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A systematic review of the literature was performed to assess the necessity of a pyloric drainage procedure during an esophagectomy with gastric conduit reconstruction. Earlier data recommend performing a pyloric drainage procedure for all esophagectomies; however, recent studies have questioned this. A thorough literature search (January 2001-November 2011) was performed using the terms esophagectomy, pyloroplasty, pyloromyotomy, botulinum toxin, and pyloric drainage. Only studies that compared patient outcome after undergoing an esophagectomy with a pyloric drainage procedure with those undergoing an esophagectomy without a pyloric drainage procedure were selected. Only four studies, comprising 668 patients in total, were identified that compared patient outcome after undergoing an esophagectomy with or without a pyloric drainage procedure, and two additional meta-analyses were identified and selected for discussion. All studies were retrospective, and because of the heterogeneity of studies, patient demographics, reporting, and statistical analysis of patient outcome, pooling of data and meta-analysis could not be performed. Careful analysis demonstrated that pyloric drainage procedure was associated with a non-significant trend for delayed gastric emptying and biliary reflux, while not affecting the incidence of dumping. No correlation was determined between a pyloric drainage procedure and anastomotic leaks, postoperative pulmonary complications, length of hospital stay, and overall perioperative morbidity. While there are risks associated with a pyloric drainage procedure and data exist supporting its omission during an esophagectomy, no good conclusion can be drawn from the current literature. Larger multi-institutional, prospective studies are required to definitively answer this question., (© 2013 Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus.)

This review considers the esophagectomy techniques in the treatment of esophageal cancer and provides the guidelines for optimizing the patients' chances at cure, minimizing the risk of mediastinal enteric leak (which carries a mortality rate as high as 50%) and minimizing associated pulmonary insufficiency and infection. The 4 most commonly used routes for resection and replacement include a transhiatal, transthoracic (Ivor-Lewis), tri-incisional (right chest then simultaneous abdominal and left neck), and left chest (distal tumors). Each of these techniques will be described as will the use of colon and jejunum for esophageal replacement. The healthy stomach is the preferred conduit for esophageal replacement. The stomach is well vascularized, easily reaches to the neck, and requires only a single anastomosis for re-establishing intestinal continuity. When the stomach is not available (usually because of prior surgery or disease) the choice of conduits include colon and jejunum. With respect to minimally invasive esophagectomy for esophageal cancer, several groups have significant experience with this and report excellent results. This is an evolving technique but holds much promise for improving the quality of life of patients with cancer without compromising their survival. In locally advanced middle third tumors, thoracotomy and dissection under direct vision's desirable and improves the safety of the operation. The same may apply to tumors receiving neoadjuvant therapy. For tumors of the distal esophagus, transhiatal, tri-incisional, and Ivor-Lewis resection are probably equally as safe, and appear to result in equivalent long-term survival. An intrathoracic anastomotic leak is disastrous, carrying a mortality rate of up to 50%. Any surgeon who performs esophagectomy with an intrathoracic anastomosis must do so with a low incidence of leakage, certainly under 5%. Consideration should be given to a cervical placement if there are factors increasing the risk such as the use of induction therapy.

Background: Several techniques for esophageal resection have been reported. This study examines the morbidity, mortality, and early survival of patients after transthoracic esophagectomy for esophageal carcinoma using current staging techniques and neoadjuvant therapy. The technique includes right thoracotomy, laparotomy, and cervical esophagogastrostomy (total thoracic esophagectomy) with radical mediastinal and abdominal lymph node dissection., Methods: Three hundred forty-two patients had surgery for esophageal carcinoma between 1989 and 2000 at our institution. Two hundred fifty consecutive patients had esophagectomy using this technique. Kaplan-Meier curves and univariate and multivariate analyses were performed by postsurgical pathologic stage., Results: Median age was 62.7 years (31 to 86 years). Fifty-nine were female. Eighty-one percent (202) had induction chemotherapy (all patients with clinical T3/4 or N1). Early postoperative complications included recurrent laryngeal nerve injury (14% [35]), chylothorax (9%, [22]), and leak (8%, [19]). Median length of stay was 13 days (5 to 330 days). In-hospital or 30-day mortality was 3.6% (9). Overall survival at 3 years was 44%; median survival was 25 months, and 3-year survival by posttreatment pathologic stage was: stage 0 (complete response) (n = 60), 56%; stage I (n = 32), 65%; stage IIA (n = 67), 41%; stage IIB (n = 30), 46%; and stage III (n = 49), 17%. Mean follow-up was 24 months (SEM 1.6, 0 to 138 months). Five patients with tumor in situ, 6 patients with stage IV disease, and 1 patient who could not be staged (12 pts) were excluded from survival and multivariate calculations. In univariate and different models of multivariate analysis, age more than 65 years, posttreatment T3, and nodal involvement were predictive of poor survival. For univariate analysis, p = 0.002, p = 0.004, p = 0.02, respectively; for multivariate analysis, p = 0.001, p = 0.003, p = 0.02, respectively., Conclusions: Total thoracic esophagectomy with node dissection for esophageal cancer appears to have acceptable morbidity and mortality with encouraging survival results in the setting of neoadjuvant therapy. Patients who show complete response after induction chemoradiotherapy appear to have improved long-term survival.

The three-incisional technique described above allows the surgeon to do a safe resection that includes a complete lymphadenectomy and a cervical esophagogastric anastomosis. The advantages of a neck anastomosis have been detailed elsewhere and briefly include a lower incidence of reflux symptoms, a more extensive proximal resection margin, position outside prior radiation ports, and easier management of an anastomotic leak should it occur. By performing this in two phases, the operation can be performed efficaciously. The subtle nuances detailed, such as the use of Penrose drains and the arthroscopic camera bag to deliver the specimen, help to avoid some of the potential complications generally associated with an esophagectomy.

The definition of a standard therapy for resectable esophageal cancer remains a clinical controversy. In the past decade, a variety of strategies have been developed in an attempt to improve local control and decrease the all too common problem of distant metastases. Preoperative treatment with radiotherapy or chemotherapy has been proved to be feasible, although neither strategy has resulted in improved survival rates. More recently, concurrent, neoadjuvant chemoradiation has been utilized with encouraging pathologic responses. Equally important is the recognition that such aggressive therapy does not lead to worse surgical outcomes. The evidence for the safety, feasibility, and efficacy of induction therapy followed by esophagectomy is presented in the context of developing a rational methodology to allow for the ongoing modification of standards of care in the management of this difficult disease.