Esophagectomy: Ivor Lewis and Other Procedures

Published on 19/07/2015 by admin

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Last modified 22/04/2025

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

image 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

image Esophagogastric anastomosis is created high in thorax, above level of azygous arch
• Perioperative complications

image Hemorrhage
image Injury to recurrent laryngeal or vagus nerve (5-10%)
image Injury to tracheobronchial tree
image Chylothorax (2-4%)
• Postoperative complications

image Essentially all patients have some degree of dysphagia, early satiety, and reflux following esophagectomy
image Anastomotic leak (10-16%)
image Anastomotic stricture (15-25%)
image Diaphragmatic hernia (1-6%)
image Delayed emptying of conduit

– Causes: Redundant conduit (excess length of gastric tube), mechanical obstruction, twisted conduit, functional delay
image Recurrent carcinoma
• Complication rates vary substantially according to experience and skill of surgical team

image Open surgical procedures tend to result in higher perioperative morbidity and mortality
image High (cervical) anastomoses result in slightly higher incidence of injury to laryngeal nerve
image
(Left) 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 image is done to facilitate gastric emptying.

image
(Right) Graphic shows the gastric conduit anastomosed to the mid esophagus image and the pyloroplasty image.
image
(Left) Graphic shows the gastric conduit image anastomosed to the cervical esophagus. Note the position of the gastric staple line image along the right side of the conduit.

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

TERMINOLOGY

Definitions

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

IMAGING

Surgical Procedures

• Usual indication for surgery

image Curative or palliative resection of esophageal carcinoma
image Resection of Barrett esophagus with severe dysplasia
• Many surgical options for surgical excision of portion of esophagus
• Transthoracic esophagectomy

image Usually performed through right intercostal approach (Ivor Lewis procedure)

– Generally begins with laparotomy for mobilization of stomach, which is then used to create gastric tube/conduit that will replace resected esophagus

image Either entire stomach or tubularized portion (divided along long axis) is used
image Stomach is ideal conduit, as it has reliable blood supply and can reach high into thorax or neck for anastomosis
– As part of laparotomy, upper abdominal lymph nodes (celiac, gastrohepatic) are resected
– Pyloroplasty or pyloromyotomy is performed to facilitate gastric emptying and to minimize gastroesophageal reflux
– At thoracotomy, esophagus and thoracic duct are dissected from vertebral column
– Esophagus and regional lymph nodes (mediastinum and neck) are resected en bloc
– Esophagogastric anastomosis is created in thorax, above level of tracheal carina

image Some surgeons make anastomosis in lower neck
– Gastric conduit is usually placed in pre- or paravertebral space of posterior mediastinum

image Less commonly in retrosternal, intrapleural, or subcutaneous position
– Colon and jejunum are used much less commonly to bypass or replace resected (or obstructed) esophagus

image Usually after failed gastric interposition
image Many variations exist

– e.g., left thoracotomy approach, transhiatal open approach (without thoracotomy), minimally invasive procedures (performed through ports in thorax and abdomen without open incision into either)
– Surgical approach may be affected by patient condition (site and depth of tumor, mediastinal scarring from prior surgery, etc.)
– Experience and preference of surgeon play larger role in surgical approach
image Complication rates

– No proof of significantly different morbidity or mortality among various surgical approaches

image Complication rates vary substantially according to experience and skill of surgical team
– Open surgical procedures tend to result in slightly higher perioperative morbidity and mortality
– High (cervical) anastomoses result in slightly higher incidence of injury to laryngeal nerve
image Contraindications to esophagectomy (relative or absolute)

– Tumor invasion of trachea or aorta
– Extensive mediastinal scarring, e.g., from prior perforation, surgery, radiation therapy

Complications

• Perioperative complications

image Hemorrhage

– Can be substantial problem during dissection and removal of esophagus
image Injury to recurrent laryngeal or vagus nerve (5-10%)

– Mediastinal and lower cervical nodes lie close to vagus and recurrent laryngeal nerves

image Nerves may be damaged during lymph node resection
– Results in impaired cough and increased risk of aspiration pneumonia
image Injury to tracheobronchial tree

– Esophageal tumor may invade tracheobronchial tree; attempts to separate tumor may damage bronchus
– Can result in fistula, aspiration pneumonia
image Chylothorax (2-4%)

– Thoracic duct may be damaged or transected during surgery
– Can result in persistent chylothorax
• Postoperative complications

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

– Most patients learn to cope with these symptoms, which may decrease over time
– Many complications are treated medically, and some respond to minimally invasive interventions
– Mortality

image 30-day mortality (6-10%)
image 5-year mortality (70-80%)
image Nonspecific complications

– Respiratory complications (∼ 25%)
– Cardiovascular complications (10-15%)
– Wound infections (5-10%)
– Chylothorax (2-5%)
image Anastomotic leak (10-16%)

– Early complication, usually detected within days of surgery
– Occurs more commonly with neck anastomoses, but thoracic anastomotic leaks cause more serious complications
– Some may respond to conservative management (controlled by surgical drains left in place)
– Accessible, loculated leaks may be treated by placing percutaneous drainage catheter

image Larger, uncontained leaks usually require surgical revision of anastomosis
– Usually leads to abscess in mediastinum &/or pleural space
image Anastomotic stricture (15-25%)

– Early or late complication
– Most due to benign, probably ischemic, stricture

image Irregular, long stricture raises concern for recurrent malignancy in esophagus or mediastinum
– Diagnosed by barium esophagram with delayed passage, air-fluid level, dilation of esophagus
– Usually responds to balloon dilation (may require repeated treatments)
image Diaphragmatic hernia (1-6%)

– Omental fat &/or colon may herniate into chest behind gastric conduit
– Usually requires surgical revision but may recur
image Delayed e mptying of conduit

– Very substantial problem leading to significant symptoms in 25-30% of patients

image Places patient at increased risk of regurgitation and aspiration; impairs nutrition
image Severe enough to require surgical revision in 1-5% of cases; skill and experience of surgeon affects prevalence of this complication
– Redundant conduit (excess length of gastric tube)

image Results in horizontal portion of conduit above diaphragm that impairs emptying
image Looks and behaves like end-stage achalasia
image Treated by surgical revision (pulling excess conduit back into abdomen)
– Mechanical obstruction

image At hiatus (too small or tight for gastric conduit): Some degree of narrowing of gastric conduit through diaphragm is expected
image At pylorus: Should be obviated by pyloroplasty
– Twisted conduit

image Gastric suture line along resected lesser curve should appear at 9-o’clock position
image Rotation > 90° indicates twist or volvulus of conduit
image May require surgical revision
– Functional delay

image Conduit is not very dilated or mechanically obstructed but is slow to empty
image May be due to vagotomy or injury to vagus nerve
image Resection of lesser curve of stomach causes loss of gastric pacemaker neurons
image Recurrent c arcinoma

– Majority of patients treated for esophageal carcinoma with esophagectomy will die of recurrent or metastatic disease

image 5-year mortality exceeds 75% (varies according to aggressiveness of surgeon in operating on patients with early or advanced cancer)

Radiographic Findings

 

Imaging Recommendations

• Protocol advice

image Esophagram

– Often performed within 1st few days of surgery

image To assess for anastomotic leak or redundant conduit within chest
– 1st study is performed with water-soluble contrast medium, preferably nonionic, low osmolar

image Reduce danger of aspiration pneumonitis from hyperosmolar contrast medium
image Reduce danger of mediastinal or peritoneal inflammation from extravasated barium
– Subsequent exams are performed with ingestion of barium

image Evaluate anastomosis for stricture
image Evaluate degree of distention and rate of emptying of gastric conduit
image CECT

– Complementary role to esophagram
– Assessment of anastomotic leak, thoracic complications (mediastinitis, pleural effusion, etc.)
image PET/CT

– Best test for detection of recurrent carcinoma

image Usually apparent as FDG-avid sites
– Uncommonly occurs within esophagus or gastric conduit
– Pleural or peritoneal seeding are more common
– Hematogenous metastases to liver, lungs, bones, and other sites

CLINICAL ISSUES

Natural History & Prognosis

• Perioperative mortality of 5-10%

image > 75% of patients will die within 5 years
• Almost all patients have symptoms of reflux, early satiety, and dysphagia

image > 5% will have 1 or more complications that require surgery or intervention
• In spite of problems, modern surgical techniques for esophagectomy offer significant improvement in morbidity and mortality compared with earlier treatment options

image
(Left) Axial CECT in a 65-year-old man postesophagectomy shows the fluid-distended gastric conduit image and evidence of severe aspiration pneumonia and pleural effusion. The conduit is probably twisted, as evidenced by the position of the gastric staple line image.
image
(Right) Axial CECT in the same patient shows impaired emptying and fluid distention of the gastric conduit image, as well as severe lung disease and pleural effusions.
image
(Left) Esophagram film of a redundant conduit with delayed emptying shows marked distention of the gastric conduit with a horizontal component above the diaphragmatic hiatus. Note the similarity to end-stage achalasia.

image
(Right) Esophagram shows kinking of the redundant conduit image above the diaphragm image. The conduit is dilated with an air-fluid level, indicating partial obstruction. The conduit was pulled down into the abdomen at revision laparoscopy with resolution of symptoms.
image
(Left) Graphic shows a redundant conduit with distention and delayed emptying. The horizontal portion of the conduit contributes to the impaired gastric emptying. Note that the point of narrowing is at the diaphragm image, not the pylorus, which has been widened by pyloroplasty image.

image
(Right) Note the point of narrowing image, which is proximal to the collapsed gastric antrum image in this patient with mechanical obstruction of the conduit at the diaphragmatic hiatus (the most common site).

image
(Left) Film from an esophagram in a patient with obstruction shows a dilated conduit with air-fluid-barium levels image. The stomach is narrowed as it traverses the diaphragm image, but the pyloroplasty image is neither the site nor the cause of the delayed emptying.
image
(Right) Esophagram in a patient with functional delayed emptying shows only mild dilation of the gastric conduit and no mechanical deformity. Slow emptying is seen as air-fluid-barium levels image on upright film. Vagal nerve injury is the most common etiology.
image
(Left) Graphic shows herniation of transverse colon through the diaphragmatic hiatus between the conduit and the left crus, the most common location for a diaphragmatic hernia.

image
(Right) Axial CECT shows herniation of the transverse colon image and omental fat posterior to the gastric conduit image.
image
(Left) Graphic shows a twisted conduit. Note the position of the gastric staple line image, which has rotated to the left anterolateral position.

image
(Right) In the same patient, NECT shows a dilated gastric conduit image, suggesting impaired emptying. The position of the gastric staple line image indicates rotation or volvulus of the conduit, as it is expected to be at the 9-o’ clock position

image
(Left) Film from an esophagram shows a tight stricture image at the esophagogastric anastomosis with delayed emptying of the esophagus, evident as an air-fluid level. Note the smooth surface of the esophagus and the rugal fold pattern of the gastric conduit image.
image
(Right) Spot film from an esophagram in a 70-year-old man with fever and chest pain 3 days after partial esophagectomy shows the anastomosis image between the esophagus and the gastric conduit image. There is an anastomotic leak image into the mediastinum.
image
(Left) Coronal reformatted NECT in the same patient shows oral contrast medium within the gastric conduit image.

image
(Right) Another NECT section in the same patient shows contrast extravasation image from the esophagogastric anastomosis image into the mediastinum.
image
(Left) Axial CECT 18 months after esophagectomy shows the nondilated gastric conduit image. There is a large soft tissue mass image abutting the conduit and extending into the mediastinum in this patient with a recurrent tumor.

image
(Right) Coronal reformation of CECT in the same patient shows the gastric conduit image and extensive mediastinal mass effect image, representing recurrent esophageal tumor. A portion of the anastomotic staple line image is seen.

 

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