13 and figure 17) [75], the contemporary surgical approach for resecting EGJ cancer is summarized as follows [2]:
●Patients with Siewert type I tumors (-5 to -1 cm) should preferentially undergo a transthoracic en bloc esophagectomy and partial gastrectomy with two-field lymphadenectomy. Lymphadenectomy is important to assess the disease stage and evaluate response to neoadjuvant therapy with minimal added risk in morbidity or mortality rates. Other reasonable options include a transhiatal approach, which does not include a lymphadenectomy.
●Patients with Siewert type II tumors (-1 to +2 cm, true junctional cancer) may undergo either an Ivor-Lewis esophagectomy or a total gastrectomy with transhiatal resection of the distal esophagus. There is intense ongoing investigation in this field [76], including a randomized trial [77].
●Patients with Siewert type III tumors (+2 to +5 cm) should undergo a total gastrectomy with a transhiatal resection of the distal esophagus with lymphadenectomy of the lower mediastinum and an extended lymph node dissection including nodes along the hepatic, left gastric, celiac, and splenic arteries as well as those in the splenic hilum. (See "Surgical management of invasive gastric cancer", section on 'Extent of lymph node dissection'.)
An extended gastrectomy should be converted to a transhiatal or transthoracic esophagectomy in the setting of a positive proximal resection margin at frozen section examination. The extent of the esophageal resection that can be achieved solely via a transabdominal approach without thoracoabdominal incision or transhiatal esophagectomy is limited, and therefore, this approach is not accepted for tumors that involve the distal esophagus due to difficulties in achieving an adequate negative proximal margin.
HOW SHOULD ESOPHAGECTOMY BE PERFORMED? —
For surgical resection of esophageal cancers, the margin status is an important prognostic factor. Achieving an R0 resection has been shown to increase median overall survival by 8 to 25 months following surgery [78]. Regardless of the approach, complete (R0) and resection of at least 15 nodes in basins appropriate for the primary tumor location are necessary [79-81].
Margins — Surgeons should aim for negative proximal, distal, and circumferential resection margins (CRMs).
Proximal and distal margins — Most surgeons require a proximal and distal negative margin as determined by intraoperative frozen sections. The proper margin is not clear. The author of this topic strives for 3 to 5 cm margins, but for upper-third tumors, this is not always possible. The length of the proximal and distal margin is a function of the size and location of the tumor. The larger the proximal margin, the more likely a cervical anastomosis is required.
From a thoracic surgery survey, 85 percent of surgeons use intraoperative frozen section margin analysis to guide surgical decision-making during an esophagectomy, with attempts at re-resection to achieve negative margin [82].
Circumferential resection margin — The College of American Pathologists (CAP) and the United Kingdom Royal College of Pathologists (RCP) provide two different definitions of CRM involvement [83].
●The CAP defines a positive CRM as the presence of esophageal cancer at the resection margin [84].
●The RCP defines a positive CRM as the presence of esophageal cancer within 1 mm of the resection margin [85,86].
A meta-analysis of 28 studies, with a wide range of CRM involvement (8.6 to 83.1 percent), analyzed the prognostic effect of a positive CRM in esophageal cancer [87]. There was a significant association between a positive CRM and patients' survival irrespective of RCP (odds ratio [OR] 2.52, 95% CI 1.96-3.25) or CAP (OR 4.02, 95% CI 2.25-7.20) criteria. The influence of neoadjuvant therapy on the CRM remains unclear.
Extent of lymphadenectomy — In a retrospective review of 1361 patients with squamous cell carcinoma of the thoracic esophagus, the pattern of nodal metastasis was neck (9.8 percent), upper mediastinum (18.0 percent), middle mediastinum (18.9 percent), lower mediastinum (11.8 percent), and upper abdomen (28.4 percent) [88].
The appropriate extent of lymphadenectomy during esophageal cancer surgery is debated. At least two randomized trials have compared different extents of lymphadenectomy during esophageal cancer surgery, although neither provides a conclusive result as to the benefit of extended lymphadenectomy [73,89].
●In the United States, en bloc resection of the mediastinal and upper abdominal lymph nodes is a standard component of transthoracic esophagectomy, whereas a three-field lymphadenectomy is not a standard treatment for patients with esophageal cancer.
●An even more extensive lymphadenectomy, three-field lymphadenectomy of the mediastinal, abdominal, and cervical nodes, is commonly practiced in Asian countries for upper thoracic esophageal cancers [61-67,88].
Guidelines suggest resecting and examining a minimum of 15 lymph nodes at esophagectomy [3,90]. However, as many lymph nodes should be removed as is feasible since more extensive lymphadenectomy has been associated with better survival [67,91-96]. A greater number of retrieved lymph nodes generally reflects more accurate staging. In centers with the most experience, the extent of lymphadenectomy does not correlate with operative risk [95,97].
Anastomosis — The selection of anastomotic location (cervical versus thoracic) is primarily determined by the esophagectomy technique; both anastomoses can be performed by hand or with various staplers.
Cervical versus thoracic anastomosis — The selection of anastomotic location (cervical versus thoracic) is primarily determined by the esophagectomy technique, which itself is influenced by the tumor's location and also the surgeon's preference. (See 'What type of esophagectomy should be performed?' above.)
When performed using a standardized technique, cervical and thoracic esophagogastric anastomoses are equally safe [98,99]. In general, cervical anastomosis has a higher leak rate and a higher risk of injury to the recurrent laryngeal nerve (RLN) [98,100,101]. However, the anatomic confines of the neck and thoracic inlet limit surrounding tissue contamination, and thus limit morbidity. This is illustrated by the following meta-analysis:
●In a 2011 systematic review of four clinical trials that included 267 patients, patients undergoing a cervical esophagogastric anastomosis (n = 132) had a higher rate of anastomotic leak compared with those undergoing a thoracic esophagogastric anastomosis (18 versus 4 percent; OR 3.43, 95% CI 1.09-10.78) [98]. A cervical esophagogastric anastomosis has a significantly higher rate of RLN injury (OR 7.14, 95% CI 1.75-29.14). However, there was no difference in the rate of pulmonary complications, perioperative mortality, benign stricture formation, or tumor recurrence at the anastomotic site.
●In another 2017 meta-analysis of 21 studies (including three randomized trials) comprised of 7167 patients, thoracic anastomosis yielded a lower anastomotic leak rate than cervical anastomosis (9.8 versus 12 percent; OR 0.56, 95% CI 0.34-0.92); there was no significant difference in overall 30-day mortality (3.9 versus 4.3 percent) and morbidity (59 versus 66.6 percent) [102].
The diagnosis and treatment of anastomotic leak are discussed elsewhere. (See "Complications of esophageal resection", section on 'Anastomotic leak'.)
Hand-sewn versus stapled anastomosis — Anastomotic closure techniques include hand-sewn (single versus double layer), stapled (circular versus side-to-side linear), and hybrid linear stapled technique (triangulating), with surgeon experience likely being the most important determinant at present [98,103-111]. Studies comparing these techniques have yielded varying conclusions, likely due to differences in tumor location and other patient-related factors.
●In a meta-analysis of 12 randomized controlled trials that included 1407 patients, the rate of anastomotic leak was similar for a circular stapled anastomosis compared with a hand-sewn anastomosis (OR 1.02, 95% CI 0.66-1.59) [111]. However, a stapled anastomosis was associated with a significantly higher rate of anastomotic stricture (OR 1.67, 95% CI 1.16-2.42).
●A meta-analysis of 101 mostly nonrandomized comparative studies on intrathoracic anastomosis found that the use of a circular stapler was associated with lower anastomotic leak rate (6 percent) than both hand-sewn (10 percent) and linear-stapling techniques (9 percent) [112].
●Another meta-analysis of 29 studies, including seven randomized trials, on cervical anastomosis reported lower anastomotic leak and stricture rates with the triangulating stapling technique than hand-sewn or circular stapling techniques [113].
Recurrent laryngeal nerve identification — RLN injury can occur during dissection of the cervical and thoracic esophagus [21,37-39]. Rates of injury range from 2 to 17 percent and occur more commonly when a cervical approach is utilized [32,114-116]. Principles for the avoidance of RLN injury include precise knowledge of cervical esophageal anatomy (figure 18), maintaining the plane of dissection as close as possible to the esophagus, and avoidance of metal or rigid retractors along the tracheoesophageal groove.
For procedures that involve a cervical incision, a left neck exposure is generally preferred because the left RLN follows a predictable path in the tracheoesophageal groove, making it easier to identify and avoid during surgery, whereas the right RLN has a shorter, more variable course that increases the risk of injury. (See 'Available esophagectomy techniques' above.)
Reconstruction — Most surgeons prefer the stomach as a conduit placed orthotopically in the posterior mediastinum. Alternates such as jejunum or colon conduits and retrosternal or subcutaneous placement may be required for anatomical reasons. A draining pyloromyotomy or feeding jejunostomy may be added but does not have to be routine. Whenever possible, minimally invasive techniques should be used.
Conduit choice — Most surgeons prefer the stomach as a conduit due to its ease of preparation, robust blood supply, and adequate length, with alternatives like the colon [117] and jejunum [118] used only when the stomach is unavailable (eg, following prior gastric surgery) [117,119]. No definitive conclusions can currently be made about the long-term functional advantages of one graft over another [120].
Conduit placement — The posterior mediastinal, retrosternal, and subcutaneous routes are the three possible esophageal reconstruction routes. Each route has advantages and disadvantages, and the optimal reconstruction route after esophagectomy remains controversial. The final reconstruction route might differ depending on the tumor stage and patient comorbidities [121]. For example, the retrosternal route is often selected for patients who are at high risk of postoperative local recurrence because irradiating the posterior mediastinum is easier. Conversely, the posterior mediastinal route is frequently selected for patients with a history of cardiac surgery because constructing the retrosternal route through the front of the heart is difficult. Currently, the subcutaneous route is an option only in high‐risk patients or when gastric conduit is unavailable [53].
Orthotopic placement of the neoesophagus in the posterior mediastinum is generally preferred by most thoracic surgeons. A 2022 meta-analysis of 19 studies (eight randomized trials) associated the posterior mediastinal route with a lower anastomotic leakage rate (OR 0.56, 95% CI 0.43-0.74), a lower anastomotic stricture rate (OR 0.42, 95% CI 0.3-0.59), and fewer pulmonary complications (OR 0.63, 95% CI 0.47-0.84) than the retrosternal route [122]. Cardiac complications and postoperative mortality were not significantly different between the two routes.
Role of pyloric drainage — The role of a pyloroplasty or pyloromyotomy to reduce the risk of gastric outlet obstruction following a gastric pull-up procedure is debated. A meta-analysis of nine trials and 553 esophagectomy patients randomized to pyloromyotomy versus none found a lower risk of gastric outlet obstruction for patients treated with a pyloromyotomy (OR 0.18, 95% CI 0.03-0.97, p <0.046) [123]. However, there was no difference in operative mortality, esophagogastric anastomotic leaks, pulmonary morbidity, or fatal pulmonary aspiration. Thus, the clinical significance of the reduction in gastric emptying time (weighted mean difference: -67.71, OR: 2.75) remains controversial [124].
Some experts routinely perform a pyloric drainage procedure at the time of esophagectomy and gastric pull-up reconstruction; others prefer to wait for any clinical gastric outlet obstruction to develop after esophagectomy and treat it endoscopically [125].
Jejunal feeding tube placement — Nutritional support is crucial for patients undergoing esophagectomy, particularly those who are malnourished. A feeding jejunostomy tube is traditionally inserted 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.
For patients who will likely resume oral intake early, it is reasonable to omit a jejunal feeding tube placement. The timing of oral feeding differs among surgeons [126].
●In a trial of 280 patients undergoing minimally invasive McKeown esophagectomy, early oral feeding starting on the first postoperative day did not result in more gastrointestinal complications than late oral feeding starting on the seventh postoperative day [127]. Patient fed early also passed flatus and bowel movements early and reported higher satisfaction at two weeks postoperatively.
●In another trial of 222 patients undergoing minimally invasive esophagectomy with intrathoracic anastomosis, starting a limited liquid diet on the day of surgery sped up patients' functional recovery without incurring more anastomotic, pulmonary, or other complications than delay oral feeding until postoperative day 5 [128].
Despite that, a 2019 guideline paper on esophagectomy from the Enhanced Recovery After Surgery (ERAS) Society concluded that "the ideal route of administration of enteral nutrition in the early postoperative period remains unclear" [12]. Thus, the choice of tube feeding via a jejunostomy versus early oral feeding depends on surgeon preference. (See 'Postoperative management' below.)
Open versus minimally invasive surgery — All three commonly performed esophagectomy procedures (Ivor-Lewis, McKeown, and transhiatal) can be performed with open or minimally invasive (laparoscopic or robotic) techniques. Compared with open surgery, minimally invasive esophagectomy, either total or hybrid (meaning with a portion performed open), is associated with reduced short-term morbidities and comparable long-term oncologic outcomes to those of open surgery. However, given the complexity of esophageal surgery, minimally invasive esophagectomy should be performed by surgeons experienced in both foregut oncologic surgery and minimally invasive techniques, who are usually at high-volume centers. (See "Minimally invasive esophagectomy".)
POSTOPERATIVE MANAGEMENT —
Enhanced Recovery After Surgery (ERAS) programs have been shown to predictably improve short-term outcomes associated with surgical procedures. Since esophagectomy has historically been associated with significant levels of morbidity and mortality, routine application of ERAS guidelines specifically designed for esophageal surgery has potential to improve outcomes [12]. (See "Overview of enhanced recovery after major noncardiac surgery (ERAS)".)
Nutrition — In our practice, enteral feedings via the jejunostomy tube are started on postoperative day 2 and slowly advanced until feeding goals are attained at approximately postoperative day 5. A barium swallow is performed on postoperative day 7 to evaluate for leak and emptying of the conduit. The nasogastric tube generally remains in place until the barium swallow is performed and demonstrates no anastomotic leak. Patients are maintained on a minimal liquid diet for approximately two weeks to allow the conduit to remain decompressed and straight in the mediastinum. Other surgeons may reasonably choose early oral feeding over enteral tube feeding; this remains controversial. (See 'Jejunal feeding tube placement' above.)
Venous thromboembolism prophylaxis — The American College of Chest Physicians (CHEST) guidelines on the prevention of venous thromboembolism [129,130] classify esophagectomy as a high-risk procedure and thus recommend postoperative thromboprophylaxis with low-molecular-weight heparin daily or unfractionated subcutaneous heparin three times daily, if restricted due to renal function. Conversely, some would classify esophagectomy as a high risk for bleeding, especially in the setting of blunt mediastinal dissection, and thus argue for less aggressive prophylaxis. Further complicating the matter is the frequent use of neuraxial anesthesia, which further limits the use of perioperative anticoagulants for thromboprophylaxis [131]. Unfortunately, a paucity of data exist to help clarify these issues, and, therefore, clinical practice varies. We use subcutaneous heparin and pneumatic boots in the operating room. Starting postoperative day 1, patients receive a daily prophylactic dose of low-molecular-weight heparin and continue until postoperative day 30, provided there are no contraindications. For those with a high risk of having a thromboembolic event, thromboprophylaxis may be extended to 30 days. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients".)
Adjuvant therapy — After surgery for esophageal cancer, adjuvant therapy is required for high-risk patients identified by surgical pathology. These include patients with a positive margin, locally advanced disease (T3 to T4 or node-positive), or T2N0 disease with unfavorable histology (lymphovascular invasion or poor differentiation).
The choice of adjuvant therapy also depends on tumor histology (squamous cell carcinoma versus adenocarcinoma), whether the patient has received neoadjuvant therapy (as opposed to upfront surgery), the type of neoadjuvant therapy (chemotherapy or chemoradiation), and their response to neoadjuvant therapy (pathologic complete response or not). This is discussed in detail separately. (See "Neoadjuvant and adjuvant therapy for locally advanced resectable thoracic esophageal cancer", section on 'Role of postoperative (adjuvant) therapy' and "Neoadjuvant and adjuvant therapy for locally advanced resectable esophagogastric junction and gastric cardia adenocarcinoma", section on 'Patients who undergo surgery first'.)
MORBIDITY AND MORTALITY —
Morbidity and mortality rates vary, depending upon hospital and/or surgeon volume, patient comorbidities, and operative approach (eg, open, minimally invasive, tri-incisional) [132-134]. Complications, mortality, and management of complications are discussed in a separate topic. (See "Complications of esophageal resection".)
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Esophageal cancer" and "Society guideline links: Esophagectomy".)
SUMMARY AND RECOMMENDATIONS
●Who should undergo esophagectomy – Esophagectomy should be offered to medically fit patients with localized or locoregional (ie, nonmetastatic) esophageal cancer. (See 'Who should undergo esophagectomy?' above and "Management of superficial esophageal cancer" and "Neoadjuvant and adjuvant therapy for locally advanced resectable thoracic esophageal cancer".)
●When should esophagectomy be performed – For early-stage esophageal cancer (Tis to T2 and node-negative), upfront resection is typically the standard approach, although the management of T2 diseases is more nuanced. By contrast, for locally advanced patients (T3 to T4a or node-positive) who are candidates for esophagectomy, surgery is conducted after administering neoadjuvant chemotherapy or chemoradiation therapy (CRT). For patients receiving definitive CRT or those on active surveillance following neoadjuvant therapy, salvage esophagectomy may be necessary for managing persistent or recurrent disease, but is usually delayed for several months, allowing time for the effects of radiation to subside. (See 'When should esophagectomy be performed?' above and "Management of superficial esophageal cancer" and "Neoadjuvant and adjuvant therapy for locally advanced resectable thoracic esophageal cancer".)
●What type of esophagectomy should be performed – Esophagectomy can be performed transhiatally or transthoracically, the latter can be performed through one incision (left thoracoabdominal), two incisions (abdomen and right chest; Ivor-Lewis), or three incisions (left neck, right chest, and abdomen; McKeown). The choice is primarily determined by tumor location and surgeon preference. (See 'What type of esophagectomy should be performed?' above.):
•Cervical tumor – Most patients with carcinoma of the cervical esophagus <5 cm from the cricopharyngeus are treated primarily by CRT. Those who require surgical resection often present with advanced disease, which requires the removal of portions of the pharynx, the larynx, the thyroid gland, and portions of the proximal esophagus. If there is sufficient margin on the upper esophageal sphincter, we perform a McKeown esophagectomy with a hand-sewn anastomosis to preserve esophageal length. (See 'Cervical esophageal cancer' above.)
•Thoracic tumor – Patients with cancer involving the middle or lower third of the esophagus, except esophagogastric junction (EGJ) cancers, usually undergo either a McKeown or an Ivor-Lewis esophagectomy based on tumor location. Tumors too proximal for a thoracic anastomosis can only be removed by a McKeown esophagectomy; more distal tumors can be removed with either a McKeown or an Ivor-Lewis esophagectomy. The surgeon decides what precludes a thoracic anastomosis and chooses the procedure when both are feasible. (See 'Thoracic cancer resection' above.)
•Esophagogastric junction tumor – Patients with an EGJ tumor can undergo either an esophagectomy with partial gastrectomy or a total gastrectomy with lower esophagectomy, depending upon the Siewert classification of the tumor location. (See 'Esophagogastric junction cancer resection' above and "Complications of esophageal resection", section on 'Conduit complications'.)
●How should esophagectomy be performed – Surgeons should ensure negative proximal and distal with intraoperative frozen section and aim for circumferential resection margins (CRMs). Either a two-field (abdomen and mediastinum) or a three-field (abdomen, mediastinum, neck) lymphadenectomy can be performed with the goal of recovering ≥15 lymph nodes. (See 'Margins' above and 'Extent of lymphadenectomy' above.)
The selection of anastomotic location (cervical versus thoracic) is primarily determined by the esophagectomy technique; both anastomoses can be performed by hand or with various staplers. Most surgeons prefer the stomach as a conduit placed orthotopically in the posterior mediastinum. A draining pyloromyotomy or feeding jejunostomy may be performed by surgeon preference. (See 'Anastomosis' above and 'Reconstruction' above.)
Minimally invasive techniques (hybrid or total) are preferred to open surgery with all approaches. (See 'Open versus minimally invasive surgery' above and "Minimally invasive esophagectomy".)
