Esophagectomy

Published on 16/04/2015 by admin

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Chapter 5

Esophagectomy

Lee L. Swanstrom

Introduction

Franz Torek performed the first successful esophagectomy in 1913, after this high-risk surgery had been described 30 years with no patient survivors. Improvements in technique and patient care have reduced the mortality and morbidity, but esophagectomy remains one of the most dangerous surgeries performed, with a mortality rate of 4% to 10% and a complication rate of 20% to 60%. This dramatic risk profile results from (1) difficult anatomic position of the esophagus (Fig. 5-1), (2) involvement of three body cavities in the resection, (3) tenuous blood supply of all reconstruction options, and (4) nutrition impact on the surgical patient.

FIGURE 5–1 Esophagus in situ.

Because of the associated morbidity, most esophagectomies are performed on cancer patients (Fig. 5-2, A and B). Benign indications arise from absolute loss of function caused by end-stage motility disorders or from refractory strictures (Fig. 5-2, C). Worldwide, the primary esophageal cancer is squamous cell type, the result of dietary insults or smoking. In North America, however, this is no longer true: 80% or more of esophageal cancers are now adenocarcinomas related to gastroesophageal reflux and Barrett syndrome (metaplasia).

FIGURE 5–2 Indications for esophagectomy.

Radical resectional surgery remains the only cure for invasive esophageal cancers that are relatively resistant to radiation and chemotherapy. Neoadjuvant chemoradiation, however, is gaining popularity as a treatment for stage II and stage III cancers, although the survival benefit is not great. Overall, the 5-year survival rate for esophageal cancer is dismal: 18% for all patients and 25% for those able to have surgery.

Preemptive esophagectomy for patients with Barrett syndrome with high-grade dysplasia once was the most frequent indication for esophagectomy at most high-volume centers. This is no longer the case; endoscopic treatments such as radiofrequency ablation and cryotherapy are now effective low-morbidity alternatives.

Surgical Approaches

Active controversy surrounds the necessity for surgery, with minimalists stressing the morbidity of radical surgery and the poor survival statistics for patients with esophageal cancers. Recently, however, the trend has been for more radical en bloc resections, which offer survival advantages for patients with some early-stage cancers.

The three main approaches to esophagectomy are transhiatal, Ivor Lewis, and “three-hole,” or modified McKeown. Increasingly, all three approaches are performed with laparoscopy or thoracoscopy for an approach called minimally invasive esophagectomy (MIE). Choosing among the three approaches depends partly on the surgical indication (e.g., transhiatal approach for benign and low-grade cases), stage of cancer, and location of the tumor. The approach is mostly determined by institutional and surgeon preference, because no overwhelming evidence exists to demonstrate that one approach is dramatically better than the others.

Reconstruction of the resected esophagus is most often performed using the stomach, either tubularizing it or as a “whole-stomach” interposition. Less frequently, a colonic interposition is used, and, rarely, a jejunal interposition, often with microvascular augmentation. Because the vascularity of any of these conduits is tenuous at best, the surgeon needs to be familiar with the other esophageal replacement options.

Transhiatal Esophagectomy

The transhiatal esophagectomy is performed with the patient supine and the left side of the neck prepped and exposed. Either an upper midline incision or, increasingly, a five-port laparoscopic access is performed. Exploration is performed to rule out disseminated tumor, which would obviate resection in most cases. The greater curvature of the stomach is retracted anteriorly, and the gastrocolic omentum is divided from the spleen to the hepatic flexure, wide of the gastroepiploic blood supply, which is critical for the viability of the gastric graft (Fig. 5-3, A). Once the greater curvature is fully mobilized, the retrogastric adhesions to the peritoneum are divided. The lesser curvature of the stomach is then mobilized, a Kocher maneuver is performed to mobilize the duodenum, and the gastrohepatic ligament is divided near its attachment to the liver (Fig. 5-3, B). This exposes the D1 node area, which is routinely dissected.

FIGURE 5–3 Anatomy of the lesser curve, second portion of the duodenum, and gastrohepatic ligament (stomach is rotated cephalad).

Node dissection margins include the porta hepatis (hepatic portal) structures, the hepatic artery, and the vena cava (Fig. 5-4, A). Dense nodal tissue around the base of the left gastric artery is dissected, and the coronary vein and left gastric artery are divided with an energy sealing device, stapler, or suture ligation. Node tissue is left in continuity with the specimen. The hiatus is typically opened by excising a rim of the hiatal musculature and entering the mediastinum in the plane of the mediastinal pleura, pericardium, and preaortic and prespinal planes. This maneuver is more feasible with a laparoscopic approach and allows good lymphatic clearance of the lower mediastinum.

FIGURE 5–4 Transhiatal esophagectomy.

Open transhiatal surgery is performed by the surgeon, with the smallest hand on the team cupping the esophagus in the extended fingers and bluntly stripping the esophagus up to the proximal mediastinum. Care must be taken at the upper end of the blind dissection to avoid injury to the recurrent laryngeal nerve or membranous portion of the trachea (see Fig. 5-1).

Laparoscopic mediastinal dissection is performed by advancing the angled laparoscope into the mediastinum with the surgeon’s instruments. At the same time, a 5- to 7-cm incision is made in the left side of the neck from the sternal notch along the anterior margin of the sternocleidomastoid muscle (Fig. 5-4, B). The platysma muscle is divided and the sternocleidomastoid is retracted laterally (Fig. 5-4, C). After dividing the omohyoid muscle, the esophagus is located and surrounded by a soft drain. The upper mediastinal dissection is performed with lubricated gauze on a long, curved vascular clamp to meet with the dissection from below.

The gastric conduit is prepared by grasping the longest portion of the gastric cardia and stretching it into the left upper quadrant. Starting at the “crow’s foot,” a green load linear staple is used to divide the stomach parallel to the greater curvature to create a 3- to 4-cm gastric conduit (Fig. 5-4, D). Once transected, the specimen is placed in a plastic specimen bag and withdrawn through the neck. A chest tube is inserted through the neck and into the abdomen, and the gastric conduit is sutured to it and pulled up into the neck. A hand-sewn or stapled anastomosis is created to restore continuity.

Ivor Lewis and McKEOWN Approaches

The McKeown and Ivor Lewis approaches both require transthoracic access, either by a posterolateral thoracotomy in the 6th intercostal space or by thoracoscopy. The Ivor Lewis approach is defined by an intrathoracic anastomosis, whereas the McKeown procedure brings the anastomosis up to the neck. The order in which the dissection is performed also differs between techniques. The Ivor Lewis approach addresses the gastric mobilization first, then proceeds with the thoracic (or thoracoscopic) mobilization and intrathoracic anastomosis. The modified McKeown procedure uses right thoracoscopy or thoracotomy to dissect out the mediastinal esophagus, with or without an en bloc lymph node dissection.

The patient is then repositioned to allow the abdominal dissection and gastric conduit creation. In this procedure the left side of the neck is exposed, often by a second operating team, and a gastric conduit is created along the greater curve of the esophagus. This is then brought to the neck to perform the anastomosis.

Ivor Lewis Esophagectomy

The patient is positioned supine for the Ivor Lewis esophagectomy, and in the case of a laparoscopic procedure, in split-leg position. The abdomen is accessed through an upper abdominal incision or by five-port upper abdomen laparoscopic placement.

After a careful staging examination, the left lobe of the liver is retracted to expose the stomach. For potentially curative resections for cancer, we routinely perform a D1 or D2 lymph node dissection. For benign resections, the goal is to stay on the stomach and esophagus to prevent ancillary damage.

The gastrocolonic omentum is divided, staying 1 to 2 cm away from the critical gastroepiploic vessels of the greater curvature of the stomach (see Fig. 5-3, A). This dissection is extended medially past the second portion of the duodenum and laterally to the inferior pole of the spleen. This allows the stomach to be reflected anteriorly, exposing the lesser sac to allow the surgeon to check for metastatic disease, and exposes the right gastric artery to allow dissection of station 8 lymph nodes, if indicated (see Fig. 5-4, A). The greater curvature of the stomach is further mobilized by dividing the short gastric vessels, once again wide of the gastric margin. This dissection is taken to the left crus. For the lesser curvature, the gastrohepatic omentum is divided from the 2nd part of the duodenum up to the right crus. The base of the left gastric artery is identified either from the right side of the stomach or from underneath the stomach. It is skeletonized and divided to provide access to the preaortic plane, which will be extended into the mediastinum.

The gastric interposition is created by stapling the stomach as described for transhiatal esophagectomy, except that the final staple load to separate the fundus is not fired. The esophageal hiatus is dissected several centimeters into the mediastinum. Lastly, a feeding jejunostomy tube is placed by tacking the jejunum to the anterior abdominal wall and accessing it percutaneously with a guidewire and then a dilator with peel-away sheath that allows placement of a 12-Fr catheter. Addition of a pyloroplasty to improve gastric emptying is controversial. In general, if a wide gastric tube or whole-stomach pull-up is used, a pyloroplasty is performed. If a narrow gastric tube is created, theoretically a pyloroplasty is unnecessary because physical properties enable better emptying.

The patient is then repositioned in a left lateral decubitus position to allow access to the right side of the chest (5th intercostal posterolateral thoracotomy or four-port thoracoscopy). The right mediastinal pleura is widely excised in continuity with the esophagus. The esophagus is isolated away from the tumor and surrounded by a plastic drain for retraction. A wide resection of the esophagus is performed, incorporating surrounding node-bearing tissues with the specimen (Fig. 5-5). The esophagus is divided above the azygos vein, high in the mediastinum, with an endoscopic linear cutting stapler. The specimen is pulled up into the chest, along with the attached gastric conduit. A staple or hand-sewn anastomosis is performed, according to surgeon preference.

FIGURE 5–5 Ivor Lewis esophagectomy: five-port laparoscopic placement.

Modified McKeown (Three-Hole) Esophagectomy

The modified McKeown approach begins with thoracic mobilization. Therefore, if not routinely used by the surgeon, it is certainly the best choice for middle and upper cancers or when thoracic staging is important to determine resectability.

The three-hole procedure begins with the patient in the left lateral decubitus position with the arm carefully positioned overhead. A 5th or 6th intercostal posterolateral thoracotomy is done or a four-port thoracoscopic access is created. Wide resection of the right mediastinal pleura leaves the pleura with the esophagus, particularly over the area of the tumor. The azygos vein is typically divided with ties or a vascular stapler (Fig. 5-6, A). The esophagus is surrounded with a drain for retraction, and with the use of cautery or ultrasonic coagulating shears, the esophagus with all of its surrounding lymph node–bearing tissues is progressively mobilized.

FIGURE 5–6 Modified McKeown esophagectomy: azygos system of veins and esophageal lymph nodes/vessels.

Controversy surrounds the required extent of the dissection. Some argue that both the azygos vein and thoracic duct need to be resected with the periesophageal tissue, whereas others believe that only the periesophageal nodes require resection (Fig. 5-6, B). The proximal dissection should be taken as far as possible into the thoracic outlet and the distal dissection down to the crura.

Particular care must be taken throughout the mediastinal dissection because there are multiple critical structures, particularly in the more proximal mediastinum. In the area of the carina the particularly dense and vascular node tissue can bleed, and proximally the membranous trachea can be easily injured, with disastrous results. The aortic arch, recurrent laryngeal nerve, pulmonary hilum, and pericardium also must be safeguarded.

Once the thoracic dissection is complete, a chest tube is left inside the patient and the chest is closed. The patient is repositioned supine as described for transhiatal esophagectomy. Gastric mobilization is done and an interposition conduit is created as previously described. Once again, the final staple load to transect the stomach is not done. A second team will typically open the left side of the neck and surround the esophagus.

The upper esophageal dissection is performed by staying on the esophagus and using mostly blunt dissection. Care must be taken to avoid the recurrent laryngeal nerve in this area as well (Fig. 5-7, B). Small tumors can be brought out through the neck incision, pulling the interposition up at the same time. Larger cancers should be pulled into the abdomen, placed in an impermeable specimen bag, and withdrawn through a small abdominal incision. The anastomosis is performed with staples (circular or double linear firing) or is hand-sewn. Drains are placed and the incisions are closed.