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Nowadays, it is only relatively rare and in selected situations that colonic interposition is chosen rather than the stomach as a reconstructive organ for replacing the oesophagus. The colon is a reliable organ for tubular replacement of the oesophagus when the stomach is not available for reconstruction. Colon interposition is a complex and complicated operation. It requires a specific indication and thorough preoperative preparation. From a technical point of view, colon interposition places high demands on the selection and surgical dissection of the vascular supply to the reconstructed organ. The reconstruction route and elevation of the interposition graft to the proximal oesophagus and the need to create 3 or 4 gastrointestinal anastomoses also place significantly higher demands than reconstruction using a gastric tube. Overall, despite the significant surgery-related morbidity, good functional results and a good quality of life can usually be achieved. The surgical technique applied in our own practice is described in detail. An overview from literature on the results of colonic interposition is given, particularly with regard to surgical complications and quality of life after colon interposition., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Robot-assisted total gastrectomy for gastric cancer is a demanding operation that is increasingly being performed, not only in Asia but also in specialised centres in Europe. The minimally invasive resection - and above all the lymphadenectomy and the minimally invasive intracorporal reconstruction by oesophagojejunostomy - are technically demanding surgical steps. These techniques are performed internationally in different variations, but have not yet been well standardised. In the video presented, we show the DaVinci Xi-assisted minimally invasive technique of total gastrectomy with D2 lymphadenectomy and intracorporal reconstruction using side-to-side oesophagojejunostomy with linear stapling., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

A relevant number of patients with locally advanced esophageal squamous cell carcinoma and adenocarcinoma show a locoregional complete response of the tumor in the resected material after neoadjuvant therapy with modern chemotherapy and chemoradiation protocols. Due to a high rate of perioperative morbidity and decreased long-term quality of life following esophagectomy, the current treatment algorithm with neoadjuvant therapy and post-neoadjuvant esophagectomy on principle is critically questioned. An individualized treatment algorithm with extended clinical evaluation of post-neoadjuvant remission status and esophagectomy as needed is discussed. Patients with complete remission after neoadjuvant therapy are identified in an extended restaging protocol. Cases of clinical complete remission are treated with an active surveillance concept with esophagectomy as needed, i.e. surgery only when a local tumor recurrence is detected. Retrospective cohort studies have suggested that the active surveillance concept with esophagectomy as needed does not lead to a deterioration of overall survival rates in the patient collective. European prospective randomized, controlled, noninferiority studies with an oncological endpoint are currently evaluating the possibilities of organ-preserving concepts for clinical complete remission of esophageal cancer., (© 2021. Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Locally advanced esophageal cancer is mostly treated in multimodal therapy protocols according to the current western treatment guidelines. In squamous cell cancer, neoadjuvant chemoradiotherapy is in the foreground. Unimodal surgical and chemoradiation treatment alternatives achieve poorer results for this entity. Surgical salvage resection for tumor recurrence after definitive chemoradiotherapy can be carried out with good oncological results but the frequency of postoperative complications is increased. For locally advanced adenocarcinoma of the esophagus, perioperative chemotherapy and neoadjuvant chemoradiotherapy are two competing level 1 evidence-based treatment concepts that are superior to treatment by surgery alone. The results of head-to-head comparative treatment studies are still pending. A significant number of patients show a complete locoregional remission of the tumor in the surgical specimen after treatment with the modern neoadjuvant protocols. Currently, European prospective randomized noninferiority studies with an oncological endpoint are testing the possibilities of organ-retaining concepts in clinical complete remission (surgery as needed; watch and wait). For the future, it is to be expected that the curative treatment results of locally advanced esophageal carcinoma will again significantly improve, in particular through the additional possibilities of immunotherapy and organ-preserving therapy concepts for postneoadjuvant complete remission., (© 2021. Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Within the framework of the quality initiative of the German Society for General and Visceral Surgery (DGAV) a review article was compiled based on a systematic literature search. Recommendations for the current diagnostics and treatment of esophageal cancer were also elaborated., Methods: The systematic literature search was carried out in March 2019 according to the PRISMA criteria using the MEDLINE databank. The recommendations were formulated based on a consensus in the DGAV., Results and Conclusion: Operations below the currently valid minimum quantity threshold should no longer be carried out. There are many indications that the minimum quantity in Germany should be raised to ≥20 resections/year/hospital in order to comprehensively improve the quality. Prehabilitation programs with endurance, strength and intensive breathing training as well as nutritional therapy improve patient outcome. The current treatment of esophageal cancer is stage-dependent and incorporates endoscopic resection of (sub)mucosal low-risk tumors (T1m1-3 or T1sm1 low risk), primary esophagectomy of submucosal high-risk tumors (T1a), submucosal cancer (T1sm2-3) and T2N0 tumors, multimodal treatment with neoadjuvant chemoradiotherapy or perioperative chemotherapy and operations for advanced stages. Esophagectomy is nowadays carried out in one stage as a so-called hybrid procedure (laparoscopy and muscle-preserving thoracotomy) or as a total minimally invasive operation (laparoscopy and thoracoscopy).

Background: Chylothorax is a rare complication after thoracic trauma or surgery, especially oesophagectomy, which, if left untreated, can be potentially life-threatening., Methods: This article provides an overview of the existing literature on the prevention and surgical therapy of chylothorax., Results: The risk of chyle leakage after oesophagectomy increases with the difficulty of mediastinal dissection and is reported to be around 3% for oesophagectomy. With this risk, there is the possibility of a prophylactic intraoperative ligature of the thoracic duct, either as a selective or mass ligation. Meta-analyses confirm the effectiveness of this measure, with a reduction in the risk to less than 1%. In the case of postoperative chylothorax, a conservative therapeutic trial may be undertaken with drainage of up to 1000 ml per day for up to one week. If there is any indication of persistent leakage, rapid surgical reintervention appears appropriate. This can be either transthoracic or transhiatal as a selective or mass ligation and has a probability of success of over 90%., Conclusion: The prophylactic primary or therapeutic secondary ligature of the thoracic duct is an effective surgical preventive measure and therapy of postoperative chyle leakage., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

The majority of curatively treatable esophageal and gastric carcinomas are currently diagnosed in a locally advanced stage in Western Europe. The vast majority of patients in Western Europe and the USA are now treated in multimodal treatment protocols. These protocols consist of neoadjuvant chemoradiation or perioperative chemotherapy plus radical surgical resection including lymphadenectomy. Radical esophagectomy and gastrectomy are still the main curative therapeutic step in these  multimodal protocols. The current surgical recommendations and guidelines were, however, based on experience and studies from almost exclusively unimodal treatment of patient groups. The validity for the patients, particularly those who undergo multimodal treatment, therefore urgently needs to be reviewed. In particular, there are results and indirect indications from recent studies that show a difference between unimodal surgical therapy and multimodal therapy in the efficacy of radical lymphadenectomy on the oncological results. Against the background of these studies, the question arises whether it is possible to adapt surgical resection to the multimodal overall concept under the influence of the additional therapeutic modalities. Future prospective randomized surgical trials should have a tailor-made adaptation to the multimodal therapy concepts concerning primary tumor and locoregional tumor compartments. The different histological tumor entities of the upper gastrointestinal tract must also be included.

The incidence of esophageal adenocarcinoma is dramatically increasing in several Western countries. In Germany, the incidence increased by sevenfold since 1991. The most important risk factors for esophageal adenocarcinoma are gastroesophageal reflux and obesity. Early diagnosis is possible within surveillance programs for Barrett metaplasia. Endoscopic resection is effective for diagnosis and curative treatment of early carcinoma. Esophagectomy is the central curative treatment modality for non-metastasized tumors exceeding the mucosal layer. Both neoadjuvant chemoradiation and perioperative chemotherapy are increasingly applied. Long term prognosis for locally advanced tumors improved to nearly 50 % five year survival., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: An increasing incidence of adenocarcinoma, a modified surgical strategy and the increasing use of multimodal therapeutic protocols have had a major impact on the surgical treatment of esophageal cancer during the last 3 decades., Objectives: This study analyzed the development of these factors and their impact on the short and long-term prognosis of esophageal cancer over the last 25 years., Patients and Methods: The study included 366 patients with esophageal cancer treated by esophagectomy at the University Hospital in Freiburg from 1988 to 2012. The study period was split into four time periods for further comparisons, i.e. 1988-1994, 1995-2001, 2001-2006 and 2007-2012., Results: Within the time periods analyzed a marked increase in adenocarcinoma was found (time periods1988-1994, 1995-2001, 2001-2006 and 2007-2012: 21%, 37%, 61% and 64%, respectively, p<0.001). The initially commonly used transhiatal approach and reconstruction with cervical anastomosis was gradually replaced by the thoracoabdominal procedure with intrathoracic reconstruction (i.e. Ivor Lewis esophagectomy, 2007-2012: 98 %). During the study period increasingly more patients received multimodal therapy (13%, 85%, 72% and 84%, p<0.001), the overall rate of perioperative complications (70%, 88%, 73% and 56%, p<0.001) and perioperative mortality (16%, 18%, 8% and 2.5%, p<0.001) were significantly reduced, while the overall 5-year survival (12%, 34%, 41% and 62%, p<0.001) improved. An early tumor stage (p=0.002), N0 status (p<0.001) and histological type of adenocarcinoma (p=0.011) were identified as independent predictors of improved survival., Conclusion: During the period from 1988 to 2012 a significant improvement of long-term survival as well as a marked reduction of perioperative mortality after esophagectomy were observed. The improved outcome was associated with an increased use of multimodal therapeutic protocols, the preferred use of thoracoabdominal esophagectomy and epidemiological changes in histology over the study period.

Introduction: In the past decades various techniques of esophagectomy for the curative treatment of esophageal cancer have been described. Especially minimally invasive techniques of esophagectomy have been used increasingly in the last decade. Technical issues and results of hybrid laparoscopic-thoracotomic en bloc esophagectomy with intrathoracic esophagogastric anastomosis (HMIE) are presented and discussed in the article., Patients and Methods: Between May 2013 and April 2014 a total of 23 patients underwent esophagectomy for esophageal cancer at the University of Freiburg Medical Center. Of these patients 10 were treated by HMIE and the other 13 patients had open esophagectomy (OE)., Results: A detailed description of the operative technique of HMIE is given in a step-by-step fashion. Margin negative resection was achieved in all patients after HMIE and OE and the median lymph node yield of lymphadenectomy in HMIE and OE (29 vs. 27) was nearly the same. The medium duration of the operation (347 min vs. 412 min) and median length of stay on the intensive care unit (6 days vs. 9 days) and hospital (13 days vs. 17 days) were decreased in HMIE patients compared to OE, respectively. Overall postoperative morbidity (40 % vs. 69 %) and especially pulmonary morbidity (10 % vs. 46 %) were also favorable in HMIE. No anastomotic leakage and postoperative in-hospital mortality occurred after HMIE., Conclusion: The HMIE procedure combines the advantages of minimally invasive operative approaches on especially postoperative pulmonary morbidity after esophagectomy with the high safety of anastomosis and reconstruction achieved in OE. Further advantages are shorter duration of operation and shorter length of hospital stay in HMIE.

Laparoscopic total gastrectomy for early and advanced gastric cancer is an exacting procedure which is increasingly performed in specialised institutions. Not only gastric resection and extended lymphadenectomy but especially the reconstruction by oesophagojejunostomy is a technically demanding and vulnerable operative step. In this article we present our laparoscopic technique of total gastrectomy with extended lymphadenectomy and complete intracorporal reconstruction by end-to-side circular stapled oesophagojejunostomy. The operative technique of the gastric resection, the extended lymphadenectomy and the reconstruction are described in detail in a step-by-step approach and demonstrated in a supplemental video., (Georg Thieme Verlag KG Stuttgart · New York.)