The anatomical structure and physiological functions of the hypopharynx to the cervical esophagus are complicated. The surgical procedure should be determined carefully because the loss of vocal function by combined laryngectomy largely affects the postoperative QOL of the patient seriously.

Thoracic esophageal carcinoma is often associated with extensive lymph node involvements in the cervical, thoracic, and abdominal regions. Right thoracotomy with total extirpation of the thoracoabdominal esophagus and lymph node dissection in all the three regions (cervical, thoracic, and abdominal) is generally carried out in Japan [8, 9]. Intensive lymph node dissection along bilateral recurrent laryngeal nerves is essential and these procedures are the most demanding.

Three routes of reconstruction, i.e., antethoracic, retrosternal, and posterior mediastinal, are available. Although these routes have its own advantages and disadvantages, the posterior mediastinal route has been the most frequently employed recently. Stomach is the most common organ used for reconstruction.

Although thoracoscopy- or laparoscopy-assisted esophagectomy and mediastinoscopy- or laparoscopy-assisted transhiatal esophagectomy have been reported as promising surgical procedures, they are still under investigation, in view of the minimal invasiveness and oncological safety. It has been reported that thoracoscopic esophagectomy is comparable to conventional standard thoracotomic surgery in terms of the operating time, amount of blood loss, and number of dissected lymph nodes and is advantageous in terms of providing early recovery from postoperative pain and rapid restoration of vital capacity, as long as it is carried out at institutions with accumulated clinical experience [10, 11].

Although thoracic manipulations were predominantly carried out with the patient in the left lateral decubitus position previously, complete thoracoscopic procedures with the patient in the prone position have been introduced recently in Japan [12].

However, no definitive conclusions have been arrived yet as to the long-term outcomes of this form of minimally invasive esophagectomy as compared with those of conventional standard open esophagectomy with node dissection, and further investigation in randomized controlled trials is required.

The 10th edition of the Guidelines for Clinical and Pathologic Studies on Carcinoma of the Esophagus defines the esophagogastric junction region as the region within 2 cm above and below the esophagogastric junction and esophagogastric junction carcinoma as carcinoma with its center located within this region [13]. In cases of esophagogastric junction carcinoma extending more to the esophageal side than to the gastric side (E, EG), right thoracotomy with dissection including the upper mediastinal lymph nodes and reconstruction using a gastric tube are performed in the same manner as for cases of thoracic esophageal carcinoma. In some cases, lower esophagectomy with proximal gastrectomy or lower esophagectomy with total gastrectomy via left thoracolaparotomy or serial left thoracoabdominal incisions may be carried out, considering that cervical or upper mediastinal lymph node dissection is of lesser significance. A transhiatal approach to the lower mediastinum without thoracotomy is also reported. In cases of esophagogastric junction carcinoma extending more to the gastric side than to the esophageal side (G, GE), metastasis to the mediastinal lymph nodes is less frequent; thus dissection of these lymph nodes is of lesser consequence. Therefore, these lymph nodes are classified as group 3 in the 10th edition of the Guidelines for Clinical and Pathologic Studies on Carcinoma of the Esophagus.

In transhiatal esophagectomy, the thoracic esophagus is mobilized via the cervical and abdominal approaches without thoracotomy. This technique has been employed mainly in lower thoracic esophageal carcinoma or carcinoma of the esophagogastric junction in western world. RCT conducted in the Netherlands could not show survival benefit of transthoracic esophagectomy for adenocarcinoma on EG junction in comparison with transhiatal esophagectomy [14]. Now, optimal extent of lymph node dissection for carcinoma of the esophagogastric junction is controversial and under investigation.

Currently, the indication of transhiatal esophagectomy has become limited because of the spread of chemoradiotherapy and endoscopic submucosal dissection in Japan.

In recent years, a clinical path for resection and reconstruction of the esophagus has been proposed by various institutions and been applied in clinical practice. However, there have been only limited data from large-scale clinical studies evaluating the usefulness of a clinical path for perioperative management.

Many institutions have introduced nutritional support teams (NST) for perioperative nutritional management of patients with esophageal carcinoma, facilitating early implementation of enteral nutrition [15]. In patients undergoing radical surgery for esophageal carcinoma, it has been considered that early enteral nutrition rather than central venous nutrition is desirable to maintain the postoperative immunity. An enteral feeding tube should be placed during surgery, and a liquid diet should be initiated by 1–3 days after surgery. As an element of perioperative management, steroid administration is useful and recommended in perioperative management [16]. Abstinence from smoking, respiratory physical therapy, and preoperative oral care are generally considered to be important for the prevention of postoperative complications.

The 10th edition of the Guidelines for Clinical and Pathologic Studies on Carcinoma of the Esophagus defines salvage surgery as surgery for residual or recurrent cancer after definitive (chemo)radiotherapy with 50 Gy or more as total irradiation dose [13]. The incidence of complications is higher in cases of salvage surgery than in patients treated by surgery alone or surgery combined with preoperative chemoradiotherapy (radiation dose less than 50 Gy). The reported in-hospital mortality after salvage surgery is 7–22 %, indicating that this type of surgery is associated with a higher surgical risk than usual surgery [17]. The high incidence of complications and high in-hospital mortality should be taken into account when considering the indications for salvage surgery.

Currently, no treatment other than salvage treatment including endoscopic resection is accepted as curative treatment for residual or recurrent tumor after definitive chemoradiation. However, salvage surgery must be undertaken only with the informed consent of the patients obtained after explaining the risks and long-term outcomes, and thus requires cautious consideration.

A randomized controlled trial (JCOG9204 study) comparing surgery with and without postoperative chemotherapy (cisplatin + 5-FU, 2 courses) conducted in Japan demonstrated that postoperative chemotherapy resulted in a significant improve in the disease-free survival as compared to surgery alone. However, there was no significant difference in the overall survival [19]. Subgroup analysis from the JCOG9204 study demonstrated that the recurrence-preventive effect of 2 courses of cisplatin + 5-FU therapy administered postoperatively was observed only in patients with positive lymph node metastasis; therefore, in clinical practice, postoperative adjuvant chemotherapy has been recommended only after referring to the results of pathological examination after radical surgery. However, according to the results of the JCOG9907 study, implementation of neoadjuvant chemotherapy has been recognized as a standard treatment as describe above.

The results of a randomized controlled trial of pre- and postoperative radiotherapy vs. postoperative radiotherapy alone carried out by the JCOG showed that the overall survival rate was significantly higher in postoperative radiotherapy alone group when the analysis was focused only on eligible patients who received treatment according to the protocol. Based on this finding, preventive postoperative irradiation was once in widely used in Japan. On the other hand, in randomized controlled trials in the West that compared surgery with and without postoperative irradiation (usual fractionation, 45–60 Gy), postoperative irradiation was associated with a decrease in the local recurrence in the irradiated area, but without a significant increase in the survival rate. Therefore, there is little evidence for recommending postoperative irradiation after curative resection as a standard treatment. At present, the significance of postoperative (chemo)radiotherapy is unclear. (Chemo)radiotherapy has been employed in clinical practice and also been reported to be effective, for cases of non-curative resection or postoperative local recurrence. Although there is insufficient evidence, some local therapy may be necessary for patients who have undergone non-curative resection and who have macroscopic residual tumor without distant metastasis. (Chemo)radiotherapy seems to be a useful treatment option for such patients.

While 15–44 % of patients have been estimated to respond to monotherapy, cases of complete response (CR) are rare, and no monotherapy has been shown to have survival benefit [22]. At present, the most commonly used drugs are 5-FU and cisplatin. Basic studies have demonstrated that these two drugs are effective when used as monotherapy and exert a synergistic effect when combined with some other drugs and a sensitizing effect when combined with radiotherapy. A few reports of these drugs yielding good results when used in combination in the clinical setting have also been published. These are the reasons for the wide use of these two drugs.

Although various combination therapies using cisplatin have been employed since this drug was introduced clinically, the currently most commonly used combination regimen is 5-FU + cisplatin [23]. Recently, regimens containing paclitaxel, irinotecan, or gemcitabine have been tried in the West [24], and regimens using nedaplatin or docetaxel have been tried in Japan; no large-scale phase III trials of these regimens have been carried out. Thus, the survival benefit of these regimens over the standard combination of 5-FU + cisplatin has yet to be demonstrated. Currently in Japan, the combination of 5-FU + cisplatin is commonly used as the first-line treatment, following by docetaxel as a second-line treatment. In any event, the effect of the use of chemotherapy alone, regardless of whether it is combination therapy or monotherapy, is limited, and chemotherapy not combined with other treatment modalities is applied only to patients with unresectable metastatic lesions.

Cisplatin, a chemotherapeutic drug that is in wide use, is classified as a highly pro-emetic drug. Guidelines for appropriate use of antiemetic drugs recommend the triple-drug combination of a 5-HT₃ receptor antagonist, corticosteroid, and aprepitant to prevent emesis while using cisplatin. For other drugs, it is necessary to check the risk of emesis against guidelines for appropriate use of antiemetic drugs and to take appropriate prophylactic measures.

A randomized controlled study (RTOG9405/INT0123) carried out by the RTOG that compared chemoradiotherapy using standard-dose (50.4 Gy) and high-dose (64.8 Gy) radiation in patients with T1-4N0-1M0 esophageal carcinoma (corresponding to UICC-TNM classification, 2002 edition) revealed no superiority of high-dose radiation over standard-dose radiation in terms of the median survival time, the 2-year survival rate, and the local control rate and concluded that the standard radiation dose for chemoradiotherapy using a combination of 5-FU plus cisplatin should be 50.4 Gy (1.8 Gy × 28 times) as described above [28]. On the other hand, a radiation dose of 60 Gy has been used commonly in Japan. Although the standard radiation dose has not yet been established in Japan, change to 1.8 Gy/fraction × 28 times (total dose of 50.4 Gy) is now under clinical investigation.

The standard chemotherapy regimen for concurrent chemoradiation is 5-FU + cisplatin. In the RTOG9405/INT0123 study, a course of 4-day continuous intravenous infusion of 5-FU at 1,000 mg/m²/day plus intravenous cisplatin at 75 mg/m² on day 1 was repeated every 4 weeks up to a total of 4 courses (concurrent radiation was used in the initial 2 courses) [28]. In Japan, although use of the 5-FU + cisplatin regimen is variable, a phase II clinical study (JCOG9708) of chemoradiotherapy (5-FU + cisplatin + irradiation of 60 Gy) for cases of stage I esophageal carcinoma (T1N0M0, UICC-TNM classification, 1997 edition [*corresponding to stage IA: T1N0M0 in the 2009 edition]) conducted by JCOG used 2 courses of 4-day continuous intravenous drip infusion of 5-FU at 700 mg/m²/day plus intravenous drip infusion of cisplatin at 70 mg/m² on day 1 repeated every 4 weeks. In the JCOG9708 study, the complete response rate was 87.5 %, the 4-year survival rate was 80.5 %, and the 4-year progression-free survival rate was 68 %, suggesting equivalent results to those of surgery [33]. Currently, a phase III clinical study (JCOG0502) comparing definitive chemoradiotherapy with surgery alone is under investigation. In another phase II JCOG study (JCOG9906) of chemoradiotherapy (5-FU + cisplatin + irradiation of 60 Gy) performed in cases of resectable stage II–III esophageal carcinoma, a course of 5-day continuous intravenous infusion of 5-FU at 400 mg/m²/day for 2 weeks plus intravenous cisplatin at 40 mg/m² on days 1 and 8 was repeated every 5 weeks for a total of 4 courses (the initial 2 courses were combined with concurrent irradiation) [34]. On the other hand, the introduction of chemotherapy according to the RTOG regimen is now under investigation in Japan.