Esophagus: Esophagectomy

Surgical Approach

Surgical Approach to the Esophagus

  • Cervical: Left Cervical Incision
  • Thoracic Upper 2/3: Right Posterolateral Thoracotomy (Avoid Aorta)
  • Thoracic Lower 1/3: Left Thoracotomy (Aorta Transitions to Right)

Esophagectomy

Techniques

  • Transthoracic Esophagectomy (TTE)/Ivor Lewis
    • Methods:
      • Open: Abdominal Midline & Right Thoracotomy Incisions
      • Minimally Invasive: Laparoscopy & Right Thoracoscopy
    • Most Common Surgery for Esophageal Cancer
  • Transhiatal Esophagectomy (THE)
    • Methods:
      • Open: Abdominal Midline & Left Cervical Incisions
      • Minimally Invasive: Laparoscopy & Open Left Cervical Incision
    • Compared to TTE: Lower Hospital LOS, Similar M&M
      • *A Recent Study Saw a Higher Risk of Anastomotic Leak
      • *Some Believe to Have Lower Oncologic Yield Although Not Proven
  • McKeown (Three-Field) Esophagectomy
    • Three Stages: Abdominal, Thoracic & Cervical
    • Possible Indications:
      • Proximal Thoracic Tumor
      • Concern for Proximal Margin
      • Extensive Barrett’s Esophagus
    • Compared to TTE: Cervical Leak Easier to Manage than Thoracic Leak

Transthoracic Esophagectomy (TTE)/Ivor Lewis – Minimally Invasive 2-Stage Procedure

  • Stage 1: Abdominal Phase
    • Examine for Metastatic Disease
    • Expose Right Crus at Gastrohepatic Ligament
    • Preform a D2 LN Dissection
    • Divide Left Gastric Vascular Pedicle
    • Divide Gastrocolic Ligament & Extend to Fundus (Divide Short Gastrics)
      • Avoid Injury to Right Gastroepiploic Artery
    • Divide Retroperitoneal Attachments
    • Preform Pyloroplasty or Botox Injection of Pylorus
      • Prevents Delayed Emptying of Conduit
    • Preform a Transhiatal Dissection of the Distal Esophagus
    • Divide Stomach to Create a 3-5 cm Wide Gastric Conduit
      • Conduit Extends from the Pylorus to the Fundus Along the Greater Curvature
    • Finish with Creation of a Jejunostomy Tube for Future Nutrition
  • Stage 2: Thoracic Phase
    • Right Lung Collapsed
    • Divide Pulmonary Ligament & Azygos Vein
    • Divide Esophagus at Thoracic Inlet
      • Send Proximal Margin for Frozen Section
    • Pull Gastric Conduit into the Chest
    • Pass a Transoral Circular Stapler Anvil Through the Mouth to the Esophageal Stump
    • Pass EEA Stapler Through an Opening in the Proximal Gastric Conduit
    • Engage Anvil to Stapler and Fire to Complete the Anastomosis

Basics

  • Vascular Alteration:
    • Will Divide Left Gastric, Short Gastrics & Possibly Left Gastroepiploic
    • New Primary Supply to Gastric Conduit: Right Gastroepiploic
  • Need to Preform Concurrent Gastric Outlet Procedure (Pyloromyotomy vs Botox)
  • If Unable to Use Gastric Conduit: Use a Colonic Interposition

Complications

  • Pulmonary Complications – Most Common
    • Include: PNA, ARDS, Bronchospasm, COPD Exacerbation & PE
  • Atrial Fibrillation
  • Anastomotic Leak
    • Cervical Anastomotic Leak
      • Less Morbid (Although No Difference in Mortality)
      • Tx: Drainage & Wet-to-Dry Dressings
        • Surgery if Fails
    • Thoracic Anastomotic Leak
      • Less Likely to Leak than Cervical – Shorter with Less Tension
      • Tx: Surgery vs Stenting
  • Postoperative Stricture
    • Tx: Serial Dilations
  • Conduit Ischemia
  • Recurrent Laryngeal Nerve Injury
  • Chylothorax
  • Dysphagia
  • Delayed Gastric Emptying
  • Reflux
  • Hiatal Hernia