Controversies in the surgical management of esophageal adenocarcinoma

The incidence of esophageal adenocarcinoma (EAC) has risen dramatically over the last decade. Over this same period, our understanding and treatments have been revolutionized. Just over a decade ago, the majority of patients with locally advanced esophageal cancer went directly to surgery and our overall survival was bleak. Our current strategy for locally advanced esophageal adenocarcinoma is a multi-disciplinary approach. This approach consists of chemotherapy plus or minus radiation followed by surgical resection followed by adjuvant immunotherapy with the presence of any residual disease. Therefore, now more than ever, the goals of surgery are to minimize morbidity, provide aggressive local control and allow patients to receive to quickly recover so they can receive adjuvant systemic therapy. Surgery continues to play a crucial role in the multi-disciplinary approach to EAC. This review will highlight the on-going areas of controversy in surgical treatment. These controversies are around surgical selection, perioperative decision making and the role of surgery. Specifically, there are controversies in the type of surgical approach offered. This review will discuss the benefits of minimally invasive versus open esophagectomy. The indications for gastrectomy versus esophagectomy in patients with gastroesophageal junction EAC. Further, at the time of operation, there is still debate and on-going trials addressing the addition of a pyloric intervention. Lastly, as we push the limits of systemic therapy, there are those who may not even need a surgical resection. This review will cover the most recent data on selective esophageal resection and the concerns regarding this approach.