Definitive chemoradiation (without surgery) is an accepted treatment for esophageal cancer. Persistent or recurrent local disease is not infrequent after chemoradiation, and this is its greatest drawback. Selected patients with isolated local failures of definitive chemoradiation can be salvaged by esophagectomy. However, salvage esophagectomy is a high-risk operation; operative mortality is higher than for standard esophagectomy. In contrast to planned esophagectomy after induction (neoadjuvant) therapy, salvage esophagectomy is often carried out months after completion of definitive chemoradiation. Previous thoracic radiotherapy contributes to the genesis of postoperative complications. Respiratory failure (ARDS, pneumonia) and septic complications of esophageal reconstruction (anastomotic leaks) are major causes of postoperative death. Gastric conduit necrosis, airway necrosis, and tracheogastric fistulae are infrequent but highly lethal complications. We propose modifications of surgical practice that may reduce complications. These include strict guidelines for patient selection, conservative mediastinal dissection, prevention of intraoperative lung injury (barotrauma and oxygen related toxicity), near total esophagectomy with cervical esophagogastric anastomosis, anterior mediastinal reconstruction, judicious use of staged reconstruction, perioperative enteral nutritional support, and aggressive detection and treatment of postoperative complications. By conceptually breaking the operation into component parts, such as resection and reconstruction, and then modifying each component to minimize complications, we believe that the operative mortality of salvage esophagectomy can be reduced to an acceptable level.

Keywords: Carcinoma, Squamous Cell - radiotherapy, Carcinoma, Squamous Cell - surgery, Combined Modality Therapy, Esophageal Neoplasms - radiotherapy, Esophageal Neoplasms - surgery, Esophagectomy - adverse effects, Esophagectomy - methods, Esophagectomy - mortality, Postoperative Care, Postoperative Complications, Reconstructive Surgical Procedures, Salvage Therapy - adverse effects, Salvage Therapy - methods, Salvage Therapy - mortality