Esophagectomy: How the Surgery Is Performed, and the Shift Toward Robotic Techniques

There is a lot of ignorance in our community, especially in our country, about a complex disease like esophageal cancer. Patients have early, subtle symptoms of difficulty swallowing, but they are often ignored and mistaken for some other common ailment. The need for awareness is foremost. As doctors, we should involve ourselves in educating more and more of the public about the disease, its diagnosis and the treatments available, so that if it is detected early, we can offer patients the maximum curative options.

That is a very valid question. Even in our community we see a lot of cases of caustic esophageal injury, and this chronic esophagitis can eventually lead to stricturous disease and become a predisposing cause for esophageal cancer. Patients who survive such an injury and go on to develop stricturous disease should be kept on a very stringent surveillance protocol.

In our practice, screening is recommended after the age of 35 to 40 years, particularly for patients with reflux symptoms or a risk of Barrett's esophagus, though this is a variable number depending on institutional protocol. In practice, we take these patients up for endoscopic mapping: any area showing dysplastic change is biopsied. If there is no evidence of dysplasia after multiple biopsies, the patient is kept on surveillance. Low-grade dysplasia is followed up. High-grade dysplasia in a flat lesion under 2 cm is ablated, and high-grade dysplasia over 2 cm, or with a nodular appearance, is taken for endoscopic resection with histopathology follow-up on the specimen.

Most of these patients go on to develop stricturous disease, leading to significant dysphagia and a chronic inability to take oral nutrition. In such patients, an esophagectomy with a neo-esophagus is offered. In patients who do not develop stricturous disease, six-monthly endoscopic evaluation with biopsy of any suspicious area is done instead, and further imaging is not required unless a biopsy proves malignancy.

The protocol is endoscopic mapping. The endoscopist localises exactly where the tumour sits relative to the GE junction, using a standard landmark of around 40 cm from the incisors, which varies slightly with the patient's own oesophageal length. Once that is determined, the malignancy is mapped against the gastroesophageal junction, and this is cross-checked against the axial imaging. If there is any disagreement between the endoscopic and imaging findings, the axial imaging representation is preferred to finalise the diagnosis.

Removing the entire esophagus from the thoracic inlet to the gastroesophageal junction and reconstructing a neo-esophagus from a gastric conduit brought through the posterior mediastinum.

It offers more precise tumour dissection, better oncological radicality of the specimen, and faster early post-operative recovery compared with open or standard laparoscopic surgery.

It is offered to frail or borderline-fitness patients, particularly with a non-bulky gastroesophageal junction tumour, since it is better tolerated than a trans-thoracic approach in this group.