Esophagectomy

Esophagectomy is peformed typically for esophageal cancer and rarely for end-stage achalasia or
perforation. The 3-Hole is the preferred approach with incisions in the right chest, left neck, and abdomen.
However, other approaches are occasionally used (transhiatal, left thoracoabdominal, Ivor-Lewis, etc)


Transhiatal Esophagectomy
Part1
An upper midline incision is made from the xiphoid process to the umbilicus and wide exposure is
provided .

The abdomen is thoroughly explored, and biopsies are performed on all suspicious nodules; the
specimens are sent for frozen-section analysis as any evidence of metastatic disease will abort the
intended proce- dure.

The ligamentum teres is ligated and divided, both the falciform and left triangular ligaments are divided,
and the left lateral segment of the liver is retracted upward and to the right.

Attention is then directed to the greater curvature of the stomach, where division of the greater
omentum outside the right gastroepiploic artery (which must be identified and protected throughout the
procedure) is commenced.

Injury to the right gastroepiploic vessels is avoided by maintaining a safe distance of at least 2 cm inferior
to the vessels until the termination of the right gastroepiploic artery.

The left gastroepiploic vessels and short gastric vessels are then encountered and may be ligated just
outside the border ofthe greater curvature.

The dissection is continued until all anteriorly based short gastric vessels are ligated and divided.

In the avascular plane overlying the caudate lobe of the liver, the gastrohepatic omentum is divided along
the liver edge, cephalad to the crus of the diaphragm.

If a replaced left hepatic artery is identi- fied, this should be preserved.

Dissection is then car- ried along the lesser curvature inferiorly until the right gastric vessels (which should
be safeguarded) are encountered.

The surgeon then dissects the remainder of the gastrocolic omentum from the greater curvature of the
stomach, identifying and palpating the right gastroepiploic vessels and ensuring their preservation as
dissection proceeds to the taking off of the right gastroepiploic vessels from the gastroduodenal artery.

A generous Kocher maneuver is then performed to the border of the superior mesenteric vessels, and the
hepatic flexure is taken down, thereby allowing full mobilization of the pylorus so that it may reach to the
esophageal hiatus.

At this time, either a pyloroplasty or pyloromyotomy is performed to limit gastric stasis secondary to
vagal interruption.

A common hepatic, celiac-axis, proximal splenic, and left gastric lymphadenectomy is then performed,
whereby all lymphatic and nodal tissue is swept up with the specimen prior to the division of the left gas-
tric vessels.

The stomach is then retracted anteriorly and superiorly, allowing both the coronary vein and left gastric
artery to be ligated and divided at their origins.

The remaining posterior gastric vessels are divided, and all lymphatic and nodal tissue is swept off of the
crus of the diaphragm and abdominal aorta.

At this point in time, the peritoneum overlying the esophagus and esophageal hiatus is incised, the gas-
troesophageal junction is encircled with finger dissection, and then an umbilical tape or Penrose drain
(which will be used for traction as the esophagus is mobilized from the mediastinum) is secured around
the distal esophagus.

The esophageal hiatus is widened by dividing the crus of the diaphragm, with the cautery following the
ligation of the inferior phrenic vein. This allows excellent exposure to the lower mediastinum up to the
level of the carina.


Part 2

The cervical component of the procedure is begun by making an incision approximately 6 to 7 cm long at
the anterior border of the sternocleido- mastoid muscle from just above the suprasternal notch .

Following the division of the platysma muscle with the cautery, the dissection is carried down along the
medial border of the stern- ocleidomastoid muscle, and the omohyoid muscle is incised.

The dissection is continued medial to the left carotid artery and left internal jugular vein, dividing the
middle thyroid vein to gain entrance to the prevertebral space.

Blunt self-retaining Wheit- lander retractors are then used to retract the stern- ocleidomastoid muscle,
carotid artery, and internal jugular vein laterally and the thyroid and trachea medially.

The cervical esophagus is then encircled with careful blunt and sharp dissection, maintaining the
dissection on the adventitia of the esophagus to avoid injury to the recurrent laryngeal nerve in the
tracheoesophageal grove.

With upward and superior traction on the Penrose drain, blunt dis- section is continued circumferentially
almost to the level of the carina.



Part3

The mediastinal component of the procedure is now addressed.

With caudal traction on umbilical tape that has been secured to the gastroesophageal junction, a hand is
placed through the open hiatus, posteriorly between the esophagus and the aorta, and the esophagus is
bluntly freed from its posterior attachments.

This maneuver is continued until the cervical portion of the dissection is reached by confirming that a
finger placed through the cervical wound into the posterior mediastinum is able to be palpated by the
other hand placed through the diaphragmatic hiatus and into the posterior mediastinum.

Anteriorly, the hand placed through the transabdominal incision must hug the anterior wall of the
esophagus, slip under the carina, and carefully free the esophagus from the membranous trachea until
the cervical dis- section is encountered.

During this maneuver, periods of extreme hypotension can occur that respond well to volume
resuscitation and limiting compression of the heart that may require the dissection to be stopped for
short periods of time.

The lateral attachments to the esophagus are then usually hooked with the index finger and, with the use
of a long sweetheart retractor placed into the mediastinum, divided between large hemoclips with the
cautery.

The most superior of these attachments are often divided blindly by finger dissection circumferentially
and by a combination of a pushing and pulling of the final periesophageal attachments.

Now that the entire esophagus is free from its attachments, the cervical and upper mediastinal
esophagus is mobilized into the cervical wound.

A long 1-inch Penrose drain is placed on the esophagus, and both are divided, with the GIA stapler
effectively securing the Penrose drain to the distal divided esoph- agus.

The stomach, with the attached esophagus, is now brought through the abdominal wound, to lie on a
moist lap pad.

The attached Penrose drain has been drawn through the posterior medi- astinum and will be used to
help transpose the gastric tube through the mediastinum to the cervical incision.

Selecting the highest point of the stomach , a gastric tube is formed by multiple firing of the GIA stapler
(Figure 711), preserving the greater curvature and its blood supply and opening the lesser curvature
angle to provide the greatest length possible (Figure 712).

In so doing, the specimen will consist of the esophagus and its contained tumor and a considerable
portion of the fundus cardia and lesser curvature (with the appropriate lymphadenectomy speci- men),
securing an adequate margin beyond the tumor edge.

The right gastric vessels are preserved, and care is taken not to oversew the staple line.

The abdominal end of the Penrose drain is now secured to the posterior wall of the stomach with 3-0 silk
sutures.

The lesser-curvature suture is left long, and the suture along the greater curvature (the short gastric
vessel side) is cut short so that the orientation of the transposed gastric tube can be easily identified and
maintained.

With very gentle traction on the cervical end of the Penrose drain, the gastric tube is placed through the
esophageal hiatus by hand and gingerly pushed upward through the posterior mediastinum to the
cervical incision.

In doing so, a good 6 to 8 cm of stomach wall will be easily mobilized into the cervical field.

The Penrose-drain sutures to the posterior wall of the stomach are now inspected to ensure proper
orientation and to confirm that there is no twisting of the gastric conduit.
The sutures are then cut, and the Penrose drain is removed.

An automatic purse-string suture applier is then placed on the cervical esophagus, and the excess cer-
vical esophagus is excised.

Either a 28- or 25-mm EEA circular stapling device anvil is placed in the cervical esophagus, and the purse-
string suture is tied.

Through an anterior gastrotomy, the shaft of the EEA circular stapling device is inserted into the gastric
tube, and the trocar is brought through the posterior gastric wall.

The circular stapling device is then attached to the anvil, and the device is closed and fired, forming an
esophagogastrostomy.

The stapling device is removed, and the anvil is checked for two complete donuts of tissue; the proximal
esophageal donut is sent to pathology as the final proximal margin.

Through the anterior gastrotomy, the anastomosis can be inspected for bleeding and completeness.

The excess gastric tube proximal to the anastomosis including the anterior gastrotomy is then excised
with a linear stapling device (TA-60 with 4.8-mm staples).

An endoscope is then passed transorally through the cricopharygeus to the anastomosis, and air is
insufflated, with the anastomosis submerged under saline to detect any air leaks that need to be secured
with 3-0 silk sutures.

The gastric tube is also inspected for viability and to ensure that there has been no unrecognized
twisting of the transposed stomach. Two 3-0 silk sutures are used to secure the gastric tube to the
surrounding available tissue (but not to the pre-vertebral fascia).

A nasogastric (NG) tube is passed through the anastomosis, to lie just above the esophageal hiatus.

The platysma is closed with a series of interrupted 3-0 absorbable sutures, and the skin is closed with skin
staples.

No drain is placed in the cervical field.

Shifting attention to the abdominal compartment, the surgeon secures the stomach to the diaphragmatic
hiatus with two 3-0 silk sutures.

A needle catheter feeding jejunostomy is placed, and the abdominal wound is closed.



Transthoracic Esophagectomy

The standard transthoracic approacha combined midline laparotomy and right thoracotomy (Ivor Lewis
esophagectomy)
The abdominal component of the transthoracic esophagectomy is identical to the abdominal phase of
the transhiatal esophagectomy described above.
Mobilization of the distal esophagus and stomach, lymphadenectomy, pyloromyotomy, and needle
catheter feeding jejunostomy are performed, and the abdominal wound is closed prior to repositioning
the patient for the mediastinal dissection.

The patient is placed in a left lateral decubitus position, and a right lateral thoracotomy is performed, the
thoracic cavity being entered through the fifth or sixth intercostal space.

As opposed to the transhiatal approach, a double-lumen endotracheal tube allows single-lung ventilation
and provides ideal exposure to the esophagus and surrounding mediastinal structures.

The azygos vein is divided with the endo-GIA vascular stapler (2 mm).

The mediastinal pleura is incised along the entire length of the esophagus; the esophagus is encircled,
and traction is applied as the dissection proceeds.

The lymphadenectomy should include mediastinal lymph nodes from stations 2 and 4 (upper and lower
paratracheal nodes from the intersection of the caudal margin of the innominate artery to the azygos
vein), 3 (posterior mediastinal nodes above the tracheal bifurcation), 7 (subcarinal lymph nodes), and 8
(middle and lower periesophageal nodes from the tracheal bifurcation to the inferior pulmonary vein and
extending inferiorly to the gastroesophageal junction to meet the abdominal dissection).

The proximal esophagus is divided as far superior to the tumor edge as is possible (preferably with a 5-cm
margin) with the GIA stapler.

The gastroesophageal junction and stomach are then pulled through the esophageal hiatus and into the
chest, ensuring that there is no twisting of the stomach that is to serve as the reconstructive conduit. The
stomach is then divided with the GIA stapler, incorporating the lesser-curvature lymph nodes. The
specimen is sent to pathology to confirm negative proximal and distal margins. If a stapled anastomosis is
preferred, the technique described in the previous section on the transhiatal technique is applicable as
outlined. Alternatively, a hand-sewn anastomosis can be performed in an end-to-side fashion in two
layers or (as this author prefers) with a single layer of inter- rupted 3-0 silk sutures. A nasogastric tube is
then passed beyond the anastomosis, to lie in the distal
stomach. An angled and straight 28F chest tube is placed, and the thoracotomy is closed. If there is
concern regarding an adequate proxi- mal margin or if there is aversion to an intrathoracic anastomosis,
the anastomosis can be performed in the cervical region, as previously described. If this decision is made
prior to operation, one would start with a thoracotomy first and then reposition the patient for the
abdominal and cervical portion of the procedure. If this decision is made intraoperatively following
closure of the thoracotomy, the patient is repositioned for the cervical dissection.



Other Techniques
Siewert and colleagues described the technique of radical transhiatal esophagectomy with two-field lym-
phadenectomy.5 This approach essentially combines the technique of transhiatal esophagectomy with
that of radical en bloc esophagectomy, accepting the con- cept that most patients with distal esophageal
tumors have regional lymph node spread to the abdominal and lower periesophageal lymph node basins,
which are accessible through an abdominal and transhiatal approach. The diaphragm is opened widely,
and the distal third of the esophagus is dissected and resected with the crus of the diaphragm and the
pariental pleura bilaterally to achieve a normal tissue envelope around the tumor mass (Figure 729).

The upper mediastinal dissection is facilitated by a special mediastinoscope and by microinstruments.

Alternatively for tumors of the gastroesophageal junction, a totalgastrectomy or esophagogastrectomy via
a transabdominal approach has also been described.

Reconstructive Techniques
The stomach is the preferred esophageal substitute, and the reconstructive technique has been outlined
in detail in this chapter. Although it is most unusual that the stomach is deemed not to be a suitable
conduit for the reconstruction, the surgeon must be prepared to use an alternative segment of intestine
when it is required. The use of the colon as an esophageal substitute has been well described. The
decision as to the preferred segment of colon (ie, right, transverse, or left) should be based on which
vascular pedicle would provide the longest viable segment of colon. Therefore, test occlusion is used to
confirm the viability of the segment to be transposed prior to division of the vascular pedicles (Figure 7
30). This author prefers the transverse colon and the technique described by Akiyama.6


Minimally Invasive Esophagectomy

A number of approaches to achieving a minimally invasive esophagectomy have been described, including
combined thoracoscopic and laparoscopic esophagectomy, thoracoscopic esophagectomy with open
gastric mobilization, laparoscopic gastric mobilization with minithoracotomy, laparoscopic transhiatal
esophagectomy, and hand-assisted laparoscopic transhiatal esophagectomy.

The largest experience to date has been reported for the com- bined thoracoscopic and laparoscopic
approach, which are described in detail elsewhere.4 This authors center has adopted the hand-assisted
laparoscopic transhiatal esophagectomy, which is described below.
The actual and theoretic advantages of this approach are that (1) there is no need for repositioning, (2)
there is no need for single-lung ventilation, (3) tumor palpation achieves adequate distal mar- gins, and (4)
there is a shallow learning curve, and the procedure therefore has wide applicability to the surgical
community. The patient is placed in the supine position, with the left arm at the patients side and the
right arm at 90 as described for the open transhiatal approach. Although lithotomy is often used in
laparoscopic approaches to foregut surgery, this author does not feel it is necessary in this situation. The
patient is prepped and draped in a routine fashion (Figure 721). A periumbilical trocar is placed to the
left of the linea alba, through the rectus muscle just cephalad (approximately 2 cm) to the umbilicus
(Figure 722). A 30 laparoscope is passed through the periumbili- cal port. Next, three additional trocars
are placed in the right hemiabdomen. The liver retractor port is placed as close to and as lateral to the
costal margin as possible. This position allows the fulcrum of the retractor to elevate the left lobe of the
liver while remaining outside the operative field. The next two trocars are placed in position to facilitate
dissection along the greater curvature of the stomach. These are the working hands of the surgeon; they
should be placed low enough to facilitate access to the duodenal sweep, to accomplish a wide Kocher
maneuver. The trocar closest to the midline should not obscure the camera view into the mediastinum.
The site of the incision through which the hand will be introduced into the peritoneal cavity is then
selected in the left hemiabdomen, with the abdomen insufflated (Figure 723). The incision should be
placed 2 to 3 cm below the costal margin, with its center in the projection of the lateral border of the
rectus abdominus muscle. A peritoneal cavity while allowing for retraction of the abdominal wound and
maintenance of the pneu- moperitoneum. These devices include the Pneumo- sleeve, which requires a
sterile sleeve apparatus over the routine gown and gloving, and the Gelport, which requires no
additional sleeve apparatus (Figure 724). The beauty of the hand-assisted laparoscopic transhi- atal
esophagectomy is that it exactly mimics the open technique and thus almost completely eliminates the
learning curve and requires no extraordinary laparo- scopic expertise (but it does require the prerequisite
expertise in esophageal resection). Following visual identification and palpation of the right gastroepiploic
artery, the gastrocolic omentum is divided with a harmonic scalpel. The gastrohepatic ligament is likewise
divided (with the harmonic scalpel) up to the crus of the diaphragm and inferiorly to the right gastric
artery, which is preserved. A wide Kocher maneuver is then performed, and the hepatic flexure is taken
down, ensuring easy identification and preservation of the takeoff of the right gastroepiploic artery from
the gastroduodenal artery. The stomach is then retracted cephalad and anteriorly, to divide any posterior
attachments between the pancreas and the stomach, and the left gastric vessels are isolated (Figure 7
25). These vessels are then divided with the endo-GIA vascular stapler. All lymphatic and nodal tissue is
swept up with the specimen. The peri- toneum overlying the gastroesophageal junction is then divided,
and the esophageal hiatus is opened
with the harmonic scalpel. A Penrose drain is then doubly looped around the gastroesophageal junction
and is secured tightly with a 2-0 endostitch. This is then brought through the abdominal wall inferiorly to
provide caudal traction for the mediastinal dissection (Figure 726). The hand-facilitated mediastinal dis-
section is undertaken (with the harmonic scalpel) up to the level of the carina (Figure 727). An attempt is
made to perform a pyloromyotomy, which is facili- tated with the placement of a lighted bougie intro-
duced transorally through the esophagus and the stomach and into the duodenum through the pylorus.
This author and colleagues have found this to be a technically difficult exercise and frequently have
converted to a pyloroplasty, performed in the usual manner by making a longitudinal incision from the
duodenum and through the pyloric muscle to the stomach and then closing the incision transversely with
interrupted 3-0 endostitches. The cervical com- ponent of the dissection is an exact duplicate of that
described for the open technique. The remainder of the mediastinal attachments are then bluntly divided
by finger dissection, with a hand introduced through the abdominal port. The cervical esophagus is
divided as described previously, and the specimen is brought through the left upper abdominal incision.
The gastric tube is formed exactly as described for the open technique, allowing palpation of the tumor
for an adequate margin. The Penrose drain from the cervical incision to the abdominal incision is then
5- to 6-cm transverse incision is made and then extended into the anterior rectus sheath, and the rec- tus
abdominus muscle is retracted medially. Next, a vertical incision is made in the posterior rectus sheath
underneath the rectus muscle, and the peritoneum is entered. A number of devices have been designed
to allow the introduction of the surgeons hand into the secured to the stomach. Once the
pneumoperitoneum is again created, the gastric conduit is transferred from the abdomen through the
mediastinum to the cervical incision under direct laparoscopic vision, thus ensuring proper orientation.
The anastomosis is completed as described earlier. The fascia is closed, and the skin is approximated with
a subcuticular clo- sure (Figure 728).




Three-Field Lymphadenectomy for esophagectom
For those who adhere to the advantages of the radical esophagectomy, three-field lymph node dissec-
tion has been described and advocated by some authors because 30 percent of patients with mides-
ophageal and lower esophageal cancers may have cervical lymph node involvement.3 Whether this
represents systemic disease or locoregional spread that can be addressed by a more radical procedure is
not discussed here. Instead, the technique of the cer- vical component of lymph node dissection is briefly
described. (The abdominal and mediastinal compo- nents have already been described.) A U-shaped
incision just above the suprasternal notch provides exposure to the bilateral lymph node stations to be
dissected (Figure 720). The plane just deep to the platysma muscle is entered, and a flap is raised
superiorly (as is done in a thyroid or parathy- roid procedure). The boundaries of the dissection are
superior to the middle thyroid vein, inferior to the pleura, and lateral to the spinal accessory nerve. The
sternocleidomastoid muscle will be retracted either medially or laterally, depending on the point of dis-
section, and the division of the clavicular head usu- ally facilitates this maneuver. The strap muscles are
divided inferiorly as necessary to improve access to the lymph node basins to be dissected. The omohy-
oid muscle is divided with a cautery, and the deep external and lateral cervical lymph node basins are
dissected from the pleura, from the posterior scalene muscles, and along the lateral border of the internal
jugular vein. The thyrocervical trunk and its branches (as well as the phrenic, vagus, and spinal accessory
nerves) are all preserved. The thoracic duct is divided at its proximal point of drainage into the venous
system. Attention is then directed to the deep internal cervical lymph nodes around the internal jugular
vein and medial to the common carotid artery. The recurrent laryngeal nerve must be identi- fied and
preserved. The dissection of the deep inter- nal cervical nodes that run along the course of the recurrent
laryngeal nerve is an extension of the level-two lymph nodes previously dissected during the thoracic
component of the radical lymphadenec- tomy procedure.









Typical Postoperative Course
DOS:
Epidural for pain control
minimize sedation (epidural rate should be turned down if patient hypotensive and in mimimal or no pain)
Lopressor (Hold if HR<55, SBP<110 mm Hg),
Please keep conduit perfused with SBP>110 mm Hg
Usually keep intubated overnight,
Nebulizers if extubated
NPO,
NGT (DO NOT MANIPULATE OR REPLACE )
Pepcid
IVF: D5LR or D51/2NS at 150 cc/hr
SQ Heparin TID or Lovenox daily( HOLD 24 hrs prior to epidural removal )
Ancef/Levofloxacin/Flagyl x 5 days
Central Line
Insulin Protocol
CXR
Watch out for dilated conduit


Post- Operative Day 1:
Extubate if not extubated
Continue NGT
Heplock later in day (may need additional fluids if SBP < 110 mm Hg to maintain conduit perfusion and
avoid ischemia)
Ambulate with assistance

Post- Operative Day 2:
Continue NGT
Diuresis if tolerated
Ambulate with assistance
Start tube feeds FAA at 10cc/hr if flatus otherwise wait

Post- Operative Day 3- Post- Operative Day 6:
Ambulate with assistance
Diuresis as needed
Increase tube feeds to goal or start tube feeds if bowel activity.
Start medications through J-tube if bowel activity and tube feeds tolerated
Reconcile medications with preoperative medications

Post- Operative Day 7:
Swallow study to rule out leak
Chest Tube DCd if Swallowing Study negative
Remove drains as listed below

Post- Operative Day 8-10:
Cap epidural
D/c Foley if chest tube is out and J-tube medications tolerated
Discharge




Esophagectomy Patient Drain Management
CHEST TUBE
In general, chest tubes for esophagectomy are kept in and removed after swallow study and eating.
General criteria for chest tube removal:
No leak
Output less than 200 cc/24 days
Ancef for 24 hours.

NASTROGASTRIC TUBE
NGT tubes are pulled after the swallow if it is negative for a leak with good motility of the conduit and
gastric emptying. (The tube is placed in the anastomosis in the neck for pulmonary toilet.)

NECK DRAINS
Neck drains are kept in until patient has had colored drink day after swallow test and drain quality shows
no evidence of leak.





Laparascopic Nissen/Paraesophageal Hernia Reduction
Nissen fundoplications are performed for those patients who have medically intractable reflux. The
procedure involves wrapping the stomach around the lower esophageal sphincter.
The procedure can now be done laparascopically.
Paraesophageal hernia involves the herniation of the stomach into the chest in various manners. They are
treated when strangulated or cause symptomatic pain or reflux. The reduction procedure can be done
laparascopically often with an esophageal lengthening procedure where the stomach is divided to
lengthen the esophagus (Collis gastroplasty) and a Nissen is also often included for the reflux.
An esophageal myotomy is typically performed for achalsia. It involves breaking the muscular esophageal
fibers near the GE junction.It too can be performed laparascopically and often a Nissen or Dor wrap is also
included for reflux or to protect the myotomy.
These procedures are grouped together as their postoperative management can be loosely grouped
together with the more complex procedures often needed additional tests.


Typical Postoperative Course

DOS:
Neurological Minimize sedation Cardiovascular Lopressor (Hold if HR<60, SBP<110 mm Hg)
Respiratory Nebulizers Gastrointestinal NPO, NGT DO NOT MANIPULATE OR REPLACE Pepcid
Genitourinary IVF: D5LR or D51/2NS at 125 cc/hr Hematology SQ Heparin TID or Lovenox daily
Infectious Disease Ancef x 24 hours


Post- Operative Day 1:
Nissen without Collis
no intraoperative problems: D/C NGT, start sips

Nissen with Collis
no intraoperative problems: Swallow study prior to d/c NGT

Paraesophageal hernia repair without Collis,
no intraoperative problems: D/C NGT, start sips

Paraesophageal hernia repair with Collis,
no intraoperative problems: Swallow study prior to d/c NGT

Myotomy
no intraoperative problems: Swallow study prior to d/c NGT
Heplock later in day
Ambulate with assistance


Post- Operative Day 2:
Clears if tolerated Ambulate with assistance
POD3-5:
Full Liquids
Reconcile preoperative medications and give crushed or only if fairly small pill (0.5 cm length or smaller)
Discharge on Full Liquids or Clear Liquids Only