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Surgical Approaches to Remove the Esophagus: Open
Surgical Therapy
Surgical resection remains the cornerstone of therapy for patients with resectable cancer of the esophagus in the absence of systemic metastases. Surgery, most of the time combined with neoadjuvant therapy in current practice, offers the highest likelihood of cure for patients with locoregional disease. To obtain the best results, the management of esophageal cancer should be individualized and based on a combination of factors including the physiologic status of the patient, tumor type and location, and stage of disease. In this chapter, we describe the different open surgical approaches to remove the esophagus in patients with esophageal cancer. Although minimally invasive techniques (see Chapter 39B ) are increasingly applied, the benefits of fully minimally invasive esophagectomy have not yet been proven unequivocally, and an open or hybrid esophagectomy remains the standard procedure to remove the esophagus in many leading high-volume centers worldwide. At present, the only strong available evidence comes from preliminary results of the French randomized MIRO trial comparing hybrid transthoracic esophagectomy (TTE, laparoscopic gastric mobilization, and open thoracotomy) with fully open TTE. These results suggest that hybrid TTE significantly reduces postoperative complications compared with open TTE (odds ratio [OR] for postoperative morbidity, 0.31; 95% confidence interval [CI], 0.18 to 0.55; P = .0001; percentage of pulmonary complications: 17.7% vs. 30.1% vs. P = .037). The open thoracic part of hybrid TTE is similar to that of fully open TTE (this chapter), whereas the laparoscopic (abdominal) part is described in detail in Chapter 39B .
Patient Assessment
Esophageal cancer is a disease that occurs predominantly in the sixth and seventh decades of life. Advanced age alone should not be considered a contraindication for esophageal resection. Although the risk of mortality is higher in patients older than 70 years of age, this increased risk is due to the higher frequency of medical comorbidities such as heart, liver, and kidney disease in the elderly population rather than age per se. It is important to note that when operative mortality is excluded, long-term survival after resection in the elderly population is similar to that observed in younger patients. As a result, octogenarians and nonagenarians can be considered candidates for potentially curative resection, but particular attention needs to be paid to the preoperative assessment of patients' general condition.
The strong etiologic ties between (squamous cell) cancer of the esophagus and alcohol and tobacco usage make it imperative that patients be carefully screened for the presence of cardiovascular, pulmonary, and hepatic dysfunction regardless of their age. It has been estimated that between 20% and 30% of patients with esophageal cancer will have evidence of cardiovascular disease if carefully screened. This evaluation should at least consist of electrocardiography for all patients. The preoperative evaluation should also include pulmonary function testing. Patients with significant impairment in the forced expiratory volume at 1 second (FEV 1 < 1 L) and those with chronic obstructive pulmonary disease are at increased risk of respiratory complications following surgery. Cirrhosis of the liver is not uncommon in patients with esophageal cancer, particularly those with squamous cell carcinoma. Well-compensated cirrhosis (Child classification A) alone is not a contraindication to resection of an otherwise curable esophageal cancer, but one should be careful when considering resection in the setting of more advanced stages of cirrhosis, especially in the presence of ascites. Furthermore, patients who are planned to undergo neoadjuvant chemo(radio)therapy should be screened for renal insufficiency.
Extent of Resection for Locoregional Esophageal Cancer
For several decades, the optimal surgical strategy for the potentially curative treatment of patients with locoregional esophageal cancer has been under debate. Historically, the Ivor-Lewis procedure has been widely applied, including a thoracotomy with limited lymphadenectomy and thoracic anastomosis. Ever since, two main surgical techniques have evolved. First, the extended en bloc TTE was developed. With extensive two-field lymphadenectomy (upper abdomen and posterior mediastinum), this technique attempts to increase locoregional tumor control by enhancing the radicality of the resection. It is established that extensive lymphadenectomy provides the benefit of more accurate staging, but its beneficial effect on survival is still unclear. Second, the limited transhiatal esophagectomy (THE) was introduced, which focused on minimization of postoperative morbidity and mortality by preventing a thoracotomy.
Lymphatic dissemination in esophageal cancer occurs early and is unpredictable. Once the tumor has penetrated the submucosal layer, up to one-half of patients will have nodal metastases. More than 80% of patients with invasion of the muscularis propria will have at least one involved lymph node. In the presence of transmural invasion, nodal involvement will be present in more than 85%, and the median number of involved nodes and the proportion of patients with more than four involved nodes increases ( Table 39A.1 ). Extended lymphadenectomy as performed during TTE increases the chance of removal of all tumor-positive lymph nodes and theoretically improves regional tumor control and perhaps even long-term survival. However, high-quality clinical evidence on the optimal extent of lymphadenectomy is absent, especially in the present era of neoadjuvant treatment. Consequently, individual opinions and institutional preferences currently dominate the choice of surgical technique and extent of lymphadenectomy.
TABLE 39A.1
Relationship Between Tumor Depth (T-stage) and Lymph Node Status (N-stage) for Esophageal Adenocarcinoma
Modified from Hagen JA, DeMeester SR, Peters JH, Chandrasoma P, DeMeester TR. Curative resection for esophageal adenocarcinoma: analysis of 100 en bloc esophagectomies. Ann Surg. 2001;234:520-530.
| Tumor Depth | Prevalence of Node Metastases (%) * | Number of Involved Nodes (Median [IQR]) † | Number With 1–4 Involved Nodes (%) ‡ | Number With >4 Involved Nodes (%) § |
|---|---|---|---|---|
| Intramucosal (T1A) | 1/16 (6) | 2 (n/a) | 1/16 (6) | 0/16 (0) |
| Submucosal (T1B) | 5/16 (31) | 1 (n/a) | 4/16 (25) | 1/16 (6) |
| Intramuscular (T2) | 10/13 (77) | 2 (1–4) | 9/13 (69) | 1/13 (8) |
| Transmural (T3) | 47/55 (85) | 5 (3–13.5) | 22/55 (40) | 25/55 (45) |
* χ 2 = 42.0, P < .0001 (chi-square test for trend).
† χ 2 = 11.02, P = .0116 (Kruskal-Wallis; includes only patients with involved nodes).
Technique of Open en Bloc Transthoracic Esophagectomy
En bloc TTE is performed through a right thoracotomy and a midline laparotomy. The proximal anastomosis is performed either through an extra incision made at the left side of the neck or in the chest (see “Anastomosis”). When a cervical anastomosis is performed, the procedure starts with a thoracotomy followed by the abdominal part of the operation, whereas in case of an intrathoracic anastomosis the laparotomy is performed prior to the thoracic phase.
The thoracic dissection includes removal of the azygos vein with its associated nodes, the thoracic duct, and the paratracheal, subcarinal, paraesophageal, and parahiatal nodes in continuity with the resected esophagus. Nodes in the aortopulmonary window are removed separately. The block of tissue removed is bounded laterally on each side by the excised mediastinal pleura, anteriorly by the pericardium and membranous part of the trachea, and posteriorly by the aorta and vertebral bodies.
During the thoracic phase the patient is placed in the left lateral decubitus position with a posterolateral thoracotomy performed entering the chest through the fifth or sixth intercostal space. The inferior pulmonary ligament is divided to the level of the inferior pulmonary vein. The pleura overlying the right main bronchus is divided, taking into account its membranous part. The pleura lying on both sides of the azygos arch is incised, and the arch is ligated or closed with a stapling device and subsequently transected. The pleura cranial to the azygos arch is incised and saved to create a pedicled “flap” to cover the subsequent intrathoracic anastomosis. The right paratracheal nodes are removed in between the trachea, superior vena cava, and the azygos arch. The right vagal nerve and the bronchial artery are divided. The vagal nerve should not be divided with use of electrocautery to prevent injury to the right recurrent nerve. The pleura overlying the lateral aspect of the vertebral bodies is incised from the level of the azygos arch to the diaphragm, and the intercostal veins are divided between ligatures or clips where they enter the azygos vein. A dissection plane is then created following each intact intercostal artery to reach the adventitial plane of the aorta. Dissection continues across the anterior surface of the aorta until the left mediastinal pleura is reached. Direct branches of the thoracic aorta to the esophagus should be carefully ligated before dividing. One or two communicating veins to the hemiazygos need to be ligated as they pass behind the aorta. The mediastinal tissue posteriorly between the azygos vein and the aorta just above the diaphragm includes the thoracic duct, which should be identified and transected at this stage. A heavy nonresorbable ligature should be placed caudally to prevent the development of a chylothorax. The dissection can be ended at the level of both crura of the diaphragm.
The anterior portion of the dissection is performed along the previously incised inferior pulmonary ligament. Hereby, the posterior aspect of the pericardium is freed by blunt and sharp dissection. The pericardium should only be removed when the tumor is adherent. Once the left mediastinal pleura is reached, the plane can be connected with the previous dissection over the aorta. Sometimes the left pleura is incised. The thoracic esophagus is then encircled with a Penrose drain for traction. The anterior dissection is then continued cephalad along the pericardium until the subcarinal nodes are encountered. Careful dissection along the right main bronchus up to the carina and then distally along the left main bronchus allows for removal of the entire subcarinal node basin in continuity with the resected esophagus. At this point, the anterior dissection is also transitioned to the wall of the esophagus by dividing the left vagal nerve where it crosses the left main bronchus. The esophagus is separated from the membranous part of the trachea. In case of an intrathoracic anastomosis, the esophagus is divided above the level of the azygos arch. In case of a cervical anastomosis, the dissection is continued toward the root of the neck. The lymph nodes in the aortopulmonary window can be dissected after identification of the left vagal nerve. The left vagal nerve is divided between ligatures at the level of the left main bronchus. The proximal side is carefully moved upward with use of the same ligature, thus preventing damage to the left recurrent nerve when dissecting the aortopulmonary window nodes. The proximal thoracic duct is also ligated and cut at the level of the fourth vertebral body where it crosses from right to left.
The abdominal portion of the operation begins with a midline laparotomy and inspection of the peritoneal cavity and liver. Normally, segments two and three of the liver are mobilized by incising the left triangular ligament with electrocautery. The flaccid part of the lesser omentum is identified and incised in the direction of the right crus. The right gastric artery is identified, and the lesser omentum is further mobilized. Then the gastrocolic omentum is divided, carefully preserving the gastroepiploic arcade. This dissection should begin distally at the level of the pylorus, continuing proximally to include division of the short gastric vessels. The short gastric vessels should be divided as close as possible to the spleen to preserve as many collateral vessels to the fundus as possible. In this fashion, an omental wrap around the future anastomosis can also be created.
All of the lymph node–bearing tissue overlying the proximal border of the hepatic artery and portal vein is removed. This dissection is continued proximally along the hepatic artery to its origin from the celiac axis. The retroperitoneal tissue above the pancreas overlying the right crus of the diaphragm is dissected medially and superiorly to remain attached to the esophagectomy specimen. Attention is then turned to the greater curvature of the stomach where the gastrocolic omentum is divided. The gastric fundus is rotated to the right to continue the dissection in the retroperitoneum, removing all of the node-bearing tissue above the splenic artery and overlying the left crus of the diaphragm. The musculature of the diaphragmatic hiatus is then incised (in case of a bulky tumor) to meet the incision made in the diaphragm during the thoracic dissection. Often the diaphragmatic vein needs to be ligated. Retracting the stomach anteriorly, ample exposure of the celiac axis can be achieved to allow for ligation of the coronary vein (=left gastric vein). After this, the upper abdominal lymph adenectomy around the celiac trunk can be completed. The left gastric artery is divided at its origin. A Kocher maneuver can be performed if needed to allow additional mobility of the stomach.
Reconstruction is preferably performed by creation of a gastric tube after resection of the gastric cardia. The gastric tube is created using a linear stapling device. The staple line should begin on the upper fundus at least 5 cm from the distal limit of the tumor and should continue to a point along the lesser curvature corresponding to the fourth or fifth branch of the right gastric artery in the case of a cervical anastomosis, where more length can be achieved by staying closer to the greater curve (consequently a narrower tube). When an intrathoracic anastomosis is performed, more of the right gastric vessels can be preserved; consequently, a wider tube can be created. Finally, the staple line is oversewn.
Technique of Transhiatal Esophagectomy
The operation begins with an abdominal lymph node dissection and gastric mobilization (see “ Technique of Open En Bloc Transthoracic Esophagectomy ”). Next, the tendinous part of the esophageal hiatus is incised anteriorly or the muscular part is incised circumferentially after division of the diaphragmatic vein with ligatures. This ensures removal of any potentially involved parahiatal nodes, but it also enlarges the hiatal opening that facilitates the lower mediastinal dissection. Placement of appropriate retractors through the widened esophageal hiatus allows for en bloc dissection of all the fatty tissue and lymph nodes surrounding the lower thoracic esophagus under visual control as far as possible. Under normal circumstances, this can be done up to the level of the inferior pulmonary veins. To not damage the thoracic duct, care should be taken not to dissect at the right side of the thoracic aorta. Subsequently, the gastric tube is created and the cervical esophagus is exposed (see “ Cervical Anastomosis ”). The upper thoracic esophagus is delivered into the cervical wound and it is divided in the neck. A large-bore vein stripper is inserted through the cervical esophagus and brought to the gastric remnant. After a long tape is tied to the distal part of the transected esophagus, it is bluntly stripped from the neck toward the abdomen, while the adhesions between the esophagus and surrounding structures are manually freed via the widened hiatus. In the lower mediastinum, the vagal nerve trunks that are separated from the esophagus by this maneuver can be divided below the carina with use of scissors. The right lateral attachments are mobilized by a similar maneuver passing the right hand anterior to the esophagus and using the thumb and index finger to bluntly dissect the right lateral attachments. The tape tied follows the inverting esophagus from the neck to the abdomen. The esophagus is everted again and the resection specimen is sent for pathologic examination. The tape is now sutured onto the top of the gastric tube (which has been created at an earlier stage; see previous text). The gastric tube can be wrapped in a bowel bag or laparoscopic camera bag to facilitate atraumatic passage and can be brought up to the neck by pulling gently on the tape and pushing the gastric tube into the mediastinum. Care should be taken to avoid rotation of the gastric tube. A cervical anastomosis can subsequently be performed (see “ Cervical Anastomosis ”).
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