372 Materials
The following protocol refers to standard surgical resection for a
type I esophageal adenocarcinoma via an open abdomen-thoracic
approach. Other alternative approaches, such as minimally invasive
surgical methods are not discussed [ 4 ].The indication of resection would be curative in intent with com-
plete removal of the tumor with negative margins (R0 resection)
and adequate lymphadenectomy. Modern treatment often involves
multimodality therapy and increasingly operations are performed
after preoperative treatments. The more widely practiced protocols
are either neoadjuvant chemoradiotherapy as per the
ChemoRadiotherapy for Esophageal cancer followed by Surgery
Study (CROSS) trial protocol [ 5 , 6 ] or perioperative chemother-
apy [ 7 , 8 ].Accurate tumor staging should be performed to maximize chance
of R0 resection (see Chapter 10 ). This usually involves computer
tomography scan, endoscopic ultrasound (EUS) ± fine-needle
aspiration cytology of suspicious nodal metastases. Positron emis-
sion tomography (PET) scan is becoming standard investigation at
many institutions; it provides additional information on suspicious
lesions on EUS and computer tomography scans, especially of dis-
tant metastases. Post-neoadjuvant staging is notoriously inaccu-
rate. Tissue planes between the cancer and adjacent structures are
still best assessed by EUS though accuracy decreases substantially
post-radiation.
Physiological assessments are important to exclude patients for
surgery, and optimization of cardiopulmonary functions is of par-
ticular importance. Patients with adenocarcinomas are likely to be
overweight and are at risk from cardiovascular diseases.
Preoperative assessments include a detailed history and clinical
physical examination, simple blood profiles, chest radiograph, elec-
trocardiogram, and pulmonary spirometry. More detailed cardiac
workup including echocardiography, myocardial perfusion scans,
or angiograms are selectively applied when specific indications
exist. Cirrhosis is not an absolute contraindication to esophagec-
tomy although the presence of esophageal varices usually contrain-
dicates surgery.
In general, limited improvement can be made to a patient’s
physiological status. However, the following measures should be
instituted:
●● Cessation of smoking and alcohol intake.
●● Incentive spirometry and chest physiotherapy.2.1 Indication
for Surgery
2.2 Preoperative
Preparation
Surgery for Esophageal Adenocarcinoma