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In the era of minimally invasive surgery, esophagectomy remains a highly invasive procedure with a high rate of postoperative complications. Preoperative risk assessment is essential for planning esophagectomy in patients with esophageal cancer, and it is crucial to implement evidence-based perioperative management to mitigate these risks. Perioperative support from multidisciplinary teams has recently been reported to improve the perioperative nutritional status and long-term survival of patients undergoing esophagectomy. Intraoperative management of anesthesia and fluid therapy also significantly affects short-term outcomes after esophagectomy. In this narrative review, we outline the recent updates in the perioperative management of esophagectomy, focusing on preoperative risk assessment, intraoperative management, and perioperative support by multidisciplinary teams to improve operative outcomes., Competing Interests: The authors declare no conflicts of interest for this article. Hiroya Takeuchi is an editorial board member of Annals of Gastroenterological Surgery., (© 2024 The Author(s). Annals of Gastroenterological Surgery published by John Wiley & Sons Australia, Ltd on behalf of The Japanese Society of Gastroenterological Surgery.)

Aim: Dysphagia often develops after esophagectomy. The geniohyoid muscle is involved in swallowing movements, but its significance in esophagectomy patients remains unclear. We investigated the relationship of preoperative geniohyoid muscle mass with post-esophagectomy swallowing function., Methods: We retrospectively analyzed 114 patients who underwent esophagectomy and gastric conduit reconstruction for esophageal malignancy. We evaluated preoperative geniohyoid muscle sagittal cross-sectional areas (cm 2 ) using computed tomography. Median values for each sex were considered as cutoff values. Dysphagia severity was assessed using the Penetration-Aspiration Scale (PAS) during video-fluoroscopic swallowing studies performed 7-10 days postoperatively., Results: The cross-sectional area was significantly larger in males than in females (3.2 ± 0.7 vs. 2.4 ± 0.5, p  < 0.01: median in males: 3.2 cm 2 , and in females: 2.3 cm 2 ). These values were used to define high and low cross-sectional area groups. The cross-sectional area correlated positively with grip strength (correlation coefficient (CC) = 0.530) and skeletal muscle index (CC = 0.541). Transthyretin levels (22.4 ± 6.8 vs. 25.4 ± 5.5, p  = 0.03) and cross-sectional area (2.6 ± 0.7 vs. 3.2 ± 0.8, p  < 0.01) were significantly lower in patients with (PAS score ≥6; 20%) than in those without aspiration during fluoroscopic swallowing studies. Recurrent laryngeal nerve palsy was significantly more frequent in those with than in those without aspiration during fluoroscopic studies (22% vs. 5%, p  = 0.03). In the multivariate analysis, low cross-sectional area and recurrent laryngeal nerve palsy were both independent risk factors for aspiration during swallowing studies (odds ratio = 3.6, p  = 0.03 and odds ratio = 6.6, p  = 0.02, respectively)., Conclusion: Preoperative geniohyoid muscle mass, evaluated using neck computed tomography, can predict dysphagia after esophagectomy., Competing Interests: Author H. Takeuchi is associate editor of Annals of Gastroenterological Surgery. The other authors declare no conflict of interests for this article., (© 2024 The Author(s). Annals of Gastroenterological Surgery published by John Wiley & Sons Australia, Ltd on behalf of The Japanese Society of Gastroenterological Surgery.)

Thoracic esophagectomy is a particularly invasive and complicated surgical procedure, with a reconstruction of the gastrointestinal tract, such as the stomach, jejunum, or colon. The posterior mediastinal, retrosternal, and subcutaneous routes are the three possible esophageal reconstruction routes. Each route has advantages and disadvantages, and the optimal reconstruction route after esophagectomy remains controversial. Additionally, the best anastomotic techniques after esophagectomy in terms of location (Ivor Lewis or McKeown) and suturing (manual or mechanical) are debatable. Our meta-analysis investigating postoperative complications after esophagectomy between the posterior mediastinal and retrosternal routes revealed that the posterior mediastinal route was associated with a significantly lower anastomotic leakage rate than the retrosternal route (odds ratio = 0.78, 95% confidence interval: 0.70-0.87, p  < 0.0001). Conversely, pulmonary complications (odds ratio = 0.80, 95% confidence interval: 0.58-1.11, p  = 0.19) and mortality between the posterior mediastinal and retrosternal routes (odds ratio = 0.79, 95% confidence interval: 0.56-1.12, p  = 0.19) were not significantly different. However, the incidence of pneumonia may be lower when using the retrosternal route rather than the posterior mediastinal route for performing minimally invasive esophagectomy. The McKeown procedure is oncologically necessary for tumors located above the carina to dissect upper mediastinal and cervical lymph nodes; however, the Ivor Lewis procedure offers perioperative and oncological safety for tumors located under the carina. An individualized treatment strategy for selecting the optimal reconstruction procedure can be proposed in future studies based on oncological and patient risk factors considering mid- to long-term quality of life., Competing Interests: Authors declare no conflict of interests for this article. Hiroya Takeuchi is an editorial board member of Annals of Gastroenterological Surgery., (© 2023 The Authors. Annals of Gastroenterological Surgery published by John Wiley & Sons Australia, Ltd on behalf of The Japanese Society of Gastroenterological Surgery.)