Esophagectomy

Surgical Approaches and Current Evidence for Esophagectomy

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

20. OPERATIVE PROCEDURES

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

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

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

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

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

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

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

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

29. Annals RCT

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

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

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

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

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

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

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

37. 12 studies N = 672 MIE or hybrid minimally invasive esophagectomy (HMIE) N = 612 Open esophagectomy No significant difference in 30-day mortality. Frequency of anastomotic leak MIS procedures were associated with Significantly lower blood loss Shorter ICU and hospital stay Fewer respiratory complications. 50 % reduction in total morbidity. Total morbidity was similar for HMIE procedure and open esophagectomy.

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

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

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

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

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

43. Definitions

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

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

46. 2 field vs 3 field

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

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

49. 4 clinical trials (267 patients) : 132 cervical anastomosis vs thoracic anastomosis Cervical anastomosis were associated Higher rate of anastomotic leak (18 versus 4 %). Significantly higher rate of RLN injury (OR 7.14, 95% CI 1.75-29.14) No difference in rate of pulmonary complications, perioperative mortality, benign stricture formation, or tumor recurrence at the anastomotic site.

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

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

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

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

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

55. Early Feeding after Esophagectomy

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

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

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

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