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Introduction

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The management of esophageal cancer has evolved tremendously over the past decade. Increasingly, patients are treated with an aggressive multimodal approach including neoadjuvant chemoradiotherapy followed by surgical resection.1 Despite these changing trends in the treatment paradigm for esophageal cancer, esophagectomy remains the crucial component to long-term survival.

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The key to success in managing patients with esophageal cancer is surgeon experience.2 There are numerous approaches to esophageal resection and replacement, both open and minimally invasive, but all have the potential for a high rate of morbidity and mortality. Each esophageal surgeon must develop and refine a technique of resection that is safe and expeditious to minimize morbidity while aggressively pursuing standard oncologic principles including adequate resection margins and complete lymphadenectomy to help assure long-term survival.

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The selection of operative approach is based on numerous factors: type and location of the lesion, extent of invasion, stage of disease, need for lymphadenectomy, history of previous surgeries, and type of conduit chosen for esophageal replacement (i.e., stomach, colon, or jejunum). Surgeon preference and experience plays an important role in the selection of the operation. Popular methods of esophageal resection in the United States are based on methods developed by Ivor Lewis and McKeown, among others.3-5 They differ by the approach, number of incisions, and location of the anastomosis (intrathoracic or cervical) (Table 17-1). The three-hole esophagectomy at the Brigham and Women's hospital has evolved over time and is designed specifically to limit morbidity by assimilating the best elements of each of the predecessor surgeries in a safe and expeditious procedure.6-9 This chapter will delineate the conduct of the operation and establish principles that can be applied to any approach for esophagectomy whether open or minimally invasive.

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Table Graphic Jump Location
Table 17-1Popular Methods of Esophageal Resection and Replacement in the United States

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