Esophageal Adenocarcinoma Methods and Protocols

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Alfred K. Lam (ed.), Esophageal Adenocarcinoma: Methods and Protocols, Methods in Molecular Biology, vol. 1756,
https://doi.org/10.1007/978-1-4939-7734-5_4, © Springer Science+Business Media, LLC 2018

Chapter 4

Surgical Protocol for Esophageal Adenocarcinoma

Simon Law

Abstract

Esophagogastrectomy for esophageal adenocarcinoma remains a procedure of significant morbidity and
mortality rates. Management should be within the context of a multidisciplinary team. Appropriate patient
selection, careful preoperative preparation, meticulous application of surgical technique and perioperative
care are essential for success. Enhanced recovery after surgery (ERAS) protocols are evidence based and
improve outcome. Standard protocol for open transthoracic esophagectomy is described.

Key words Esophageal adenocarcinoma, Esophagogastric junction, Surgery, Esophagectomy,

Complications

1 Introduction

The Siewert classification has been applied to adenocarcinoma

around the lower esophagus and esophagogastric junction since

the 1980s [ 1 ]. It applies to adenocarcinomas that involve the

esophagogastric junction, and with their epicenter in an area 5 cm

proximal and 5 cm distal to the anatomical esophagogastric junc-

tion. Type I cancers are mostly regarded as “esophageal” in origin

and are closely related to gastresophageal reflux disease and

Barrett’s esophagus. Type III tumors are more akin to proximal

gastric cancers that have infiltrated the esophagogastric junction

from below. Type II cancers centered on the esophagogastric junc-

tion are most controversial, whether they are more like esophageal

cancers or gastric cancers and how they should be treated are ques-

tions difficult to answer.

There are drawbacks of the Siewert classification. First, it is a

purely anatomical system based only on the epicenter of the tumor

and does not take into account the proximal and distal extent of

the cancer. So for instance, a 10 cm tumor with its epicenter at the

esophagogastric junction is classified as a type II cancer, similar to

a 2 cm tumor with the epicenter at the same location. The surgical

approach and treatment is obviously quite different. Second,

1.1 Classification
of Tumors Around the
Esophagogastric
Junction