Surgery and adjuvant therapy after esophagectomy

Successful treatment of esophageal cancer requires a multidisciplinary approach consisting of surgery, chemotherapy, and radiotherapy. Esophagectomy is highly invasive with substantial morbidity and mortality. In order to reduce surgical invasiveness and improve outcomes, minimally invasive esophagectomy (MIE) and robot-assisted MIE were introduced. MIE reduces the incidence of postoperative complications, including pneumonia, when compared to open esophagectomy. In the last decade, several studies demonstrated that the modification of neoadjuvant and perioperative therapy could further improve outcomes. However, overall survival was still unsatisfactory: 5-year overall survival rate was 45% in the FLOT4 trial, 47% in the CROSS trial, and 55% in the JCOG9907 trial. Adjuvant therapy in combination with neoadjuvant chemotherapy may be a strategy to improve oncological outcomes. However, tolerability for adjuvant treatment is a concern as postoperative complications may delay recovery and hamper the application of adjuvant treatment. Secondly, not all patients likely benefit form adjuvant treatment. Individualization of treatment based on risk stratification of recurrent disease by new technologies is the future. Although further validation and interventional studies are required, liquid biopsies may be promising indicators to guide multidisciplinary treatment for esophageal cancer.