CHAPTER 6 Esophagectomy
INDICATIONS FOR RESECTION
I. Esophageal Malignancies
A. The overwhelming majority of esophageal resections are performed for the treatment of carcinoma or premalignant lesions. The incidence of esophageal cancer varies greatly with geography; incidences are particularly high in China and South Africa. Esophageal carcinoma in the United States occurs more frequently in African Americans than in whites. The incidence of adenocarcinoma, however, has been rapidly increasing among middle-aged white men; it has now surpassed squamous cell cancer as the most prevalent histologic subtype of esophageal cancer in the United States. Alcohol and cigarette use are risk factors for both histologic subtypes. Approximately 15% of esophageal cancers occur in the upper one third, with the remainder occurring in the middle and lower thirds of the esophagus.
B. Staging of primary esophageal tumors is usually best achieved with the combination of CT, endoscopic ultrasound (EUS), and PET. CT is used to assess tumor invasion of local structures and identify distant metastatic disease. EUS (which can be combined with fine-needle aspiration) and PET are used to assess the regional lymph nodes. PET is probably the most sensitive modality for identifying distant metastases as well, assuming that the primary tumor is fluorine-18 fluorodeoxyglucose (FDG) avid. Carcinoma of the esophagus can spread widely. If a suspicious subcutaneous mass is found, biopsy should be performed. Neurologic symptoms should be evaluated using magnetic resonance imaging examination of the brain, and bone symptoms should be evaluated by bone scan.
C. The primary modalities for the treatment of esophageal cancers are surgery and chemoradiation therapy. Low survival rates with single-modality therapy, however, have prompted fairly uniform application of multimodality therapy, often consisting of neoadjuvant chemoradiation therapy and surgical resection of residual local disease. Surgery (either alone for very early disease or in combination with chemoradiation therapy for more advanced disease) provides potentially curative therapy. Importantly, surgical therapy may also provide significant palliation for dysphagia and local disease control so that oral intake may be maintained, even in patients who ultimately succumb to metastatic disease. In patients with clearly unresectable disease, palliative therapy without surgery should be the goal of treatment (Fig. 6-1).
II. Other Indications
A. Barrett’s esophagus describes the replacement of the esophageal squamous epithelium with sheets of columnar cells. The presence of Barrett’s esophagus is associated with severe gastroesophageal reflux disease and incompetence of the lower sphincter, which allows for prolonged exposure of the esophageal mucosa to acid. Barrett’s epithelium requires regular endoscopic surveillance with biopsies because it represents the first step toward dysplasia, a precursor to adenocarcinoma of the esophagus. Once Barrett’s epithelium has developed, the symptoms of heartburn may be somewhat ameliorated because the columnar epithelium is less sensitive to acid reflux. Close endoscopic surveillance is still required, however, even if symptoms have resolved or an antireflux procedure has been undertaken because neither of these guarantees subsistence of reflux or the return to normal mucosa. The presence of high-grade dysplasia or carcinoma on surveillance biopsy is an indication for esophageal resection. More recently, endoscopic therapies for dysplasia, Barrett’s epithelium, and early focal esophageal carcinoma have been explored. In skilled hands, these may displace resection for the treatment of early cases; however, long-term outcomes after such approaches have yet to be determined.
B. Caustic injury of the esophagus does not usually require immediate resection except in the rare case in which perforation occurs. Caustic burns, however, may result in stricture formation and contribute to the development of carcinoma; these may ultimately require esophagectomy for management.
C. Esophageal perforation is most commonly spontaneous (Boerhaave’s syndrome) or a complication of instrumentation (e.g., endoscopy). Esophageal perforation represents a surgical emergency; if untreated, severe mediastinitis may ensue. Surgical options include primary repair with drainage and esophagectomy.
D. Collagen vascular disorders, such as scleroderma, may result in significant esophageal atony, reflux esophagitis, and stricture formation. Patients with late-stage disease may require esophagectomy.
E. Achalasia is a functional disorder of the esophagus involving the destruction of Auerbach’s intermyenteric plexus. Patients typically have dysphagia that progresses over years. The esophageal dysfunction of achalasia is characterized by lack of coordinated peristalsis as well as nonrelaxation of the lower esophageal sphincter. These, in turn, lead to stasis and progressive esophageal dilation. Treatment may consist of endoscopic dilation of the lower esophageal sphincter or surgical esophagomyotomy. Because the stasis of achalasia favors the development of squamous cell carcinoma, long-term endoscopic surveillance is required, even after successful treatment. The persistent risk of carcinoma despite these therapies probably reflects imperfect relief of obstruction. In the absence of esophageal cancer, esophagectomy may be considered in patients with symptomatic megaesophagus or after failure of esophagomyotomy.
PREOPERATIVE EVALUATION
I. History and Physical Examination: Dysphagia and weight loss are the hallmarks of esophageal carcinoma and mandate a thorough evaluation. A history of gastroesophageal reflux disease, previous endoscopy, alcohol and tobacco use, and weight loss should be elicited. Specific symptoms suggesting advanced disease include hoarseness (sometimes indicative of recurrent nerve invasion) and cough or hemoptysis (sometimes indicative of a tracheoesophageal fistula).
II. Studies
A. Esophagoscopy allows for visualization of the entire esophagus. Brush cytology with biopsy is obtained when appropriate. EUS may be used to improve the sensitivity of esophagoscopy, particularly when brush cytology or biopsy is not diagnostic. EUS is also used to stage esophageal carcinoma and allows for an assessment of the depth of invasion of the tumor and involvement of regional lymph nodes (Fig. 6-2).
B. Barium swallow provides detailed imaging of the mucosal contour of the esophagus and serves as an important adjunct to esophagoscopy in the evaluation of symptoms and the characterization and localization of esophageal lesions.
COMPONENTS OF THE PROCEDURE AND APPLIED ANATOMY
Approaches to Esophagectomy
I. Ivor-Lewis esophagectomy is most often used for midthoracic tumors and allows for preparation of the conduit through an abdominal incision and dissection of the esophageal tumor and anastomosis in the chest under direct visualization.
II. En bloc esophagectomy may be used for distal tumors and, like the Ivor-Lewis approach, allows for nodal dissection and dissection of tumor from adherent pleura under direct visualization. A disadvantage of this approach is the limited proximal resection margin it affords because the anastomosis must be performed distal to the aortic arch.
III. Lesions involving the lower third of the esophagus are ideally suited to resection via transhiatal esophagectomy (described later), which allows for local regional nodal dissection and resection of the primary tumor under direct vision via the abdominal incision. Upper esophageal and pharyngeal cancers can be removed via the transhiatal approach as well; in such cases, the abdominal portion of the operation consists of removal of the distal normal esophagus and preparation of a stomach conduit. Restoration of gastrointestinal continuity is achieved through an anastomosis of the cervical esophagus to a conduit. This represents a theoretical advantage of the transhiatal approach over approaches that involve the creation of thoracic anastomoses because a leak in the neck is generally better tolerated than one in the chest.
IV. Minimally invasive esophagectomy usually involves mobilization of the esophagus through right thoracoscopy or laparoscopy and dissection of the most proximal esophagus and anastomosis through an open cervical incision. The operation can be safely performed in the hands of surgeons who are skilled in minimally invasive procedures, but significant benefits over the standard approach have yet to be demonstrated.
Preoperative Considerations
I. Prophylactic antibiotics should be administered before skin incision and should cover mouth flora. When esophageal obstruction has been significant, agents that provide broader-spectrum coverage as well as antifungal agents should be used.
II. Given the length of the procedure and the risk of intraoperative blood loss, a urinary catheter should be placed to decompress the bladder and facilitate intraoperative monitoring of volume status.
III. An epidural catheter should be placed preoperatively, particularly in patients with a thoracic incision, to facilitate postoperative pain management.
Exposure and Creation of the Gastric Conduit
I. The greater omentum is divided to release the stomach from its connection to the colon. Care is taken to preserve the right gastroepiploic vessel, which traverses the omentum parallel to the greater curvature of the stomach and will serve as the major blood supply to the gastric conduit (Fig. 6-3).
II. The stomach is freed from the spleen by dividing the gastrosplenic ligament, which contains the short gastric vessels. The vessels are ligated as far from the gastric wall as possible to preserve intramural collaterals.
IV. The stomach is reflected cephalad. The left gastric artery is identified and ligated near its take-off from the celiac axis (Fig. 6-4).
V. The stomach is divided along a line beginning at the lesser curvature and ending at the fundus, ensuring a distal tumor margin of 5 cm or more (Fig. 6-5).
VII. A pyloroplasty is performed by making a longitudinal incision through the pylorus, which is then closed transversely. Mobilization of the duodenum is usually not necessary and does not provide significant additional stomach length. If stomach length is insufficient to allow a tension-free anastomosis with the cervical esophagus, a right thoracic incision and creation of an anastomosis in the upper right chest should be considered (Fig. 6-6).
Figure 6-3 Blood supply to the stomach.
(From Zuidema G: Shackelford’s Surgery of the Alimentary Tract, 4th ed. Philadelphia, Saunders, 1995.)
Figure 6-4 Mobilization of the stomach and ligation of the left gastric artery.
(From Cameron JL [ed]: Current Surgical Therapy, 8th ed. Philadelphia, Mosby, 2004.)
Figure 6-5 Preparation of the gastric conduit.
(From Khatri VP, Asensio JA: Operative Surgery Manual. Philadelphia, Saunders, 2003.)
Mobilization of the Esophagus and Anastomosis
I. The diaphragmatic hiatus is widened using manual retractors to allow for dissection of the distal esophagus.
II. The esophagus is separated from the crux under direct vision. If necessary, the fibers of the crux can be divided anteriorly to provide wider access to the lower mediastinum. Mobilization of the esophagus under direct visualization can generally be carried out up to the level of the inferior pulmonary vein and frequently to the level of the carina (Fig. 6-7).
III. A left neck incision is made parallel to the sternocleidomastoid muscle. The omohyoid muscle is divided in its midportion. The esophagus is identified medial to the carotid sheath. The recurrent laryngeal nerve is identified in the tracheoesophageal groove and left in situ.
IV. The esophagus is freed from surrounding tissues circumferentially. Blunt dissection is then carried out through the hiatus and neck incision to complete mobilization of the esophagus.
V. Mobilization of the esophagus is frequently associated with hypotension secondary to displacement of the heart or compression of the vena cava. Mediastinal dissection should be interrupted as frequently as is necessary to avoid prolonged hypotension.
VI. A stapler is used to transect the cervical esophagus. A large Penrose drain is sutured to the transected esophagus and is delivered into the abdomen through the posterior mediastinum as the esophagus is removed through the hiatus.
VII. A Penrose drain is attached to the gastric conduit, which is then delivered through the posterior mediastinum to the neck with gentle traction.
VIII. A single-layer anastomosis between the proximal cervical esophagus and the gastric conduit is created using absorbable sutures (Fig. 6-8).
IX. A feeding jejunostomy tube is placed approximately 20 to 30 cm distal to the ligament of Treitz.
COMPLICATIONS
I. Pulmonary complications, including atelectasis and pneumonia, are frequent after esophagectomy. Aggressive pain control, chest physiotherapy, and pulmonary toilet are essential components of postoperative management and may lessen the incidence of these complications.
II. Cardiac arrhythmias (e.g., atrial fibrillation) are likewise common after esophagectomy, as with many intrathoracic procedures.
III. Cervical anastomotic leak is more likely when the anastomosis is under tension or when the blood supply to the conduit is tenuous. Some surgeons advocate routine evaluation of the anastomosis with a swallow study before removal of the nasogastric tube. If adequately drained, most anastomotic leaks will heal. Larger leaks may be complicated by a cervical or mediastinal abscess and require reopening of the left neck incision and antibiotic therapy.
IV. Recurrent laryngeal nerve injuries are most often traction-related. Patients may complain of hoarseness and may aspirate thin liquids. Most injuries of this type resolve over a period of 2 to 3 months.
V. Chylothorax may result from injury to the thoracic duct during right-sided esophageal dissection. The diagnosis is suggested by the development of a pleural effusion in the right side of the chest and may be confirmed by measurement of elevated triglycerides and protein in the pleural fluid. Drainage with serial thoracenteses or placement of a chest tube and bowel rest may allow for resolution of the chyle leak. If the drainage does not subsist, an operation to ligate the thoracic duct or placement of a pleuroperitoneal shunt may be necessary. Angiographic occlusion of the thoracic duct is a preferable approach in centers where this technique is available.
Casson AG. Thoracic approaches to esophagectomy. In: Kaiser LR, Kron IL, Spray TL, et al, editors. Mastery of Cardiothoracic Surgery. Philadelphia: Lippincott Williams & Wilkins; 1998:141-150.
Cope C, Salem R, Kaiser LR. Management of chylothorax by percutaneous catheterization and embolization of the thoracic duct: prospective trial. J Vasc Interv Radiol. 1999;10:1248-1254.
Inculet RI. Transhiatal esophagectomy [[eds]]. Kaiser LR, Kron IL, Spray TL, et al, editors. Mastery of Cardiothoracic Surgery. Lippincott Williams & Wilkins, Philadelphia, 1998, 134-140.
Zwischenberger JB, Savage C, Bhutani MS. Esophagus. In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL, editors. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 17th ed. Philadelphia: Saunders; 2004:1091-1150.
