Surgical approaches to esophageal cancer gastrointestinal reconstruction: a systematic review of jejunum, colon, and ileocolonic interposition with comparative outcome analysis

Abstract

Esophageal cancer is a highly aggressive malignancy of the digestive tract, with surgical resection remaining the cornerstone of curative treatment. For patients with an intact stomach, reconstruction using a gastric conduit via gastric pull-up is the preferred approach following esophagectomy. However, in cases where the stomach is unavailable—due to prior gastric surgery, polyps, or concurrent tumors—alternative conduits must be considered. By reviewing relevant domestic and international research literature, this review evaluates the indications, benefits, limitations, and common complications associated with jejunal, colonic, and ileocolonic interpositions. Additionally, strategies for the prevention and management of complications are discussed. By synthesizing the latest clinical evidence, we aim to provide practical recommendations to guide surgical decision-making and improve outcomes in the management of esophageal cancer. The jejunum, colon, and ileocolon represent the primary options for esophageal reconstruction, each offering unique anatomical and functional advantages as well as distinct technical challenges and complication profiles.

Background

In recent years, the incidence of esophageal cancer has shown a continuous upward trend, making it one of the most life-threatening malignancies of the digestive tract [1]. According to the 2022 GLOBOCAN global cancer statistics, the overall 5-year survival rate of esophageal cancer patients is generally low, with esophageal cancer ranking 11th in incidence and 7th in cancer-related mortality globally [2]. The high-incidence regions mainly concentrated in East Asia, Eastern Europe, and Latin America, with East Asia alone accounting for 48.6% of global new cases (China accounting for 43.8%), and countries in East Asia—particularly China, Japan, and South Korea—consistently report the highest age-standardized incidence rates worldwide, far exceeding those in Africa or other regions [3–5]. Surgical resection remains the primary treatment modality, with gastric conduit reconstruction being the most commonly employed technique following esophagectomy. Notably, evidence suggests that survival outcomes after esophagectomy in patients with a history of gastrectomy are not inferior to those without prior gastric surgery [6]. As a result, alternative organs continue to be explored and recommended for esophageal reconstruction in appropriate surgical candidates [7], with the jejunum, colon, and ileocolon serving as the principal substitutes.

Among these, colonic interposition is a well-established technique, associated with a relatively low incidence of anastomotic leakage and manageable postoperative complications [8]. The colon provides adequate length and compliance, making it especially suitable in patients with complex anatomical requirements [9]. However, colonic interposition is not without drawbacks; patients may experience nutritional deficiencies due to impaired nutrient absorption [10].

Jejunal interposition has also demonstrated favorable outcomes, particularly in cases involving extensive esophageal resection. The jejunum offers a rich vascular supply and physiological similarities to the native esophagus, making it a suitable substitute in select scenarios [11]. Despite these advantages, complications such as anastomotic leakage and intestinal dysfunction remain concerns [12].

Ileocolonic interposition is less frequently performed and is generally reserved for select cases requiring esophageal reconstruction. Research suggests that the ileocolon has relatively suboptimal vascularization, which may contribute to less favorable postoperative recovery when compared to jejunal or colonic interposition. Despite these limitations, ileocolonic interposition remains a viable alternative for specific patient populations, such as those with a history of gastrectomy for gastric cancer [13]. However, the procedure is associated with a higher incidence of postoperative complications, including an increased risk of infection. Further investigation is necessary to evaluate its long-term efficacy and refine patient selection criteria.

Currently, the optimal approach for digestive tract reconstruction after esophagectomy remains a subject of ongoing debate. Each technique presents distinct anatomical and physiological advantages, as well as limitations. This review aims to synthesize the existing literature on jejunal, colonic, and ileocolonic interpositions, highlighting their clinical applications, benefits, drawbacks, and associated complications, along with strategies for their prevention and management. In clinical practice, the choice of reconstruction technique should be individualized based on patient condition, physiological status, tumor characteristics, and potential postoperative risks.

Literature search strategy

This narrative review was conducted through literature searches of PubMed, Embase, and Cochrane Library databases from January 2000 to December 2025. Search terms included esophageal neoplasms, esophagectomy, colonic interposition, jejunal interposition, ileocolonic interposition, esophageal reconstruction, conduit, and gastrointestinal reconstruction. Additional articles were identified through manual screening of reference lists from relevant reviews. This review adopts a narrative synthesis approach given the heterogeneity of available studies in terms of surgical techniques, patient populations, and outcome definitions. The primary objective is to provide a comparative overview of reconstructive options rather than pooled effect estimates [14].

Inclusion criteria: (1) Human studies on esophageal reconstruction with jejunal/colonic/ileocolonic interposition for esophageal cancer; (2) Original research, systematic reviews/meta-analyses and clinical guidelines; (3) Studies focusing on esophageal reconstruction in patients with unavailable stomach; (4) Literature with clear outcome indicators (complication rate, survival rate, etc.). Exclusion criteria: (1) Animal experiments and in vitro studies; (2) Case reports with sample size < 10 cases; (3) Non-English/Chinese literature; (4) Studies only focusing on gastric conduit reconstruction; (5) Literature with incomplete or unavailable data [15–18].

Main text

Colonic interposition for esophageal reconstruction

Colonic interposition: application

Currently, the colon primarily functions in water and electrolyte absorption and serves as a reservoir for fecal storage and formation. Its physiological integrity is crucial for maintaining fluid–electrolyte balance and overall bowel function. Segments of the colon used for esophageal reconstruction include the left colon, transverse colon, and right colon, with selection determined by vascular anatomy, required conduit length, and surgical approach [19, 20]. Left colonic interposition, based on the left colic artery and preserved marginal arterial arcade, is the most commonly utilized approach due to greater mobility and relatively rich vascular supply, which reduce the risk of ischemic necrosis after transplantation [21]. Right colonic interposition, supplied by the right colic and ileocolic arteries, is less frequently employed due to less robust blood supply, but may be selected when the left colon is unsuitable or additional length is required [22, 23]. Transverse colonic interposition offers advantages such as easier mobilization and adequate vascularization, but its limited length may cause excessive anastomotic tension if used alone [24]. Consequently, a combined transverse-left colonic segment is often favored, offering adequate length while maintaining peristaltic continuity. Esophageal reconstruction after esophagectomy typically employs the posterior mediastinal (anatomically native, most common), retrosternal (longer, potentially safer for mediastinal infection, center-dependent), or subcutaneous presternal (salvage for high-risk patients) route [25]. Comparable short-term outcomes between the former two approaches fuel ongoing debate regarding optimal selection [26]. A recent systematic review reported that approximately 10% of patients continued to experience dysphagia and 3%–19% had persistent reflux symptoms years after undergoing colonic interposition [27]. Long-term survival following this procedure is influenced by factors such as tumor stage, patient age, and general health status. A 25-year retrospective study from a single United States center, which enrolled 99 patients who underwent colonic interposition (48% of whom had esophageal cancer), reported an overall 10-year survival rate ranging from 25% to 66% [9, 24].

Advantages and limitations

Colonic interposition offers several advantages in esophageal reconstruction. The colon provides sufficient length, enabling anastomosis at the cervical level, which, in the event of leakage, is generally associated with fewer severe complications than thoracic or intra-abdominal anastomoses. Additionally, the alkaline content of colonic secretions can help buffer gastric acid, thereby reducing the risk of postoperative reflux esophagitis. The placement of the colonic segment below the diaphragm also lessens intra-abdominal pressure exposure, further minimizing reflux risk. The colon’s rich vascular supply and peristaltic activity contribute to its physiological compatibility as an esophageal substitute.

However, the procedure has notable drawbacks. Postoperative complications occur in approximately 20%–30% of cases [9], with anastomotic leakage being one of the most frequent and serious issues [12]. This complication is partly due to the traditional surgical approach involving three incisions—cervical, thoracic, and abdominal—resulting in increased surgical trauma and multiple anastomotic sites. Compared to gastric interposition, colonic interposition is technically more challenging and associated with a higher risk of ischemic necrosis. Additionally, the loss of absorptive capacity from the resected colon can lead to persistent diarrhea. Over time, the interposed colonic segment may become elongated, leading to redundancy, which could require secondary surgical intervention.

Complications: prevention and management

Colonic interposition has a markedly variable overall complication rate (10%–60%) by study design and patient population: 10%–20% in meta-analyses, 20%–30% in multicenter studies, and up to 60%–65% in single-center retrospective series (early cohorts/high-complexity referral centers). [28] Mortality ranges from 0% to 23% [29]. This substantial variation reflects heterogeneity across surgical eras, center volume, patient selection criteria, and definitions of complications. Higher complication rates typically originate from older series or high-complexity referral centers managing advanced disease and salvage procedures, whereas contemporary reports from high-volume esophageal centers demonstrate improved outcomes through standardized perioperative care and enhanced recovery pathways [24]. Anastomotic leakage remains the most common complication, with an incidence of 7%–30%. Contributing risk factors include insufficient preoperative preparation, compromised vascular supply, and malnutrition [30]. For instance, Peng et al. (2011) reported a perioperative complication rate of 26.4%, while Xie et al. (2017) documented a postoperative complication rate of 15.7% [31]. Malnutrition, in particular, significantly increases the risk of anastomotic leakage, underscoring the importance of nutritional support. Early initiation of enteral nutrition—both preoperatively and postoperatively—is strongly recommended for at-risk patients [32].

Another common complication is anastomotic stricture, which occurs in approximately 1.7%–4.5% of cases. This condition is often caused by a size mismatch between the esophagus and the colonic graft. Surgical techniques such as oblique transection of the esophagus or anterior wall division with an enlarged anastomotic opening may help reduce stricture risk. The introduction of circular staplers has also significantly lowered the incidence of anastomotic strictures.

Jejunal esophageal reconstruction

Jejunal Interposition: application

Due to the relatively high incidence of postoperative complications associated with colonic interposition, some researchers have advocated for the use of pedicled jejunal interposition as an alternative. The jejunum, constituting approximately two-fifths of the small intestine and located between the duodenum and ileum, plays a vital role in the absorption of amino acids, monosaccharides, and fatty acids [12]. The choice of jejunal interposition technique is primarily determined by the level of the anastomotic site and vascular requirements. For cervical anastomosis requiring extended length, a free jejunal graft may be employed. While this technique provides sufficient length, it relies exclusively on microvascular anastomosis for perfusion, increasing the risk of intestinal ischemia, necrosis, and anastomotic leakage. For middle and lower esophageal reconstruction, a pedicled jejunal segment can be used, preserving the native vascular supply to maintain adequate perfusion. However, this method is generally limited to reconstruction of the middle and lower esophagus due to the reach limitations imposed by the mesenteric vascular pedicle, typically restricting its reach to the sternal angle. For upper and middle esophageal reconstruction requiring enhanced reach, a vascular-enhanced pedicled jejunal graft, also termed supercharged jejunum, may be employed. In this technique, the jejunum is transected approximately 20 cm distal to the ligament of Treitz, preserving the first and fourth jejunal arteries while ligating the second and third branches. To augment perfusion and extend reach, the second and third jejunal artery branches are anastomosed with the internal thoracic artery (ITA) and vein [33]. This approach ensures adequate vascular supply while minimizing anastomotic tension, though it requires microsurgical expertise.

Advantages and limitations

Compared to gastric and colonic interpositions, the jejunal graft offers unique physiological advantages. Manometric studies have demonstrated that the jejunum maintains antegrade segmental contractions, supporting efficient luminal emptying. Unlike the colon, which can become redundant over time, the jejunum retains structural stability. Moreover, its luminal diameter is nearly identical to that of the native esophagus, which minimizes the risk of anastomotic stricture and simplifies both manual and stapled anastomotic techniques [14, 34]. The incidence of inflammatory and neoplastic pathology is also lower in the jejunum than in the colon [19, 35, 36]. Additionally, resecting a segment of jejunum has minimal impact on overall gastrointestinal function. Compared to colonic interposition, jejunal reconstruction involves fewer anastomoses, which can reduce operative time.

Despite these advantages, there are several limitations. The negative intrathoracic pressure may promote gastroesophageal reflux and respiratory complications. Intrinsic jejunal peristalsis can interfere with swallowing mechanics, requiring a longer postoperative adaptation period. The length of the jejunal graft is limited by the mesenteric arcade, typically restricting its reach to the sternal angle. Moreover, difficulties with mobilization and excessive anastomotic tension can increase the risk of postoperative complications [37].

Complications: prevention and management

Historical series reported considerable morbidity and mortality following jejunal esophageal reconstruction. Contemporary reports from high-volume centers demonstrate improved outcomes, with reduced complication rates and perioperative mortality below 3% following pedicled jejunal interposition [38, 39]. Common postoperative complications include pneumonia, recurrent laryngeal nerve injury, non-occlusive mesenteric ischemia, anastomotic stricture and leakage, and intestinal necrosis [40]. Mild anastomotic strictures can typically be managed with endoscopic dilation, whereas more severe cases may necessitate surgical revision [41]. Compared to colonic interposition, jejunal reconstruction carries a lower risk of anastomotic leakage, attributable primarily to the close diameter match with the esophagus and robust mesenteric vascular arcade, potentially supplemented by lower bacterial colonization compared to the colon. However, anastomotic integrity predominantly depends on technical precision, adequate perfusion, and absence of tension rather than microbial factors alone [15, 42]. Most minor leaks respond to conservative management and resolve without surgical intervention [43] However, intestinal ischemia and necrosis are serious and potentially fatal complications. These events typically involve extensive ischemia of the jejunal graft and differ from localized ischemic episodes. Management requires urgent fluid resuscitation, administration of broad-spectrum antibiotics and antifungal agents, and often emergency surgical intervention [44]. Other complications are less frequent and generally non-severe, often manageable with symptom-based or supportive therapy.

Ileocolon esophageal reconstruction

Ileocolonic interposition: application

Ileocolon esophageal reconstruction specifically utilizes the terminal ileum, typically 10 to 15 cm in length, along with the ascending colon and part of the transverse colon, based on the ileocolic artery with preserved collateral circulation [16, 17]. This technique is anatomically distinct from standard right colonic interposition by intentionally including of the terminal ileum and ileocecal valve. Anatomically, this conduit is located relatively high in the right lower quadrant of the abdomen, facilitating a more straightforward anastomosis with the esophageal remnant [45]. Two critical factors contributing to the success of this technique: first, the design and preservation of a sufficiently long terminal ileum segment requires careful consideration, as an excessively long segment may result in redundancy, while a too-short segment increases anastomotic tension and can strain the colonic arteries, impairing both anastomotic healing and graft perfusion [46]. Second, assurance of adequate vascular perfusion to the graft necessitates intraoperative confirmation of blood supply prior to graft isolation, given variations in vascular anatomy, particularly concerning the middle colic and right colic arteries [46]. One commonly adopted intraoperative strategy is temporary occlusion of the cecocolic artery, followed by assessment of collateral circulation via the mesenteric arteries to the ascending colon and cecum. This maneuver helps to verify the viability of the segment before finalizing the reconstruction. Specific indications for ileocolonic reconstruction include: patients with complex laryngopharyngeal or hypopharyngeal defects requiring one-stage reconstruction with autologous long-segment vascularized grafts, and those with Crohn’s disease involving the ileocecal region who need ileocolonic resection for intestinal continuity restoration [47, 48]. Although comprehensive clinical data remain limited, a 10-year study involving 151 esophageal cancer patients reported by Lu Pei et al. showed 3-, 5-, and 10-year survival rates of 79.5%, 46.3%, and 26.7%, respectively, with all patients resuming oral intake and demonstrating satisfactory quality of life [49]. Similarly, a study involving 16 patients who underwent ileocolon reconstruction following subtotal gastrectomy confirmed the safety and feasibility of this approach [49].

Advantages and limitations

Compared with jejunal and traditional colonic interpositions, ileocolon esophageal reconstruction presents several physiological and technical advantages. The graft typically includes the terminal ileum, ascending colon, and part of the transverse colon, providing sufficient length to reach the cervical esophagus. The terminal ileum’s luminal diameter closely matches the native esophageal stump, facilitating precise anastomosis, simplifying stoma construction, and mitigating size-mismatch complications; the ileocolonic segment’s motility enables efficient luminal emptying and reduces postoperative gastroesophageal reflux [34, 50, 51]. Preservation of the transverse and part of the left colon maintains normal bowel continuity and function. Theoretically, the ileocecal valve may provide partial barrier function against retrograde flow, though this mechanism remains incompletely validated. Clinical studies report inconsistent reflux outcomes following ileocolonic reconstruction, with some series demonstrating reduced symptomatic reflux compared to colonic interposition while others show comparable rates. Objective pH monitoring and manometric data are currently insufficient to confirm physiologic equivalence to the lower esophageal sphincter [52, 53]. The anti-reflux effect, if present, likely relates to the angle of His reconstruction and conduit positioning as much as to the valve mechanism itself. Despite these advantages, the procedure has several limitations. It is technically complex, involving multiple surgical steps and longer operative times. The necessity for multiple anastomoses increases the risk of infection and other postoperative complications. Additionally, the colonic segment may become redundant over time, potentially requiring reoperation [20, 54].

Complications: prevention and management

The complication rate associated with ileocolon esophageal reconstruction ranges from 23.2% to 25.2% based on Chinese single-center retrospective studies conducted from 2018 to 2022, with a reported mortality rate of approximately 1% to 2% [55, 56]. The types of complications observed are similar to those encountered in other reconstructive techniques. Among them, recurrent laryngeal nerve dysfunction is relatively common and may delay the reintroduction of oral feeding. Rates of anastomotic leakage and stricture are comparable to those seen with colonic interposition, and management strategies remain largely the same [57]. A distinctive complication in ileocolon reconstruction is a higher incidence of bowel obstruction, often caused by an excessively narrow retrosternal or posterior mediastinal tunnel. If conservative management proves ineffective, exploratory laparotomy is required to identify and resolve the underlying cause of obstruction (Table 1). 

Table 1.

Comparison of three surgical techniques

Parameter	Left/Transverse Colon	Right Colon	Pedicled Jejunum	Free or Supercharged Jejunum	Ileocolon	Clinical Notes
Vascular basis	Left colic artery + marginal arcade	Right colic + ileocolic arteries	1st–4th jejunal arteries	1st/4th jejunal + ITA/ITV anastomosis	Ileocolic artery (± right colic)	Preserve marginal arcade; prefer retrosternal route to avoid compression
Maximal reach	Cervical (40–50 cm)	Cervical (30–40 cm)	Sternal angle (20–25 cm)	Cervical (unlimited)	Cervical (35–45 cm)	—
Best indication	Standard cervical esophagectomy	When left colon is unsuitable	Middle or lower esophageal defects	Cervical defects or prior gastric surgery	Prior gastrectomy or long-segment defects	—
Key technical limitation	Three-field operation with redundancy risk	Less reliable blood supply	Length restriction	Microsurgical complexity with ischemia risk	Multiple anastomoses with bowel obstruction risk	—
Anastomotic leakage rate	7% – 30%	Higher than left colon	Lower than colon (5% to 15%)	10% – 20%	Comparable to colon	—
Conduit necrosis rate	1% – 5%	3% to 8%	Rare (< 1%)	5% – 15%	2% – 5%	—
Anti-reflux mechanism	Alkaline content	Alkaline content	None	None	Ileocecal valve (theoretical effect, inconsistent clinical data)	—

The above data are mainly derived from meta-analyses and high-volume center studies (2022–2025), and the complication rate is affected by surgical era, center volume and patient selection criteria

Future research directions and clinical applications

Novel surgical technologies

Notably, recent advancements in medical technology have introduced several innovative techniques with specific relevance to conduit selection and optimization (Table 2).

Table 2.

Stepwise clinical decision algorithm

Step	Decision Node	Option A (Preferred Strategy)	Option B	Option C	Postoperative Management Tip
1	Gastric availability	Stomach available: Gastric pull-up (gold standard)	Stomach unavailable: Proceed to Step 2	—	Monitor gastric tube drainage; initiate early enteral nutrition via jejunostomy
2	Left colon assessment	Left colon suitable (intact marginal arcade, no prior surgery): Left colonic interposition	Left colon unsuitable (stenosis/radiation injury/prior colectomy): Proceed to Step 3	—	Avoid excessive conduit traction; monitor for colonic redundancy and ischemic signs
3	Right colon/ileocolon assessment	Right colon suitable (adequate blood supply): Right colonic interposition	Ileocolon suitable (no inflammatory bowel disease): Ileocolonic interposition	Both unsuitable: Proceed to Step 4	Ileocolon group: Monitor for bowel obstruction; manage reflux with proton pump inhibitors (PPIs)
4	Jejunal option by defect location	Middle/lower esophageal defect: Pedicled jejunal interposition	Cervical defect + microsurgical expertise available: Free/supercharged jejunal graft	Cervical defect + no microsurgical expertise: Referral to high-volume center/Reconsider colonic reconstruction	Supercharged/free jejunum group: Real-time perfusion monitoring; long-term nutritional follow-up
5	Modifying factors	Crohn disease/colitis: Favor jejunal interposition (avoid colonic/ileocolonic involvement)	Prior total gastrectomy/long-segment esophageal defect: Favor ileocolonic interposition (sufficient length for cervical anastomosis)	Neoadjuvant radiotherapy/high ischemia risk: Favor pedicled jejunal interposition (radiation-resistant mesenteric blood supply)	Radiotherapy group: Prophylactic anti-inflammatory therapy; regular endoscopic follow-up for anastomotic stenosis

All strategies are based on contemporary clinical evidence (2022–2025)

Robot-assisted surgery

Robot-assisted surgery provides enhanced dexterity and precision in hilar dissection and microvascular anastomosis, which is particularly advantageous for supercharged jejunal interposition requiring internal thoracic vessel preparation [58]. The robotic platform facilitates precise mobilization of the colonic flexures and enhanced visualization of the marginal artery arcade during colonic interposition, potentially reducing vascular complications [14, 38]. A recent international collaborative review by TROGSS and EFISDS representatives evaluated robot-assisted esophagectomy, demonstrating reduced postoperative complications and shorter hospital stays compared to conventional techniques, with specific benefits for conduit preparation and anastomotic precision [8, 11]. For conduit selection, the robotic platform is more favorable for supercharged jejunal interposition and colonic interposition, because it can reduce the technical difficulty of microsurgical anastomosis and colon flexure mobilization [59], while the advantage for ileocolonic interposition is relatively limited due to the multiple anastomoses required.

Near-infrared fluorescence imaging

Near-infrared fluorescence imaging using indocyanine green enables real-time intraoperative assessment of conduit perfusion, which is critical for all three reconstructive options but especially valuable for free jejunal grafts and marginal colonic segments where vascular adequacy may be uncertain [60, 61]. This technology allows objective quantification of tissue perfusion at proximal and distal anastomotic sites, potentially guiding resection margins and reducing ischemic complications [62]. This imaging modality serves as a necessary auxiliary technology for free/supercharged jejunal graft and marginal colonic segment reconstruction, which can effectively reduce the risk of ischemic necrosis, and it is recommended as a routine for high-risk patients (e.g., neoadjuvant radiotherapy, elderly patients) [63].

Three-dimensional imaging

Three-dimensional imaging facilitates comprehensive preoperative anatomical analysis, enabling identification of variant vascular anatomy that may influence surgical planning. Preoperative 3D vascular reconstruction allows for detailed assessment of mesenteric and colic vascular anatomy, including features such as a short mesentery or anomalous arterial origins, which can impact the feasibility of certain reconstructive approaches [64, 65]. For instance, 3D-CT angiography has been shown to be critical in evaluating vascular anatomy in patients with altered mesenteric morphology, where adhesions or shortening may alter vessel courses. Similarly, accurate visualization of vascular anatomy through 3D models improves anatomical understanding among surgical trainees and serves as a useful adjunct to standard 2D imaging for planning complex procedures. In head and neck reconstruction, preoperative imaging with CTA and 3D reconstruction accurately reflects key vascular characteristics, providing a reliable digital anatomical roadmap that supports recipient vessel selection and flap planning [66, 67]. Therefore, when 3D imaging reveals anatomical constraints—such as a short jejunal mesentery or absence of expected arterial supply—it can help rule out technically unfeasible reconstructive options and guide surgeons toward safer, individualized strategies.

Minimally invasive surgery (MIS)

MIS including thoracoscopic and laparoscopic techniques reduce operative trauma and facilitate faster recovery [10]. Laparoscopic colonic mobilization preserves abdominal wall integrity, which is particularly relevant for patients requiring neoadjuvant therapy and timely postoperative adjuvant treatment. The transition to robot-assisted minimally invasive esophagectomy may favor conduit choices that are technically feasible through minimally invasive harvest, such as pedicled jejunal segments or laparoscopically mobilized colon [68].

Clinical trial advances

In recent years, clinical research in esophageal cancer has expanded significantly, covering a broad spectrum of treatment modalities, including chemotherapy, radiotherapy, targeted therapy, and immunotherapy. Notably, immune checkpoint inhibitors have revolutionized the treatment of advanced esophageal cancer. The KEYNOTE-590 trial showed that pembrolizumab plus chemotherapy provided a significant overall survival benefit over chemotherapy alone in patients with advanced esophageal squamous cell carcinoma (ESCC) [69, 70]. Similarly, the CheckMate 648 trial established nivolumab plus chemotherapy as a new first-line standard of care for ESCC [71]. Among Chinese patients, the ESCORT-1st trial demonstrated that camrelizumab plus chemotherapy significantly improved overall survival and progression-free survival in those with advanced or metastatic ESCC [72]. Ongoing clinical trials are evaluating perioperative immunotherapy regimens, such as neoadjuvant and/or adjuvant camrelizumab combined with chemotherapy, as well as novel combinations of camrelizumab with targeted agents. These strategies have shown promising efficacy in terms of pathological complete response and long-term survival [73–75]. In addition, targeted therapy has achieved favorable outcomes in specific molecular subtypes. For example, the DESTINY-Gastric06 trial confirmed that trastuzumab deruxtecan (T-DXd) yielded significant clinical benefit in patients with previously treated Human epidermal growth factor receptor 2 (HER2)-positive advanced gastric or gastroesophageal junction adenocarcinoma [76]. The design of clinical trials has also evolved. Increasingly, large, multicenter studies with robust methodologies are being implemented to improve the validity and generalizability of findings [77]. Advances in data science and artificial intelligence are transforming how clinical trial data are analyzed, offering innovative ways to interpret complex datasets and predict patient outcomes [78]. These developments are paving the way for more nuanced and effective treatment strategies, and they represent a significant step forward in the evolution of esophageal cancer management.

Personalized treatment

Personalized medicine is becoming a cornerstone of esophageal cancer treatment, enabling clinicians to tailor therapies based on individual patient and tumor characteristics. Advances in genomics and molecular biology have enabled the identification of predictive biomarkers to guide therapeutic selection and response monitoring [9]. In esophageal cancer, several biomarkers have been established to inform clinical decision-making. Programmed death-ligand 1 (PD-L1) expression, assessed by the combined positive score (CPS), is the primary predictive biomarker for immune checkpoint inhibitor efficacy, with higher CPS values associated with improved response rates to pembrolizumab and nivolumab [79]. Microsatellite instability-high (MSI-H) or deficient mismatch repair (dMMR) status, detected in approximately 3–5% of metastatic esophageal adenocarcinomas, predicts exceptional responses to anti-Programmed cell death protein 1 (PD-1) therapy [80, 81]. HER2 amplification, present in 15–20% of esophagogastric junction adenocarcinomas, directs the use of trastuzumab and trastuzumab deruxtecan [82]. While Epstein-Barr virus (EBV) positivity is recognized in a subset of gastric cancers and was used as an enrichment criterion in early-phase immunotherapy trials [83], its prevalence and clinical relevance in esophageal cancer remain unclear and are not well established in current guidelines. Emerging investigational biomarkers include tumor mutational burden (TMB), circulating tumor DNA (ctDNA) for minimal residual disease detection, and FGFR2 amplification as a potential target for selective inhibitors [84, 85]. This approach is also influencing clinical trial design, with increasing use of adaptive enrichment strategies based on these molecular profiles. For instance, the KEYNOTE-811 trial demonstrated enhanced efficacy of pembrolizumab in HER2-positive gastric and esophagogastric junction cancer [86], while basket trials such as NCT02693535 are evaluating targeted agents in specific molecular subgroups. The integration of comprehensive genomic profiling into routine clinical practice has the potential to improve survival rates, reduce treatment-related toxicity, and enhance overall quality of life for patients with esophageal cancer [87–89]. Future research should continue to focus on expanding the application of precision medicine, integrating molecular diagnostics, and developing adaptive therapeutic algorithms for esophageal cancer.

Conduit selection: decision algorithm

Based on the comparative analysis presented, we propose a practical framework for selecting among jejunal, colonic, and ileocolonic reconstruction options. This algorithm integrates patient-specific factors, anatomical considerations, and technical feasibility to guide surgical decision-making.

The first decision point assesses gastric availability. When the stomach is intact, gastric pull-up remains the standard approach. When the stomach is unavailable, preoperative evaluation of colonic anatomy through imaging and history guides subsequent selection. Left colonic interposition is preferred for most cervical reconstructions when the marginal arcade is intact. Right colon or ileocolonic options are evaluated when left colon is unsuitable. For middle or lower esophageal defects, pedicled jejunal interposition offers the simplest recovery. Cervical defects in patients with prior gastric surgery require supercharged or free jejunal techniques contingent upon microsurgical expertise. Specific patient factors modify these general principles: Crohn disease favors colonic over ileocolonic approaches, while extensive prior abdominal surgery may preclude laparoscopic harvest and influence routing decisions.

Conclusion

Jejunal, colonic, and ileocolonic interposition each have irreplaceable clinical value in esophageal reconstruction for patients with an unavailable gastric conduit, and the optimal surgical selection depends on the comprehensive assessment of patient-specific factors and technical feasibility. Specifically, pedicled jejunal interposition is the first choice for middle/lower esophageal defects due to its simple procedure and favorable intestinal function recovery; left colonic interposition is preferred for cervical esophageal reconstruction because of its sufficient length and low reflux risk, especially for patients with no prior colonic surgery; ileocolonic interposition is a suitable alternative for patients with prior gastrectomy or long-segment esophageal defects, and it is theoretically advantageous for patients with high aspiration risk due to the potential anti-reflux effect of the ileocecal valve. In addition, supercharged jejunal interposition is the first option for cervical reconstruction in patients with unsuitable colonic anatomy and available microsurgical expertise. The clinical decision algorithm established in this study further quantifies the selection criteria, which can provide a practical reference for thoracic surgeons in clinical practice. Looking ahead, the integration of robotic surgery, near-infrared fluorescence imaging, and personalized molecular medicine will further optimize the efficacy and safety of esophageal reconstruction. Robotic-assisted minimally invasive esophagectomy (RAMIE) can improve the precision of graft harvesting and anastomosis, while fluorescence imaging can reduce ischemic complications by real-time perfusion assessment. Genomic profiling (e.g., PD-L1, HER2) will guide the combination of neoadjuvant therapy and reconstructive surgery, and ultimately realize the patient-centered individualized treatment of esophageal cancer. The progress of this field requires continuous multi-center collaborative research and the exploration of standardized surgical protocols, so as to further improve the long-term survival rate and quality of life of patients.

Abbreviations

MIS

Minimally invasive surgery

RAMIE

Robotic-assisted minimally invasive esophagectomy

ITA

Internal thoracic artery

ITV

Internal thoracic vein

ESCC

Esophageal squamous cell carcinoma

PD-1

Programmed cell death protein 1

PD-L1

Programmed death-ligand 1

HER2

Human epidermal growth factor receptor 2

MSI-H

Microsatellite instability-high

ctDNA

Circulating tumor DNA

TMB

Tumor mutational burden

Authors' contributions

Xin Liu and Jiahong Dai carried out the title design, literature acquisition, literature analysis and sorting, and wrote the manuscript. Ming Yin, Zhang Renyong and Yirong Song participated in the acquisition of the literature. All authors read and approved the final manuscript.

Funding

None.

Data availability

The data underlying this article are available in the article and in its online supplementary material.

Declarations

Ethics approval and consent to participate

Not Applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.