Challenging esophageal surgery: risk factors, outcomes, and a comparative single-center analysis

Esophageal cancer ranks as the eighth most common cancer among human populations and stands as the sixth leading cause of cancer-related deaths. Effective treatment of esophageal tumors necessitates a comprehensive, multidisciplinary approach encompassing surgery, chemotherapy, and radiotherapy.

In our series of 203 esophagectomies conducted at our institution, we identified 28 procedures (13.7%) categorized as "challenging esophagectomies" based on specific predefined criteria outlined in the text. These criteria encompassed factors such as medical comorbidities, local tumor extension, and involvement of lymph nodes. The remaining 175 patients comprised the group of "standard esophagectomies".

We compared our study group with the standard group. There was no statistical difference between the two groups regarding overall 5 year survival and disease-free survival. In the "challenging esophagectomies" group, our overall 5 year survival rate was 34.2%, and the disease-free survival rate was 56, 4%. In the "standard" group, our overall 5 year survival rate was 48, 6%, and the disease-free survival rate was 58, 6%. Specifically, in the "challenging esophagectomies" group, the post-operative mortality rate stood at 8%, with major complications occurring in 33% of cases, in "standard group" the post-operative mortality rate stood at 2%, with major complications occurring in 23% of cases.

Despite the challenges associated with difficult esophagectomies, they play a pivotal role not only as salvage surgeries but also as a crucial component within the integrated multimodal treatment strategy. Patient selection emerges as a critical factor influencing outcomes. For this purpose, we propose a classification system of criteria and scores to define the level of complexity in this surgery.