TSRA Content:
Author: Sadhvika Ramji, MD
This is a revision and update from the previous edition of the TSRA Primer in Cardiothoracic Surgery written by Ryan Macke, MD
Introduction
Historically, there has been significant variability in the approaches used to accomplish surgical resection and reconstruction of the esophagus. Techniques include the transhiatal, Ivor-Lewis, McKeown (3-hole), and Sweet. To date, significant controversy remains as to which open approach is best. Esophagectomy is a technically difficult operation that often carries significant morbidity as incisions are need in the abdomen, chest and sometimes even the neck. Many different approaches to performing an esophagectomy are employed by thoracic surgeons globally. The choice of surgical approach depends upon many factors, including tumor location, length of the tumor, potential involvement of tumor invasion of surrounding structures, prior treatment with radiation, previous surgical history and lastly, surgeon or institutional preference. While open surgery has been the mainstay for esophagectomy, less invasive approaches have been developed to decrease postoperative morbidity, including totally minimally invasive esophagectomy (MIE) and hybrid esophagectomy in which access to one body cavity (abdomen vs. chest) is achieved by minimally invasive techniques (laparoscopy or thoracoscopy) and to the other step by an open approach (laparotomy or thoracotomy). As such, hybrid approaches can refer to either laparoscopy with thoracotomy or laparotomy with thoracoscopy.
The main purpose of minimally invasive surgery is to decrease the morbidity and surgical trauma often associated with open esophagectomy. While totally minimally invasive surgery was thought to maximally decrease this surgical trauma, its adoption has been hindered by markedly increased operative time compared to open surgery. As such, many surgeons use a hybrid approach.
The thoracic and cervical stages of the operation, as well as discussion of anastomotic techniques are described in more detail in the following chapter.
It is important to review the history, physical exam, and all available studies (prior EGD, barium swallow, EUS, CT scan, PET scan and previous biopsy reports) beforehand. The clinical stage and whether the patient received neoadjuvant therapy should be known for patients with malignant disease. Reviewing the details of previous operations for those being resected for end-stage benign disease can aid with identification of structures during dissection. Upper endoscopy should always be performed at the time of operation to note the exact location of pathology. The proximal and distal extent of the tumor, Barrett's esophagus, or other pathology should be noted. Bronchoscopy should also be performed for upper or mid-esophageal squamous cell cancers, which are notorious for invasion into the airway.
Adjunctive Procedures
In addition to the variability in technique for resection, there is also variation in the addition or exclusion of other procedures. Staging laparoscopy should be considered in all patients with malignant disease if there is a question of resectability. Many choose to do some form of a gastric emptying procedure, almost routinely divide the vagus nerves during resection. However, those opting to omit this step argue that pyloric dilation or endoscopy Botox injection can be performed postoperatively if there are problems with delayed emptying.
Preoperative nutritional assessment is important, as many patients undergoing resection will be malnourished. A feeding jejunostomy tube should be placed at the time of resection if not placed preoperatively to support patients receiving neoadjuvant therapy. Some may choose to omit this step in healthy, robust patients. However, distal enteral access allows feeding and administration of medications should any complications occur postoperatively that would prohibit or delay oral intake. Some routinely buttress the anastomosis, while other only do so in patients receiving neoadjuvant therapy, with intercostal muscle and omental flaps being most commonly used.
Operative Technique
Ivor Lewis Esophagectomy (ILE): This approach consists of an upper midline laparotomy followed by right thoracotomy and creation of an intrathoracic anastomosis. The abdominal stage is performed first with the patient in the supine position. A double lumen endotracheal tube is required for lung isolation. Mobilize the gastrocolic ligament to create a window into lesser sac This facilitates preserving gastroepiploic artery which is the main blood supply to gastric conduit. The tip of the flap only needs to reach the area of anastomosis and should not be too thick. Transferring too much omentum can cause atelectasis or pneumonia. Mobilize short gastrics and divide gastrosplenic and short gastric ligaments. Adjunctive procedures are performed (i.e. pyloroplasty or pyloromyotomy and J-tube depending on surgeon’s preference. At the completion of the abdominal stage, the tip of the conduit is secured to the specimen, which is then placed in the chest through the hiatus for later retrieval. Abdominal lymphadenectomy is obligatory for the purposes of adequate pathologic staging and regional disease control. After the abdomen has been closed, the patient is positioned in the left lateral decubitus position. The right lung is isolated during repositioning. A right thoracotomy is made in the 4th or 5th
intercostal space. Dissection begins at the level of inferior pulmonary ligament mobilization of the thoracic esophagus is then carried out. The conduit is then brought up into the chest, the esophagus is transected proximally (typically at the level of the azygous vein), and the specimen is removed. An intrathoracic anastomosis is then performed, followed by placement of drains and closure of the chest.
ILE is ideal for mid esophageal and lower esophageal tumors, as this approach allows for mobilization of the esophagus and lymphadenectomy under direct vision. More lymph nodes tend to be harvested with this technique and the risk of vocal cord paralysis lower by avoiding a cervical approach. Anastomotic leaks are also not as common due to less tension on the intrathoracic anastomosis compared to those placed in the neck.
Historically, intrathoracic anastomotic leaks resulted in significant morbidity. Pulmonary complications and more postoperative pain are the primary negatives of the ILE, mainly due to the thoracotomy.
Transhiatal Esophagectomy (THE):
This approach consists of an upper midline laparotomy and a cervical neck incision for creation of the anastomosis. The patient is placed in the supine position and both the neck and abdomen are prepped into the field. A single lumen endotracheal tube is used, as no lung isolation is needed. The abdominal stage is carried out similarly to the ILE, except the mediastinal mobilization is performed by blunt dissection. As much of the esophageal mobilization as possible is performed under direct vision from the abdomen and neck to divide aortoesophageal branches. Care must be taken to identify and preserve the recurrent laryngeal nerves and thoracic duct. The remaining mobilization is performed with the surgeon's left hand inserted through the neck incision and the right hand through the abdominal incision. Blunt dissection is carried out circumferentially until these dissection planes are met. Significant bleeding can be encountered during this step, as aortoesophageal branches are blindly avulsed.
Once the esophagus is fully mobilized, the specimen is then delivered through the abdominal incision. The mediastinum is then checked for hemostasis, with most bleeding controlled using simple packing. Next, the conduit is brought up into the neck, which can be done in a number of ways. Perhaps one of the simplest ways is to pass a Penrose drain or chest tube from the neck to the abdomen, secure the tip of the conduit to it, and then gently push/pull the conduit up through the mediastinum and deliver it into the neck. Care should be taken here not to rotate the axis of the stomach. The neck anastomosis can then be performed which can be either hand-sewn or stapled. The hiatus is then reapproximated and adjunctive procedures are performed before closing.
THE can be considered for pathology located in the upper, middle, and lower esophagus. However, THE should not be employed for bulky tumors in the upper and middle esophagus that may be adherent to mediastinal structures. By avoiding a thoracotomy, pulmonary complications are less common, and patients typically complain of less pain, making it an ideal approach for those with significant pulmonary disease. The patient also does not need to be repositioned, saving time. Cervical anastomotic leaks are easier to manage, as simple opening of the wound is all that is needed in most cases. Negatives of this approach include a less complete lymphadenectomy, greater blood loss usually from azygos vein, and higher incidence of injury to intrathoracic structures due to the blunt mediastinal dissection, air leak from a hole in posterior trachea. Although easier to manage, leaks in the neck tend to occur more frequently, presumably from greater tension placed on the anastomosis. The neck dissection also increases risk of RLN injury and resulting risk of aspiration. Because a lymphadenectomy does not need to be performed, many prefer the THE for management of end-stage benign disease.
McKeown (Three-Hole) Esophagectomy:
This approach uses three incisions: a right thoracotomy, an upper midline laparotomy, and a left cervical incision. Because the chest is entered, lung isolation is required. The procedure typically starts in the right chest for mobilization of the thoracic esophagus and lymphadenectomy. Consideration should be given to performing a staging laparoscopy before entering the chest if there is any question of resectability to avoid an unnecessary thoracotomy. The chest is closed without dividing the esophagus and the patient is then placed in the supine position. From this point, the procedure is carried out in similar fashion to the THE. However, blunt mediastinal dissection is not required because the thoracic esophagus has already been mobilized.
The McKeown approach takes the good and the bad from both the ILE and THE. An additional incision increases the chance of wound complications and pain. If the abdomen must be entered first, the time-consuming process of repositioning the patient multiple times can also be considered a negative to this approach. However, pathology at any level can be addressed and dissection performed under direct vision. Anastomotic complications include short term complications such as leak/ bleeding and long-term complications such as stricture -Ensure that the anastomosis is not under any undue tension and has adequate blood supply. Minimize handling of conduit and hematoma formation.
Sweet or Left Thoracoabdominal Esophagectomy:
In the Sweet approach, a left posterolateral thoracotomy is performed below the scapular tip through the 5th or 6th intercostal space and obliquely into upper abdomen and a left neck incision anterior to sternocleidomastoid. The left lung is isolated. Sharp and blunt dissection of the esophagus was performed at least 5cm above lesions. Care is taken to avoid injury to thoracic duct, left vagus nerve and recurrent laryngeal nerve.
Once the esophagus was completely freed, the diaphragm was entered through a 5cm to 6cm radial incision. The stomach was mobilized through the left thoracic cavity, preserving the right gastroepiploic artery and arcades. The left gastric artery and vein were ligated at their origins.
An upper abdominal and distal mediastinal nodal dissection with complete resection of distal esophagus and proximal stomach can be performed if possible. The conduit is passed through the diaphragmatic incision into the left chest with a mechanical esophagogastric anastomosis above or below the aortic arch. The diaphragm is closed with interrupted or figure-of-eight heavy, nonabsorbable suture. The costal margin is reapproximated with a figure-of-eight heavy non-absorbable suture. The thoracoabdominal incision is then closed in layers after drains are placed.
The Sweet esophagectomy is ideal for locally advanced distal esophageal tumors. No approach is better for exposure of the hiatus and gastroesophageal junction.. The patient does not need to be repositioned, again saving time. Disadvantages include increased postoperative pain owing to the large incision, as well as risk of costal arch dehiscence and diaphragm dysfunction.
Minimally Invasive Esophagectomy (MIE):
The truest form of MIE is carried out with only laparoscopy and thoracoscopy, avoiding rib spreading, rib resection, or hand-assistance. The steps are identical to that of the ILE if the anastomosis is to be placed in the chest. If a neck anastomosis is preferred, a neck incision is added, and the steps are carried out like the McKeown approach. The size and location of the ports is variable.
For the abdominal phase, 5 ports are typically used. A common arrangement includes ports at the right and left costal margin in the mid-clavicular line for the surgeon's and assistant’s retracting instruments, ports in the right and left upper epigastrium for the surgeon's working instrument on the right and the assistant's camera on the left, and a port in the right flank or epigastrium for placement of a liver retractor. A right lower quadrant port may be helpful to provide additional retraction and is necessary if a laparoscopic jejunostomy is to be placed.
For the thoracic phase, 4 ports are typically placed as follows:10 mm camera port just above the diaphragm in the posterior axillary line (usually the 8th or 9th intercostal space (ICS)); A 10mm port one ICS above and one hands-breadth posterior to the camera port for the surgeon's working instruments; 5mm port just below and posterior to the scapular tip for the surgeon's retracting instruments; and a 10 mm port in the posterior or mid-axillary line in the 4th ICS for the assistant's retracting instrument. An additional port may be placed in the anterior axillary line in the 6th ICS for a suction irrigator to maintain a bloodless field. A stitch placed in the tendinous portion of the diaphragm and brought out through the skin at the costophrenic angle significantly aids in visualization during the thoracoscopic approach. After the thoracic stage is completed, the inferior, posterior port is enlarged slightly to allow removal of the specimen and creation of the anastomosis if a neck incision is not used. Proper port placement is key and an effort should be made to keep ports at least one hands breadth away from each other to avoid crossing of instruments and poor angles.
Advantages and disadvantages are similar to the ILE and McKeown approaches, depending on the location of the anastomosis. However, both the thoracoscopic and laparoscopic phases require considerable expertise, and the learning curve is steep.
Abdominal Phase:
The abdominal phase of an esophagectomy is similar in all approaches. An upper midline laparotomy is performed for the ILE and THE, while the thoracotomy incision is extended to the upper abdomen for the Sweet approach. The general conduct of the abdominal stage is also the same for the MIE, except all steps are performed laparoscopically.
Examine and palpate abdominal cavity and liver for metastases for staging purposes. However, at this point, the operation is beyond the point of being able to abort.
Mobilize the triangular ligament of liver to expose the hiatus. The gastrohepatic ligament is opened to expose the right crus, taking care to preserve a replaced left hepatic artery if present; an accessory left hepatic artery should be divided. The phrenoesophageal ligament is taken down with blunt or sharp dissection and the esophagus is mobilized. Divide the short gastric vessels and lesser omentum in avascular plane. Dissect GEJ and place Penrose around to help with mobilization/retraction.
Greater curvature of stomach is grasped. Right gastroepiploic artery and right gastric artery are protected, and lesser sac is entered. Perform lymphadenectomy around left gastric vessels and divide the vessels. Send nodal packet for pathological evaluation. Take down retrogastric attachments avoiding injury to the pancreas and splenic artery. Additional mobilization of the esophagus as high up into the mediastinum as possible will help with later mobilization in the chest. If not already done, the vagus nerves are divided. The pylorus should easily reach the base of the right crus or caudate lobe after con1plete gastric mobilization. If not, a Kocher maneuver is performed to gain additional length. If desired, a gastric-emptying procedure is then performed.
Next the conduit is fashioned. The starting point is typically at the level of the third branch of the right gastric artery. Using a vascular load, the linear stapler is directed from the lesser curve toward the stomach and fired. Depending on the thickness of the stomach, green or blue loads are then used to tubularize the stomach by orienting the stapler parallel to the greater curve. Most choose to make the conduit 4-5 centimeters in width. Care should be taken to avoid twisting of the stomach as the conduit is constructed, keeping the staple line oriented to the patient's right. A feeding jejunostomy tube can be inserted 30 cm distal to ligament of Treitz, secured to abdominal fascia, and brought out to the left lateral abdominal wall. The remaining steps are specific to each approach.