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Dysphagia represents one of the first possible presenting symptoms of tumors of the esophagus and is one of the main consequences of surgical intervention performed on these tumors. Its treatment is based on accurate evaluation of the residual functional deficit (as well as of the possible pre-existing deglutition deficit) and on implementing both general and specific rehabilitation treatment. These interventions should be carried out by a team of professionals who work together in an integrated and coordinated approach to the global caregiving of patients undergoing esophagectomy, taking into consideration the diverse physical and psychological problems associated with tumor pathology and its treatment modality.

Accurate staging of patients with esophageal cancer (EC) is essential for selection of appropriate treatment and to predict prognosis. In recent years, positron emission tomography using the positron emitting glucose analogue 18F- fluorodeoxyglucose (FDG-PET) has emerged as a particularly useful adjunct to anatomical imaging modalities as computed tomography (CT) and endoscopic ultrasonography (EUS). In the initial staging of EC the additional value of FDG-PET is its ability to identify distant metastases (stage IV disease), excluding patients from unnecessary surgery. The combination of FDG-PET and endoscopic ultrasonography with fine-needle aspiration (EUS-FNA) has been suggested as the most effective strategy for preoperative EC staging.

Esophageal carcinoma is often diagnosed at an advanced, non resectable stage. Only early stages show a better prognosis. Surgical treatment represents the gold standard. The various surgical techniques do not seem to affect survival. Based on the severity of esophageal cancer and on poor outcome achievable with surgery alone, multimodality treatments are the most suitable. The possible negative impact on the complication rate after neoadjuvant therapy is still debated. Most randomized trials have not demonstrated as yet an improvement in prognosis in patients undergoing a three-modality treatment. However, patients with complete pathologic response after surgical resection were shown to have a better prognosis. In conclusion, additional randomized trials are required, aimed at evaluating all technical and therapeutic variables which affect prognosis.

Esophagorespiratory fistulas, especially in the upper third of the esophagus, are a complication of malignant esophageal tumors, whose management is difficult and prognosis is poor. Treatment is palliative and involves restoration of the ability to ingest food and prevention of aspiration by insertion of esophageal or tracheobronchial stents. In selected patients the insertion of a single stent may be insufficient for pallation therefore the placement of parallel stents may be indicated in patients with symptoms caused by malignant esophagorespiratory fistula. A case of esophagorespiratory fistula managed with insertion of parallel stents is presented.

Giant liposarcoma is an unusual variant of mediastinal tumors. The case of a 73-year-old woman is reported. She presented with a posterior mediastinal tumor invading the third middle tract of the thoracic esophagus and the adventitia of the descending aorta, close to the posterior pericardium; a neoplastic thrombus 2cm in size was located in the upper left pulmonary vein. The tumor was completely excised by left thoracotomy, in extracorporeal circulation. The postoperative course was uneventful and the patient received adjuvant chemotherapy. She is currently alive after 8 months, disease-free. The natural history, pathology, and prognosis of the disease are reviewed and management of such lesions is discussed.

Symptomatic inoperable esophageal carcinoma represents a major clinical problem. With no treatment, swallowing deteriorates with a dramatic worsening of quality of life. At present, self-expanding metal stents (SEMS) are the most effective non surgical palliation in inoperable esophageal cancer. The different types of available SEMS, techniques, results and complications are discussed.

Endoscopic palliation is the most suitable approach to improve quality of life in patients with esophageal cancer since diagnosis is often made at an advanced stage, when radical treatment is unfeasible. Endoscopy offers several techniques to palliate dysphagia either by stenting the stenosis or by reducing the tumor mass with thermoablation. A small number of randomized controlled trials is available to compare the efficacy of different techniques and the ideal palliation has not been defined as yet. Recently, the development of self-expandable covered metal stents has rapidly gained ground in the endoscopy units throughout the world as a simple, single step procedure for palliation of dysphagia.

Postoperative management after elective esophagectomy for cancer has not been standardized. Thoracoabdominal incision with associated pain, extended operative time with consequent extracellular fluid shifts, single lung ventilation, potential for prolonged postoperative mechanical ventilation and comorbidities in patients with esophageal cancer, all contribute to high perioperative risk. Respiratory problems remain the major cause of both mortality and morbidity after esophagectomy for cancer. A specific pulmonary disorder, acute respiratory distress syndrome (ARDS) occurs in 10-20% of patients after esophagectomy. ARDS mortality exceeds 50%. Atrial fibrillation, that complicates recovery in 20 to 25% of patients after esophagectomy, contributes to make outcome worse. Anesthesiologists should adopt strategies known to be able to optimize patient outcome. Decreased postoperative mortality and morbidity have been associated with epidural analgesia, bronchoscopy to clear persistent bronchial secretions, intraoperative fluid restriction and early extubation. It has been shown that setting up early respiratory physiotherapy and mobilitation may improve functional recovery.

In esophageal cancer staging, the radiologic approach is represented by tumor identification, preoperative staging, and re-staging after neoadjuvant therapies. At present, while barium radiography shows a high sensitivity for early and advanced tumors, endoscopy is always necessary for confirmation. CT and MRI are the gold standard for preoperative staging of advanced (T4) esophageal cancer and for evaluation of distant metastasis; however they still show a low sensitivity in the study of possible regional lymph node involvement, in differentiating residual disease and scarring; in particular the esophageal wall cannot be carefully examined.

Cancer of the esophagus has an unfavorable prognosis with a five-year survival rate after radical surgery of less than 10%; early diagnosis is difficult. The appearance of symptoms, particulary dysphagia, is due to more than 2/3 tumor involvement of the esophageal circumference, already present in 2/3 of patients at diagnosis. Symptoms can be local and/or systemic; they can be physical, psychic, iatrogenic and evolutive. A careful rehabilitation program should follow these patients during the entire course of their disease The rehabilitation approach intends to define areas of intervention, short-term goals, possible achievements, role of health operators and overall verifications. Common problems of patients with esophageal cancer, are analyzed. A rehabilitation program including the patient care throughout the hospitalization period to improve his/her autonomy with respect to his/her social and familial activities, is illustrated.