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Esophagectomy: Ivor Lewis and Other Procedures


KEY FACTS

Terminology

  • Surgical resection of a portion of esophagus and replacement by a conduit formed by another portion of alimentary tube

Imaging

  • Many surgical options for surgical excision of esophagus

    • Transthoracic esophagectomy: Usually performed through right intercostal approach (Ivor Lewis procedure)

    • Other options include minimally invasive (laparoscopic) procedures

  • Stomach is ideal conduit, as it has reliable blood supply and can reach high into thorax or neck for anastomosis

  • Perioperative complications

    • Hemorrhage

    • Injury to recurrent laryngeal or vagus nerve (5-10%)

    • Injury to tracheobronchial tree

    • Chylothorax (2-4%)

  • Postoperative complications

    • Essentially all patients have some degree of dysphagia, early satiety, and reflux following esophagectomy

    • Anastomotic leak (10-16%)

    • Anastomotic stricture (15-25%)

    • Diaphragmatic hernia (1-6%)

    • Delayed emptying of conduit

      • –

        Causes: Redundant or twisted conduit, mechanical obstruction, functional delay

    • Recurrent carcinoma

  • Complication rates vary substantially according to experience and skill of surgical team

    • Open surgical procedures: Higher perioperative morbidity and mortality

    • High (cervical) anastomoses: Higher incidence of injury to laryngeal nerve

  • Imaging Protocols

    • Esophagram: 1st postoperative study is done with water-soluble nonionic contrast agent (e.g., Omnipaque)

    • CECT: Complementary to esophagram for strictures, leaks, abscesses, etc.

    • PET/CT: Best for detection of recurrent carcinoma

Graphic illustrates the 1st step in an esophagectomy with gastric interposition. The stomach is divided along its long axis, creating a gastric tube or conduit 5 or 6 cm in diameter, which is pulled up into the chest. This can be done through a right (Ivor Lewis) or left thoracotomy or even through laparoscopic ports. A pyloroplasty
is done to facilitate gastric emptying.

Graphic shows the gastric conduit anastomosed to the mid esophagus
and the pyloroplasty
.

Graphic shows the gastric conduit
anastomosed to the cervical esophagus. Note the position of the gastric staple line
along the right side of the conduit.

Axial CT shows a mildly dilated, gas-filled gastric conduit
in the paravertebral location. Note the position of the gastric staple line
. The conduit is not filled with retained fluid, and there is no evidence of lung injury from reflux.

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