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Esophagectomy
Introduction
Franz Torek performed the first successful esophagectomy in 1913, after 30 years of dismal results without any survivors. Improvements in technique and patient care have reduced morbidity and mortality; however, esophagectomy remains a high-risk procedure because of the challenging anatomic position of the esophagus, involvement of multiple body cavities in the resection ( Fig. 5.1 ), tenuous blood supply of all reconstruction options, and the patient’s often malnourished status.
Surgical Approaches
Active controversy surrounds the necessity for surgery in esophageal cancer, with minimalists stressing the poor cancer survival despite morbidity of radical surgery. However, it has been well validated that esophagectomy can be performed with low morbidity (33%) and mortality (3%).
The three most commonly employed approaches to esophagectomy are transhiatal, Ivor Lewis, and/or modified McKeown approach. In select patients a left thoracoabdominal esophagectomy can also be effective. Increasingly, many of these approaches are being performed minimally invasively and are broadly labeled as minimally invasive esophagectomy (MIE). The approach used depends on the surgical indication (e.g., transhiatal approach for benign conditions and small cancers), cancer stage, tumor location (e.g., modified McKeown for upper and middle esophageal cancers), and, above all, surgeon preference. There is no overwhelming evidence demonstrating the superiority of any one specific technique. The tumor location should be well established and generous proximal and distal margins ensured, because esophageal cancers spread not only to the regional lymph nodes but also along the submucosal lymphatic channels of the esophagus.
Reconstruction most often uses the stomach, with varying degrees of tubularization. Alternatives include colonic interposition or jejunal interposition, which requires microvascular augmentation or free flap, depending on the segment of esophagus that will be replaced, and rarely other soft tissue flaps for short segment reconstruction. Because any of these conduits have tenuous vascularity, the surgeon needs to be familiar with all esophageal reconstruction options.
Transhiatal Esophagectomy
The transhiatal esophagectomy is performed with the patient supine and the left side of the neck exposed. This approach begins in the abdomen, then traverses the hiatus to bluntly dissect the thoracic esophagus free, and reaches the neck to conclude the operation.
Abdominal exposure is achieved through either an upper midline incision ( Fig. 5.2 ) or appropriate laparoscopic access.
Exploration is performed to rule out disseminated tumor, which would obviate resection. The dissection starts at the short gastric vessels and moves toward the left crus. Key steps include mobilizing the greater curvature while preserving the right gastroepiploic artery, then dividing the retrogastric adhesions to the pancreas. Many surgeons use a Kocher maneuver to mobilize the duodenum to provide additional conduit length, but this is not always necessary. Gastroesophageal (GE) junction dissection involves dividing the gastrohepatic ligament and phrenoesophageal attachments to the GE junction, and exposing the aorta at the diaphragmatic hiatus. The right gastric artery and its perforators are also preserved to maintain additional blood supply to the gastric conduit.
For distal esophageal cancers and gastroesophageal junction cancers, lymph node dissection includes skeletonizing the left gastric pedicle and proximal common hepatic artery as needed ( Fig. 5.2C and D ). The extensive lymphadenectomy of gastric cancer surgery is not routinely performed unless there is lymphadenopathy on imaging. Nodal tissue is left en bloc with the specimen.
The hiatus is opened, excising a rim of the hiatal musculature and entering the mediastinum in the plane of the mediastinal pleura, pericardium, and preaortic/prespinal planes.
Transhiatal Esophagectomy (Continued)
Open transhiatal surgery is performed by cupping the esophagus in the extended fingers, bluntly stripping the esophagus up to the proximal mediastinum to the thoracic inlet. This maneuver may cause temporary hypotension resulting from cardiac compression; therefore it is important to communicate with the anesthesia team when this is being performed. Similar dissection can be performed laparoscopically.
At the same time, a 5- to 7-cm incision is made in the left neck from the sternal notch along the anterior sternocleidomastoid muscle border. The platysma muscle is divided and the sternocleidomastoid is retracted laterally. After the omohyoid muscle is divided, dissection is carried out in the tracheoesophageal groove. The fat pad, containing the left recurrent laryngeal nerve, is mobilized toward the airway, and circumferential control of the esophagus is obtained by encircling the esophagus with a soft drain ( Fig. 5.3 ). Placing a nasogastric tube helps define the esophageal anatomy to facilitate blunt dissection. The upper mediastinal dissection is then performed bluntly inferiorly to meet the dissection from below. The esophagus is pulled into the neck and transected with a tissue stapler cutter, after pulling back the nasogastric tube (see Fig. 5.3 ). The distal staple line is sewn to a Penrose drain and reduced back into the abdomen along with the drain to maintain the track.
The gastric conduit is prepared by stretching the gastric cardia into the left upper quadrant (see Fig. 5.3E ). Starting at the right gastric perforator just below the left gastric pedicle, the stomach is divided along the lesser curvature using a linear stapler, parallel to the greater curvature, to create a gastric conduit about 5 cm in width.
Some have advocated using narrow conduits to improve conduit emptying. The staple line can be started lower on the lesser curve if necessary to maintain a negative distal margin, making sure not to injure the right gastric artery (see Fig. 5.3F ).
During laparoscopic tubularization, the conduit tip is either left attached to the specimen or sewn to the specimen before being pulled up into the neck. A hand-sewn or hybrid stapled anastomosis (modified collard anastomosis) is created to restore continuity (see Fig. 5.3G ). The nasogastric tube is advanced into the conduit for decompression. Although some surgeons perform an intraoperative endoscopy to examine the anastomosis, we, and most others, do not routinely perform this.
A feeding jejunostomy tube is then placed 30 cm from the ligament of Treitz (see Fig. 5.3H ).
Pyloric drainage, which includes pyloromyotomy, pyloroplasty, or injection of botulinum toxin A to the pylorus, is also typically performed. Some surgeons who use narrow gastric conduits no longer perform drainage procedures.
The excess conduit is reduced into the abdomen and secured to the hiatus to prevent herniation of abdominal viscera into the mediastinum (see Fig. 5.3I ).
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