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Emphysema is a progressive, unrelenting disease that results in a continued decline in pulmonary function. When pulmonary function testing documents a forced expiratory volume in 1s (FEV) of less than 30% predicted values, the 3-year mortality risk has been estimated at 40% to 50%. Because of the increased mortality and the decreased quality of life seen with severe emphysema, multiple surgical treatments have been devised for patients with emphysema. The majority of these surgical interventions have been subsequently abandoned because of the lack of reproducible benefits and the false physiological principles upon which they were based. An excellent published review on the history of emphysema surgery has been provided by Deslauriers. As surgeons and physicians gained a better understanding of the pathophysiology of emphysema, most of these procedures would be considered of historical interest with no current practical value.

A pneumothorax occurs when there is air in the pleural space. Pneumothoraces are classified as spontaneous, which occur without preceding trauma or other obvious cause, or traumatic, which occur as a result of trauma to the chest. Spontaneous pneumothoraces are subclassified as primary or secondary. A primary spontaneous pneumothorax occurs in an otherwise healthy person without underlying lung disease. A secondary spontaneous pneumothorax complicates an underlying lung disease, most commonly chronic obstructive pulmonary disease.

Survival rates in esophageal cancer are closely related to the stage of the disease at the beginning of treatment and the completeness of surgical R0 resection. Preoperative staging is reasonable only if it allows selection between different treatment options. Accurate pretreatment staging is critical for optimal choice of treatment. Today’s stage-adjusted treatment of advanced esophageal cancers requires a meticulous diagnostic workup. Multimodal therapy may improve the outcome even in more advanced cases. Hence, the exact role of positron emission tomography (PET) and endoscopic ultrasonography (EUS) in restaging after neoadjuvant treatment needs to be determined. In esophageal cancer, EUS represents the gold standard for T staging, crucial when less radical approaches, such as endoscopic mucosa resection or limited resection for early carcinoma, are considered.

Despite advances in treatment regimens, overall 5-year survival rates for esophageal cancer remain low, averaging less than 30%. Although surgery remains the standard treatment and the only hope for cure, there is growing support for multimodality therapy.

Esophageal carcinoma is still a dreadful disease with a dismal prognosis. Surgery remains the mainstay of curative treatment. Optimizing the surgical treatment of esophageal cancer patients consists of different strategies such as early diagnosis, optimal patient selection, optimal perioperative care, and possibly the application of (neo)adjuvant chemoradiation therapy. The treatment of esophageal carcinoma therefore warrants a multidisciplinary approach to optimize care for these patients.

Despite advances in medical and radiation oncology, esophagectomy continues to remain the cornerstone of therapy for esophageal cancer when cure is the goal. The surgical approaches to esophagectomy, however, vary by institution. In many cases patients with esophageal cancer are older with significant comorbid diseases. Open approaches to esophagectomy can often carry significant morbidity and mortality for these compromised patients. Minimally invasive strategies, bolstered by improving techniques and technology, have made minimally invasive esophagectomy (MIE) a feasible operative strategy for esophageal cancer surgery. Minimally invasive surgery offers the potential for faster postoperative recovery and fewer pulmonary complications. Much like open surgery, MIE approaches and techniques differ based on institution and surgeon. The goal, however, regardless of the approach, is complete resection of all cancer.

The controversy surrounding the surgical treatment of esophageal cancer focuses, almost exclusively, on the extent of lymph node dissection required during esophagectomy. The majority view holds that an extended or a radical lymph node dissection will not improve overall or disease-free survival because the disease is systemic at the time of diagnosis and that long-term outcomes are largely determined by the biological behavior of the tumor; an issue that cannot be influenced by the extent of surgical dissection. Advocates of this view embrace the conventional techniques of esophageal resection where the esophagus is extracted from its mediastinal bed along with the adjacent periesophageal and lesser curvature nodes. This extent of lymph node excision is easily achieved by either a transhiatal or a transthoracic approach and thus, the terms or are descriptive only of the means of surgical access rather than the extent of lymph node dissection which is, for all intents and purposes, similar in extent.

Subtotal esophagectomy may consist of either resection of the lower 90% of the thoracic segment of the esophagus with subsequent esophagogastrostomy at the apex of the chest, or resection of the whole thoracic segment plus the lower segment of the cervical part of the esophagus with subsequent cervical esophagogastrostomy.

Esophageal resection is indicated most often for treatment of localized esophageal cancer and Barrett’s esophagus with high grade dysplasia. Despite the improved techniques utilized for resection, Karl and colleagues report esophagectomy continues to be associated with a 30-day mortality of 2.1% and a 3-year survival of 29.6%. Overall, 29% of patients experience complications such as anastomotic leaks (3.5%) and pulmonary complications (19%). Approximately 58% of patients with esophageal cancer present with significant weight loss. These patients often have nutritional deficiencies due to the obstructive nature of the tumor and the catabolic effects of the malignancy. Poor preoperative nutritional status may increase the risk of postoperative complications and therefore nutritional support is a treatment modality that may directly impact outcomes.

In the 1940s, Dragstedt reported a 20% to 25% frequency of delayed gastric emptying after truncal vagotomy alone for peptic ulcer disease. A similarly high frequency of delayed gastric emptying was reported by Bergin in 1959 in a series of 32 patients. Based on this experience, it seemed reasonable, as many authorities have, to expect prolonged gastric emptying after esophagectomy and reconstruction by gastric pullup — an operation in which bilateral truncal vagotomy is inevitable — unless a pyloroplasty or pyloromyotomy is performed.