Esophageal Resection Research Articles

Anastomotic leakage and postoperative mortality in patients after esophageal cancer resection

ObjectiveEsophagectomy is a high-risk surgical procedure with significant postoperative morbidity and mortality. This study aimed to investigate the risk factors of cervical anastomotic leakage and postoperative mortality.MethodsIn this retrospective, observational study, we recruited 1010 patients with esophageal cancer. Cox regression analysis was performed to identify factors affecting anastomotic leakage and postoperative mortality. After propensity score matching, the Kaplan–Meier curve was used to evaluate the effect of leakage on postoperative mortality.ResultsThe number of patients with cervical anastomotic leakage, in-hospital mortality, 30-day postoperative mortality, and 60-day postoperative mortality was 194 (19.2%), 13 (1.3%), 12 (1.2%), and 16 (1.6%), respectively. The total length of hospital stay and hospital stay postoperatively were 29.7 ± 21.1 and 21.3 ± 20.3 days, respectively. Diabetes, stage IV, and an upper thoracic tumor were significant risk factors for leakage. Leakage and diabetes were significant risk factors for postoperative mortality. After propensity score matching, leakage also significantly affected postoperative mortality.ConclusionsPatients with tumors in the upper thoracic segment of the esophagus may be more prone to developing anastomotic leakage compared with those with tumors in the middle or lower thoracic segment. Anastomotic leakage may prolong the length of hospital stay and increase postoperative mortality.

Future directions—minimally invasive approaches to esophageal resection: a narrative review

Future directions—minimally invasive approaches to esophageal resection: a narrative review

Continued Relevance of Minimum Volume Standards for Elective Esophagectomy: A National Perspective

BackgroundDespite minimum volume recommendations, the majority of esophagectomies are performed at centers with fewer than 20 annual cases. The present study examined the impact of institutional esophagectomy volume on in-hospital mortality, complications, and resource use after esophageal resection. MethodsThe 2010-2018 Nationwide Readmissions Database was queried to identify all adult patients undergoing esophagectomy for malignancy. Hospitals were categorized as a high-volume hospital (HVH) if performing at least 20 esophagectomies annually and as a low-volume hospital (LVH) if performing fewer than 20 esophagectomies annually. Multivariable models were developed to study the impact of volume on outcomes of interest, which included in-hospital mortality, complications, duration of hospitalization, inflation adjusted costs, readmissions, and nonhome discharge. ResultsOf an estimated 23,176 hospitalizations, 45.6% occurred at HVHs. Incidence of esophagectomy increased significantly along with median institutional caseload over the study period, while the proportion on hospitals considered HVHs remained steady at approximately 7.4%. After adjusting for relevant patient and hospital characteristics, HVH status was associated with decreased mortality (AOR, 0.65), length of stay (β = -1.83), pneumonia (AOR, 0.69), prolonged ventilation (AOR, 0.50), sepsis (AOR, 0.80), and tracheostomy (AOR, 0.66) but increased odds of nonhome discharge (AOR, 1.56; all P < .01), with LVH status as reference. ConclusionsMany clinical outcomes of esophagectomy are improved with no increment in costs when performed at centers with an annual caseload of at least 20, as recommended by patient advocacy organizations. These findings suggest that centralization of esophageal resections to high-volume centers may be congruent with value-based care models.

Ionized Hypomagnesemia Is Associated With Increased Incidence of Postoperative Atrial Fibrillation After Esophageal Resection: A Retrospective Study.

Introduction: Postoperative atrial fibrillation (POAF) is common after surgery for esophageal cancer and may prolong hospitalization and elevate mortality. POAF and hypomagnesemia are linked, but this is based on studies showing an association of POAF with serum total magnesium (tMg). In contrast, the relationship of POAF with ionized magnesium (iMg), which has physiological activity, has not been examined. In this study, the association between hypomagnesemia and POAF was investigated retrospectively to examine iMg as a possible predictive factor for POAF.Methods: The subjects were 151 patients who underwent right transthoracoabdominal subtotal esophagectomy at Saitama Medical Center between January 2011 and December 2020. The incidence of POAF and predictive factors were examined retrospectively. Perioperative predictive factors were subjected to univariate analysis, and items with P<0.1 were then included in multivariate analysis, along with five potential POAF predictors reported in the literature (age, gender, body mass index, hypertension, and diabetes mellitus). P<0.05 was regarded as significant in the multivariate analysis.Results: Of the 151 patients, 34 (23%) developed POAF. In univariate analysis, six factors with P<0.1 (oral statin, dyslipidemia, iMg level after anesthesia induction, maximum and minimum iMg during surgery, and iMg level immediately before admission to ICU) were identified. In multivariate analysis including these and the five literature factors as explanatory variables, iMg immediately before admission to ICU emerged as a predictive factor for POAF (iMg≥0.46 mmol/L, OR 0.32, 95%CI 0.14-0.74, p=0.01) (standard iMg range: 0.48-0.60 mmol/L).Conclusion: The iMg level immediately before admission to ICU may be associated with the development of POAF. A further study is needed to evaluate changes in iMg in the ICU and iMg at the time of onset of POAF.

Esophageal resection in Austria—preparing a national registry

Summary Background Esophageal resection is a technically challenging procedure. Despite improvements in perioperative management and outcome, it is still associated with considerably high morbidity and mortality rates even if performed in high-volume centers. This study aimed to shed light on the results of routine patient care in three representative referral centers concerning caseload and surgical and oncological outcomes. Methods This study is a retrospective, multicenter, national-wide analysis of a newly established database including perioperative and long-term outcome data from three referral centers in Austria. Results In a 6-year study period (2013–2018), 411 patients were eligible for analysis. The indication for esophageal resection was esophageal adenocarcinoma in 299 (72.7%) patients and esophageal squamous cell carcinoma in 90 (21.9%) patients. The abdominothoracic approach (70.1%) was the most common operation, followed by transhiatal extended gastrectomy (14.8%) and a thoracic-abdominal-cervical approach (8.5%). Most patients (77.9%) underwent neoadjuvant therapy (chemotherapy 45.3%, radiochemotherapy in 32.6%). A minimally invasive approach was chosen in 25.3%. Major complications and mortality were seen in 21.7% and 2.9%, respectively. The 1‑year survival rate was 84%, 3‑year survival 60%, and 5‑year survival was 52%. The pooled overall median survival was 110 months (95% CI 33.97–186.03). Conclusion This first publication of the Austrian Society of Esophageal Surgery shows that the outcome of esophageal surgery for cancer in Austria compares well with that of renowned international centers. However, a more comprehensive approach including as many national centers as possible will improve outcome research, offer quality management, and improve patient safety. The study group invites all Austrian institutions performing esophagectomy to participate in the initiative.

Thoracic and abdominal pain after esophageal resection

Thoracic and abdominal pain after esophageal resection

First-in-Human Segmental Esophageal Reconstruction Using a Bioengineered Mesenchymal Stromal Cell–Seeded Implant

IntroductionResection and reconstruction of the esophagus remains fraught with morbidity and mortality. Recently, data from a porcine reconstruction model revealed that segmental esophageal reconstruction using an autologous mesenchymal stromal cell-seeded polyurethane graft (Cellspan esophageal implant [CEI]) can facilitate esophageal regrowth and regeneration. To this end, a patient requiring a full circumferential esophageal segmental reconstruction after a complex multiorgan tumor resection was approved for an investigational treatment under the Food and Drug Administration Expanded Access Use (Investigational New Drug 17402). MethodsAutologous adipose-derived mesenchymal stromal cells (Ad-MSCs) were isolated from the Emergency Investigational New Drug patient approximately 4 weeks before surgery from an adipose tissue biopsy specimen. The Ad-MSCs were grown and expanded under current Good Manufacturing Practice manufacturing conditions. The cells were then seeded onto a polyurethane fiber mesh scaffold (Cellspan scaffold) and cultured in a custom bioreactor to manufacture the final CEI graft. The cell-seeded scaffold was then shipped to the surgical site for surgical implantation. After removal of a tumor mass and a full circumferential 4 cm segment of the esophagus that was invaded by the tumor, the CEI was implanted by suturing the tubular CEI graft to both ends of the remaining native esophagus using end-to-end anastomosis. ResultsIn this case report, we found that a clinical-grade, tissue-engineered esophageal graft can be used for segmental esophageal reconstruction in a human patient. This report reveals that the graft supports regeneration of the esophageal conduit. Histologic analysis of the tissue postmortem, 7.5 months after the implantation procedure, revealed complete luminal epithelialization and partial esophageal tissue regeneration. ConclusionsAutologous Ad-MSC seeded onto a tubular CEI tissue-engineered graft stimulates tissue regeneration following implantation after a full circumferential esophageal resection.

Risk prediction nomogram for major morbidity related to primary resection for esophageal squamous cancer.

Background and Objectives:Postoperative major complications after esophageal cancer resection vary and may significantly impact long-term outcomes. This study aimed to build an individualized nomogram to predict post-esophagectomy major morbidity.Methods:This retrospective study included 599 consecutive patients treated at a single center between January 2017 and April 2019. Of them, 420 and 179 were assigned to the model development and validation cohorts, respectively. Major morbidity predictors were identified using multiple logistic regression. Model discrimination and calibration were evaluated by validation. Regarding clinical usefulness, we examined the net benefit using decision curve analysis.Results:The mean age was 64 years; 79% of the patients were male. The most common comorbidities were hypertension, diabetes mellitus, and stroke history. The 30-day postoperative major morbidity rate was 24%. Multivariate logistic regression analysis showed that age, smoking history, coronary heart disease, dysphagia, body mass index, operation time, and tumor size were independent risk factors for surgery-associated major morbidity. Areas under the receiver-operating characteristic curves of the development and validation groups were 0.775 (95% confidence interval, 0.721–0.829) and 0.792 (95% confidence interval, 0.709–0.874), respectively. In the validation cohort, the nomogram showed good calibration. Decision curve analysis demonstrated that the prediction nomogram was clinically useful.Conclusion:Morbidity models and nomograms incorporating clinical and surgical data can be used to predict operative risk for esophagectomy and provide appropriate resources for the postoperative management of high-risk patients.

Esophageal Wound Vacuum Placement for Anastomotic Leak: Lessons Learned From First Time Use at a Tertiary Care Center

Esophageal atresia and tracheoesophageal fistula (TEF) are rare birth anomalies typically requiring corrective surgery over the first few months of life. Esophageal surgery can lead to a life-threatening anastomotic leak. Esophageal wound vacuums have seen increased use in adults and one cohort of children as a therapeutic modality. This case study explores a tertiary care pediatric hospital’s introductory experience in utilizing this technique. A 19-month-old male underwent staged repair for esophageal atresia/tracheoesophageal fistula requiring an esophageal stricture resection with primary anastomosis. An anastomotic leak was successfully managed with wound vacuums. Our experiences highlighted the need for individualized treatment plans with this therapy based on feeding capabilities, side effects of the vacuum, placement method, and replacement strategies.

Impact of Perioperative Thromboembolic Complications on Future Long-term Risk of Venous Thromboembolism among Medicare Beneficiaries Undergoing Complex Gastrointestinal Surgery

BackgroundVenous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), represents a common cause of morbidity and mortality following complex gastrointestinal surgery. Whether perioperative VTE also exposes patients to a higher long-term risk of VTE events remains poorly defined. MethodsThe Medicare 100% Standard Analytic Files were used to identify patients undergoing esophageal, hepatic, pancreatic, and colorectal resection between 2013 and 2017. The impact of perioperative VTE, defined as a VTE episode occurring during the index hospitalization or within 30 days of discharge, on the risk of developing subsequent long-term VTE episodes (i.e., more than 30 days following discharge) was examined. ResultsAmong 253,212 patients who underwent complex gastrointestinal surgery, 1.9% (n=4763) developed a VTE episode perioperatively. With a median follow-up period of 553 days (IQR 194–1052), a total of 11,052 patients (4.4%) developed a long-term VTE episode. Of note, patients who developed a DVT perioperatively had a higher risk of experiencing a long-term VTE episode than patients who had no perioperative thromboembolic complications (HR 6.50, 95%CI 6.04–6.98). The increase in risk was more pronounced among patients who had a PE (HR 27.97, 95%CI 25.39–30.80) at the time of surgery. Risk factors for long-term thromboembolic events following complex GI surgery included Black patients (HR 1.20, 95%CI 1.11–1.30), receipt of surgery at a teaching hospital (HR 1.09, 95%CI 1.04–1.13), nonelective surgery (HR 1.19, 95%CI 1.14–1.24), as well as a diagnosis of cancer (HR 1.10, 95%CI 1.05–1.16). The development of a perioperative DVT was associated with an increased long-term risk of VTE in both cancer (HR 5.59, 95%CI 5.29–6.61) and non-cancer patients (HR 6.98, 95%CI 6.37–7.64). Similarly, experiencing a PE at the time of surgery led to a higher long-term risk of VTE in cancer (HR 24.30, 95%CI 21.08–28.02), as well as non-cancer (HR 30.81, 95%CI 27.01–35.15) patients. ConclusionsPatients with a history of perioperative VTE had a higher risk of developing subsequent VTE events within 1–2 years following complex GI surgery. The risk was more pronounced among patients who had perioperative PE rather than DVT. These findings were consistent among both cancer and non-cancer patients.

Hypopharynx reconstruction for primary hypopharyngeal carcinoma: a retrospective study and literature review.

BackgroundThe study aims to retrospectively evaluate disparate reconstructive choices for defects in patients with primary hypopharyngeal carcinoma undergoing tumor resection.MethodsOne hundred and twenty-five patients of primary hypopharyngeal carcinamo conducted with hypopharynx reconstruction for restoring the defects causing by tumor ablation from 2003 to 2016 at Eye & ENT Hospital of Fudan University were reviewed. Most of them were treated with the following three techniques (n=115): gastric pull-up (GPU), the pedicled pectoralis major myocutaneous flap (PMMF) and the radial forearm free flap (RFFF). GPU was used for those with cervical esophagus invasion requiring esophageal resection in our institution. We focus on the postoperative complication morbidity, function of deglutition 1 month after hospital discharge and disease-free survival (DFS) outcomes.ResultsOne month after operation, 56 of 65 (86.2%) achieved solid or semisolid diet with normal swallowing function for GPU, 8 of 12 (66.7%) for RFFF and 20 of 33 (60.6%) for PMMF respectively. Postoperative complications occured in 15 (23.1%), 8 (66.7%), 16 (48.5%) for GPU, RFFF and PMMF respectively, including flap/anastomotic necrsis, pharyngeal fistula, wound infection (both recipient and donor sites), pulmonary and cardiovascular complications.ConclusionsGPU showed satisfactory outcomes for reconstruction of patients with hypopharyngeal carcinoma requiring esophageal resection. For patients without cervical esophagus invasion and underwent partial or total pharyngectomy, both PMMF and RFFF can afford good coverage and reliable functional and survival outcome as well as postoperative complication morbidity. Moreover, the only predictive factor for incidence of postoperative complication was extent of surgery, as total hypopharyngectomy was more likely to develop complications after surgery than partial hypopharyngectomy.

Evaluation of oesophageal and gastric resection outcomes in a small-volume unit

IntroductionOesophagogastric resections continue to be a major surgical challenge with high morbidity, this has led to a worldwide trend for centralisation of these complex surgeries. However, there is no clear agreement on what constitutes a high-volume centre, leading to worldwide disparity. We evaluate our experience of oesophagogastric resection in a small volume unit to seek other factors that influence patient outcome. MethodsWe analysed 173 consecutive oesophagogastric resection from 2010 to 2020. The primary outcome was 30-day mortality and secondary outcome included peri-operative morbidity, length of stay, lymph node harvest, R0 resection. Collected continuous data were compared using the Mann-Whitney test and categorical data using the chi-squared test and expressed as p value. ResultsOf the 173 patients, 94 (54%) underwent hybrid minimal invasive esophagectomy (HIMO) and 79 (46%) underwent gastrectomy. 135 (78%) patients received Neoadjuvant therapy. The site of tumour was GOJ in 29%, distal stomach in 26% and distal oesophagus in 20%. Perioperative morbidity was observed in 18 (19%) after esophagectomy and 9 (11.4%) after gastrectomy. The median lymph node harvest was 18 (range 5–42) and 168 patients (97%) had longitudinal R0 resection. The most common complication was neurological seen in 3.6% followed by pulmonary complication and anastomotic leak seen in 5 patients (3%) each. The median in hospital stay was 6 days and the 30 day mortality was 2.9% with one year survival of 87%. ConclusionSmall volume centres can produce comparable results. The outcomes depend on multifold parameters which include surgeon's experience in the field, ability to adhere to protocols and procedures and strong interpersonal relationship with individual patients.

How to Perform a High-Quality Endoscopic Submucosal Dissection

How to Perform a High-Quality Endoscopic Submucosal Dissection

Unusual approach for treatment of esophageal cancer in a patient with right-sided aortic arch: a case report

: Esophageal cancer (EC) is a leading cause of cancer-related mortality worldwide. Treatment involves a multimodal approach including chemotherapy, radiation therapy and surgery. Esophagectomy is the primary treatment for local EC. The most common surgical techniques are transthoracic and transhiatal esophagectomy. Transthoracic esophagectomy is typically performed via a right thoracotomy to circumvent the aortic arch which is typically located on the left side of the chest and also to provide adequate exposure and mobilization of the esophagus. However anatomical variants of right-sided aortic arch exist. Right-sided aortic arch can be seen in situs inversus syndrome where all organs are present in a mirror image fashion or as an isolated variant. Usually, esophageal resection and anastomosis are extremely difficult to perform in these cases through a right thoracotomy and left thoracotomy is required. It is essential for physicians to aware of these anatomical variations as they can be associated with congenital cardiac and vascular abnormalities leading to the potential risk of iatrogenic esophageal, tracheal, or aortic injury during endoscopy or surgery. We present a case of EC in a patient with an isolated right-sided aortic arch that required a transthoracic esophagectomy performed through a left thoracotomy. This case emphasizes the importance of recognizing these anatomical anomalies and planning surgery accordingly.

“Tubeless” esophagectomy: Less is more

The esophageal cancer surgery is a complex procedure with elevated rates of both morbidity and mortality, which is why, in order to achieve adequate results, it should be performed in high volume centers, where complete multidisciplinary support is available and recent clinical guidelines are applied. We describe the initial experience and the technique of “tubeless” esophagectomy where esophageal resection and mediastinal lymphadenectomy are performed and no drains nor tubes of any kind are placed, with the aim to decrease the level of surgical aggression, enhance the postoperative comfort and accelerate the patient́s recovery.

Peri-anastomotic microdialysis lactate assessment after esophagectomy

BackgroundEsophagectomy is the cornerstone in curative treatment for esophageal and gastroesophageal junctional cancer. Esophageal resection is an advanced procedure with many complications, whereof anastomotic leak is the most dreaded. This study aimed to monitor the microcirculation with microdialysis analysis of local lactate levels in real-time on both sides of the esophagogastric anastomosis in totally minimally invasive Ivor-Lewis esophagectomy.Materials and MethodsTwenty-five patients planned for esophageal resection with gastric conduit reconstruction and intrathoracic anastomosis were recruited. A sampling device, the OnZurf® Probe, along with the CliniSenz® Analyser (Senzime AB, Uppsala Sweden) was utilized for measurements. Lactate levels from both sides of the anastomosis were analysed in real time, on site, by a transportable analyser device. Measurements were made every 30 min during the first 24 h, and thereafter every 2 hours for up to 4 days.ResultsAll probes could be positioned as planned and on the third postoperative day 19/25 and 15/25 of the esophageal and gastric probes, respectively, continued to deliver measurements. In total, 89.6% (1539/1718) and 72.4% (1098/1516) of the measurements were deemed successful. The average lactate level on the esophageal side of the anastomosis and the gastric conduit ranged between 1.1–11.5 and 0.8–7.0 mM, respectively. Two anastomotic leaks occurred, one of which had persisting high lactate levels on the gastric side of the anastomosis.ConclusionApplication and use of the novel CliniSenz® analyser system, in combination with the OnZurf® Probe was feasible and safe. Continuous monitoring of analytes from the perianastomotic area has the potential to improve care after esophageal resection.

Robotic-assisted Ivor Lewis esophagectomy, a review of the technique.

Esophageal resection is a key component of the multidisciplinary management of esophageal cancer. Robotic-assisted minimally invasive esophagectomy is gaining widespread approval amongst few centers with promising early data. There is significant variability in the operative approach utilized by different centers and this review describes, step-by-step, theoperative technique at a high-volume tertiary center. The cornerstone of management is individualized surgical approach, based on patient, tumor and technical factors. Although our approach is based on aforementioned factors, our preferred approach is an Ivor Lewis esophagectomy and this review focuses on that. The procedure is broken down into three key parts, starting with an abdominal exploration and creation of the gastric conduit, placement of jejunostomy tube, moving to thoracic mobilization and creation of the side-side 6cm stapled esophagogastric anastomosis with a final abdominal portion to assure proper positioning of the conduit and reducing redundancy. This approach is fully robotic and a side to side anastomosis facilitates the creation of a widely patent anastomosis therefore minimizing the risk of anastomotic leaks and strictures. Our experience with minimally invasive esophagectomy, as has been previously published, is associated with a 5.1% of anastomotic leak and 7.6% of anastomotic stricture. The robotic platform further optimizes this technique and helps us safely accomplish a side to side stapled anastomosis. Superior instrument dexterity in a restricted thoracic space is facilitated by intracorporeal suturing and robotic stapling. Thus, it obviates the need for a larger thoracotomy incision, which is typically needed for an EEA anastomosis, and that is traditionally associated with higher stricture rate.

Esophagogastrostomy With Fundoplication Versus Double-tract Reconstruction After Laparoscopic Proximal Gastrectomy for Gastric Cancer.

We investigated that double-tract reconstruction (DTR) may be more beneficial than esophagogastrostomy (EG) with fundoplication in terms of nutritional outcomes, focusing on loss of body weight. This study included 56 consecutive patients with early gastric cancer in the upper third of the stomach who received laparoscopic proximal gastrectomy, 39 underwent EG. In the 17 patients requiring resection of the abdominal esophagus or where the size of the remnant stomach was 50% or less, we performed DTR. There was no significant difference in the rate of body weight change at 6 or 12 months, or in biochemical markers (hemoglobin, total protein, and albumin) at 12 months. However, 8 patients in the EG group had extreme body weight loss (≥20%) within 12 months. Conversely, in the DTR group, no patients had any extreme body weight loss. DTR is useful after laparoscopic proximal gastrectomy, especially in terms of preventing extreme body weight loss.

Outcome of microscopically non-radical oesophagectomy for oesophageal and oesophagogastric junctional cancer: nationwide cohort study.

BackgroundMicroscopically non-radical (R1) oesophageal cancer resection has been associated with worse survival. The aim of this study was to identify risk factors for R1 resection and to investigate how this affects long-term survival.MethodsThe Swedish National Register for Oesophageal and Gastric Cancer was used to identify all patients who underwent oesophageal cancer resection with curative intent between 2006 and 2017. Risk factors for R1 resection were assessed by multivariable logistic regression analysis, and factors predicting 5-year survival identified by multivariable Cox regression.ResultsThe study included 1460 patients. Surgical margins were involved microscopically in 142 patients (9.7 per cent). The circumferential resection margin was involved in 114 (7.8 per cent), the proximal margin in 53 (3.6 per cent), and the distal margin in 29 (2.0 per cent). In 30 specimens (2.1 per cent), two or all three margins were involved. Independent risk factors for R1 resection were male sex, low BMI, absence of neoadjuvant treatments, and clinical T4 disease. The 5-year survival rate for the entire cohort was 42.2 per cent, but only 18.0 per cent for those who had an R1 resection. Independent risk factors for death within 5 years of resection were male sex, age above 60 years, normal BMI, ASA fitness grade III, intermediate-level education, R1 resection (hazard ratio 1.80, 95 per cent c.i. 1.40 to 2.32), clinical T3 disease, and clinical lymph node metastasis.ConclusionR1 resection is common and predicts poor 5-year survival. Absence of neoadjuvant treatment is a risk factor for R1 resection.

History of esophagectomy for cancer of the esophagus and the gastroesophageal junction.

The introduction of anesthesia in 1846 created unseen opportunities for surgeons. By the end of the 19th century limited esophageal resection outside the chest had already been performed and the race for successful intrathoracic esophagectomy was on. The credit for the first successful esophagectomy for an intrathoracic cancer goes to Franz Torek of New York in 1913. But it was the introduction of double lumen intubation that really boosted the number of successful esophagectomies all over the world. In the second half of the 20th century progress in surgical techniques and perioperative management resulted in a substantial reduction of postoperative mortality. Introduction of multimodality therapies has further improved long term survival. The turn of the millennium saw the development of minimally invasive esophagectomy (MIE) improving postoperative quality of life. Undoubtly new technologies and newer drugs (e.g., immunotherapy) will further allow for refinements and more personalized targeted therapies. In this manuscript, the authors provide a deep dive into the history and development of esophageal surgery, with emphasis on the innovative pioneers that brought the field of esophageal surgery to the front line of surgery.