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In Transhiatal Esophagectomy(THE) two approaches can be used by the surgeon: abdominal and cervical, without thoracotomy. A pioneer of this technique was Orringer, with the largest experience world-wide (1085 patients). THE is associated with a lower morbidity compared with the transthoracic approach, but much controversy exists on whether THE is a suitable operation for cancer, because it is not combined with en-bloc lymphadenectomy. However, overall, there are no statistical differences between the two. Frequently esophageal carcinoma is a systemic disease and thus, the biological behavior and the stage of tumor rather than the technique, play a major role.

The impact of esophageal cancer surgery, postoperatively as well as on quality of life (QoL) is still largely unknown. Clinical experience and the scarce existing literature concur that these patients show difficulty in returning to their original lifestyles and previous social activities, not just due to the difficulties common to all tumor pathologies but also for the specific dietary and digestive disturbances which characterize esophageal cancer therapy. As specific rehabilitation protocols are nonexistent in the literature, in this study a rehabilitation planning program, is proposed based on evaluation of postoperative and long-term problems which can be tackled with rehabilitation.

Given the overall poor prognosis of patients with esophageal carcinoma and considering the new therapeutic options, surgeons should accurately stage patients preoperatively to appropriately tailor their treatment. CT, MRI, PET and EUS are still inaccurate in evaluating local surgical resectability and in detecting abdominal and thoracic lymph node metastases. Minimally invasive surgical staging is a promising adjunct to esophageal cancer staging. The thoracoscopic and laparoscopic staging provide more accurate information for evaluating local invasion, lymph node and distant metastasis. The greater accuracy afforded by minimally invasive staging is essential for patients who should undergo radical surgical or multimodal treatment. According to data reported by many authors, it seems most useful to combine nonoperative staging procedures as CT/MRI and EUS with minimally invasive staging techniques.

Esophageal carcinomas are steadily rising worldwide; they rank sixth among tumors. Adenocarcinoma is the most common histological type in Western countries while squamous carcinoma is more common in the developing countries. Both types are preceded by pre-neoplastic lesions rappresented by Barrett's esophagus for adenocarcinoma and low and high grade dysplasia for squamous carcinoma. Some continuity exists between dysplastic lesions and frankly invasive tumors. Moreover rare hystological types have been described. The surgical pathologist plays an important role in evaluating small endoscopic biopsies as well as in examining surgical specimens from esophagectomy. In the former case the role is exclusively diagnostic while in the latter surgical radicality, cancer stage and outcomes of neoadjuvant therapies are assessed. All these data are crucial not only for prognosis but also for therapy planning.

Malnourished cancer patients undergoing major surgical treatments are at a high risk of morbidity and mortality. As compared to patients affected by other tumors, the highest rate of malnutrition (78.9%) was found in those with esophageal cancer due to postoperative complications. The impact of perioperative nutritional support on outcome in esophageal cancer patients undergoing surgery is analyzed. Strategies that can be used to preserve or restore the nutritional condition in patients throughout treatment are illustrated. Oral supplementation, and enteral or parenteral nutrition are among several methods of support. Enteral option is to be preferred because the intestinal integrity is preserved, the risk of complications is reduced and costs are lower. Prevention or correction of nutrient depletion in severely malnourished esophageal cancer patients remarkably reduces or eliminates malnutrition-related morbidity and mortality. Therefore to identify and treat malnutrition is of the utmost importance.

Mortality rate after esophagectomy ranges from 2% to more than 25% and is related to preoperative and operative factors. Pulmonary complications are frequently seen after esophageal resection with a high mortality rate. The aim of preoperative pulmonary risk assessment is to identify patients who can undergo esophagectomy evaluating patient-related risk factors and their treatment. Preoperative pulmonary risk factors are smoking, respiratory diseases as COPD, elderly age and general condition. Careful medical history, physical examination and pulmonary function testing contribute to identify risk factors and strategies to reduce the risk of pulmonary complications.

Esophageal cancer with high incidence and mortality rates plays a major clinical and social role. Adjuvant radiotherapy, chemotherapy and combined chemoradiation are used for esophageal cancer patients after esophagectomy. Outcomes of these approaches are analyzed in the literature. Three randomized clinical trials and three retrospective series were reviewed; they provided a representative pattern of available data. From their analysis some critical aspects emerged in relation to the statistical design of the few, now available randomized clinical trials. The number of patients enrolled is too low to verify minimal improvements in outcomes. Therefore, to-date there is not definite evidence in the literature supporting the role of adjuvant chemotherapy in patients undergoing surgery for esophageal cancer.