Esophagectomy

Learning objectives

Esophageal cancer is the eighth most common malignancy worldwide
Curative therapy for many patients involves surgery (esophagectomy), often with preoperative chemotherapy
Esophagectomy remains high-risk with substantial associated morbidity and mortality

Risk factor	Adenocarcinoma	Squamous cell carcinoma
Lifestyle	Smoking	Alcohol, smoking (may show synergism), poor oral hygiene
Racial origin	Caucasian more common than Asian or African	Sub-Saharan African Heritage three times higher than Caucasians
		Far East Asian Heritage
Age and gender	Increasing age, male greater than female	Male greater than female
Dietary	Low dietary intake of fruit and vegetables	Salted vegetables, preserved fish
Disease	Gastro-oesophageal reflux, Barrett’s oesophagus, obesity, family history (rare)	Mutations of alcohol metabolic pathways, achalasia, caustic injury, nutritional deficiencies, non-epidermolytic palmoplantar keratoderma
Economic	Developed world	Low socioeconomic status
		Developing world
Medical/industrial	Thoracic radiation, medications that relax the lower oesophageal sphincter	Thoracic radiation

Respiratory	Pneumonia
	Atelectasis
	Acute respiratory stress syndrome
	Recurrent laryngeal nerve palsy
Surgical	Anastomotic leak
Cardiac	Supraventricular arrhythmias (e.g., atrial fibrillation)

The risk of respiratory complications can be minimized by adequate analgesia, reversal of muscular block, normothermia, chest physiotherapy and hemodynamic stability
Major anastomotic leaks require surgical exploration and revision surgery
Smaller leaks are managed by keeping the patient nil by mouth, giving high protein enteral feed or total parenteral nutrition, antibiotics, chest physiotherapy, radiologically guided drainage collection and performing serial contrast studies