Esophagectomy
What the Examiner Expects
Resection of the esophagus most commonly performed for esophageal cancer (squamous cell or adenocarcinoma). The examiner expects you to stage the patient (EGD with biopsy, CT chest/abdomen, PET scan, EUS for T and N staging), determine candidacy for neoadjuvant chemoradiation (CROSS protocol for T2+ or node-positive disease), and choose the appropriate surgical approach. Ivor Lewis (laparotomy + right thoracotomy with intrathoracic anastomosis) is most common for distal tumors. McKeown (three-field with cervical anastomosis) is used for proximal/mid tumors. Transhiatal avoids thoracotomy but provides limited mediastinal lymphadenectomy. Reconstruction uses a gastric conduit based on the right gastroepiploic artery.
Key Examiner Focus Points
- Approaches: Ivor Lewis (right thoracotomy + laparotomy), McKeown (three-field), transhiatal
- Neoadjuvant chemoradiation (CROSS protocol) for locally advanced disease (T2+ or N+)
- Gastric conduit is the preferred reconstruction; placed in the posterior mediastinum
- Anastomotic leak is the most feared complication — know the management algorithm
- Ensure adequate lymph node harvest (≥15 nodes recommended)
Common Curveballs
POD 5 drain output becomes bilious/saliva-like, patient develops tachycardia and fever
Anastomotic leak. Obtain CT with oral contrast or water-soluble esophagram. For contained leaks: NPO, IV antibiotics, percutaneous drainage, possible endoscopic stent. For free leaks with sepsis: re-exploration, washout, wide drainage, consider diversion with cervical esophagostomy.
EUS shows T2N1 disease — patient asks if they should go straight to surgery
No. Neoadjuvant chemoradiation per CROSS protocol (carboplatin/paclitaxel + 41.4 Gy radiation) followed by surgery in 6–8 weeks. CROSS trial showed significant survival benefit for locally advanced disease.
Conduit appears dusky after pulling it into the chest
Ischemic conduit. Assess perfusion (ICG fluorescence if available). If severely ischemic, do not anastomose — take down, use colon interposition or jejunal free flap as alternative conduit. Forcing an anastomosis on ischemic tissue guarantees a leak.
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