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Despite recent advances in multimodality therapy, the mainstay of therapy for esophageal carcinoma remains surgical resection. Following esophagectomy, there are a number of options to restore continuity of the upper gastrointestinal tract. Important considerations for reconstruction include: choice of conduit (e.g., stomach, colon, jejunum); technique of conduit construction (e.g., whole stomach vs. gastric tube, left vs. right colon, etc.); location of anastomosis (i.e., intrathoracic vs. cervical); need for gastric drainage procedures (pyloroplasty, pyloromyotomy, or no drainage); and the route of reconstruction (posterior mediastinal, retrosternal, transpleural, subcutaneous). Each of these factors may have a significant impact on postoperative morbidity and long-term function.

The standard procedure for esophageal cancer resection among surgeons in Japan has been a transthoracic esophagectomy with lymphadenectomy. Since the late 1980s, a three-field lymphadenectomy including dissection in the neck, mediastinum, and abdomen for patients with cancer of the thoracic esophagus has become popular among Japanese esophageal surgeons seeking a more curative intent. The rationale for an extensive three-field lymphadenectomy is based on the empirical intelligence accumulated from a conventional two-field lymphadenectomy, namely a relatively high incidence of cervical nodal metastases and cervical nodal recurrences. Therefore, cervical lymphadenectomy was added and an upper mediastinal lymphadenectomy was performed thoroughly in keeping with the new philosophy regarding aggressive surgical therapy.

Celiac lymph nodes are considered a distant metastatic site (M1) in esophageal cancer. The M1a subclassification is recommended for distal thoracic esophageal cancer metastatic to celiac lymph nodes. This suggests that although these cancers are beyond cure, they are different from esophageal cancers with other sites of distant metastases (M1b). Of 46 disease sites for which the American Joint Committee on Cancer (AJCC) has staging recommendations, only 7 (15%) require subdivision of M1: 2 with 3 subclassifications (M1a, M1b and M1c) — cutaneous melanoma and prostate; and 5 with 2 subclassifications (M1a and M1b) — bone, retinoblastoma, testis, gestational trophoblastic tumor, and esophagus. Only prostate, testis, and esophagus designate nonregional nodes as M1a.

Anti-reflux surgery has evolved greatly in the last 15 years as a durable, viable, and safe option for treatment of gastroesophageal reflux disease (GERD), mainly due to the advent of minimally invasive techniques. The debate regarding partial fundoplication (PF) versus total fundoplication (TF) for patients with defective peristalsis and GERD has evolved as well. Nissen fundoplication is by far the most common fundoplication technique used for many decades. However, many surgeons prefer a PF in patients with defective peristalsis. This tailored approach developed due to the logical, but unproven, theory that dysphagia is more likely when impaired esophageal peristalsis fails to propel a swallowed bolus across a 360° fundoplication (or TF). Recent literature has challenged this notion, suggesting that TF is not more likely to cause dysphagia than PF.

Achalasia is a primary and profound esophageal motility disorder with an unclear etiology and which is, to date, incurable. In spite of its rare occurrence in the population (1 : 100,000), it stimulates large amounts of research and commentary by gastrointestinal (GI) physicians and surgeons, in large part due to ongoing controversy over the optimal treatment of these patients. When a nalyzing treatment options it is critical to keep in mind that all treatments are palliative in nature and are primarily aimed at relief of dysphagia and regurgitation. Normal esophageal function is almost never restored, and even a patient with an excellent result will not have completely normal swallowing.

Esophageal achalasia is a primary esophageal motility disorder of unknown origin characterized by lack of esophageal peristalsis and inability of the lower esophageal sphincter (LES) to relax properly in response to swallowing. The goal of treatment is to relieve the functional obstruction caused by the LES, therefore allowing emptying of food into the stomach by gravity. However, the elimination of the LES may be followed by reflux of gastric contents into the aperistaltic esophagus, with slow clearance of the refluxate and the risk of developing esophagitis, strictures, Barrett’s esophagus, and even adenocarcinoma.

Delayed recognition of esophageal perforation occurs due to the rarity of this problem and the protean manifestations of its presentation. The great majority of reports indicate delayed diagnosis of a perforated esophagus leads to more morbidity and mortality and greater length of stay when compared to those diagnosed less than 24 hours after perforation. Earlier reports and recommendations suggested that late recognition of an esophageal perforation mandated treatment other than primary repair. Grillo was one of the first to promote the concept of primary repair even in patients who were diagnosed late with an esophageal perforation. Most recent reports confirm the safety and efficacy of primary repair regardless of time of perforation. No randomized clinical trials have been performed of treatment options in esophageal perforations.

A lengthening gastroplasty consists of the formation of a gastric tube by vertically stapling the proximal stomach from the angle of His parallel to the lesser gastric curvature. This procedure is designed to elongate the esophageal tube as part of surgical treatment of complicated cases of gastroesophageal reflux disease (GERD) in which the esophagus is irreversibly shortened, thus the gastroesophageal (GE) junction cannot be repositioned into the abdomen without excessive tension.

The herniation of stomach into the thorax has been classified into four major types. The sliding hiatus hernia (type I), which is the commonest type and accounts for 95% of all cases, has the gastroesophageal (GE) junction as the leading point of the hernia. The GE junction is herniated into the thorax in this type of hernia. The pure paraesophageal hernia (type II), which is extremely rare, is characterized by a GE junction that maintains its intra-abdominal position while the fundus herniates into the chest through the anterolateral hiatus. The majority of the paraesophageal hernias (type III) are a combination of the above two types, in which the GE junction is herniated along with the fundus into the thorax. Finally, type IV hernias are those in which other organs like colon, small intestine, and spleen are also present in the sac.

Pharyngoesophageal (Zenker’s) diverticulum is a false diverticulum of the cervical esophagus. This pulsion diverticulum is composed of mucosa, covered by thin areolar tissue, herniating at Killian’s triangle between the obliquely positioned inferior constrictor muscle and the transversely oriented cricopharyngeus muscle. Pharyngoesophageal diverticulum was first described by Abraham Ludlow in 1764 as a “bag formed in pharynx.” Friedrich Albert Zenker in 1867 described the clinicopathological characteristics of 23 previous cases and 5 of his own cases in . The pathophysiology of Zenker’s diverticulum has been attributed to functional abnormalities of the upper esophageal sphincter zone created by the cricopharyngeus muscle.