Salvage surgery after definitive chemoradiotherapy for esophageal cancer

: Salvage esophageal resection after chemoradiation is an increasingly recognized clinical challenge, especially in the context of esophageal squamous cell carcinoma. Despite that, there have been varying definitions of salvage in the literature, leading to difficulties in interpreting data. This is further complicated by the limitations in assessing clinical complete response after chemoradiation. At the same time, salvage esophagectomy has classically been approached with reservation because of the associated morbidity and mortality, especially that definitive chemoradiation is sometimes the preferred choice of treatment for borderline-operable and borderline-resectable patients. While some reports have shown good survival outcomes, others have shown the opposite. Yet, the morbidity rate remains relatively high. From a surgical point of view, borderline-operable patients can be further optimized with specialized prehabilitation programs, which have been demonstrated to be useful in gastroesophageal cancers. Intraoperatively, there are important technical modifications that need to be taken into consideration. A special consideration should also be given to patients with limited airway involvement. In this review, we explore the different definitions of salvage and discuss clinical complete response after chemoradiation. We also discuss the postoperative and survival outcomes of salvage esophagectomy. A special focus is given to preoperative optimization and intraoperative technical aspects, including airway resection. Finally, the ongoing clinical trials looking into this subject are discussed.