Perioperative management and prevention of complication for salvage esophagectomy after definitive chemoradiotherapy

Salvage esophagectomy has been increasing as a second-line treatment after failure of definitive chemoradiotherapy (CRT) for esophageal cancer. A number of patients who have received CRT, especially those who have residual tumors and shorter waiting times until operation, have developed malnutrition and problems in their immunologic condition because of decreasing oral intake and bone marrow suppression. Because high-dose radiation causes inflammation, fibrosis and peripheral circulatory disturbance of various tissues in the treatment fields, salvage surgery can be a technically difficult operation. In our previous experience, postoperative complications of salvage esophagectomy are more frequent and more serious than that of planned esophagectomy. For example, we have experienced necrosis of the reconstructed gastric tube, esophago-tracheal fistula, mediastinal abscess, hard-to-treat acute respiratory distress syndrome (ARDS) and so on. In particular, respiratory tract necrosis or perforation is the most critical complication and frequently becomes lethal. Patients who undergo a salvage esophagectomy have a significantly higher risk of pulmonary and cardiac complication, and have high rates of repeated surgery. Rapid diagnosis and appropriate treatment of complications are necessary to reduce postoperative mortality. To improve the overall outcome, it is very important to better understand the condition of patients after CRT, so appropriate surgery can be carefully planned. Furthermore, it is absolutely essential to perform the operation with great care and to meticulously manage the perioperative care for salvage esophagectomy.