Transhiatal esophagectomy with cervical esophagogastrostomy is indicated for most conditions that require esophageal resection and reconstruction. Common indications include carcinoma of the esophagus or gastroesophageal junction, end-stage achalasia, and severe esophageal strictures refractory to endoscopic dilation. This approach may be utilized for primary resection of early stage cancers or Barrett’s esophagus with multifocal high-grade dysplasia as well as following neoadjuvant chemoradiation for locally advanced cancers.
Transhiatal esophagectomy is contraindicated in patients with upper or middle third esophageal cancers with concern for tracheobronchial invasion based on imaging studies or bronchoscopy. In patients with a history of previous esophageal surgery, including fundoplication, esophagomyotomy or repair of esophageal perforation, the surgeon must be prepared to convert to a transthoracic approach as transabdominal esophageal mobilization may prove difficult or impossible in these settings. Finally, in cases where carcinoma involves the gastric cardia and may require a significant gastric resection, the colon should be evaluated preoperatively and prepared for use in esophageal reconstruction.
The preoperative workup for patients with esophageal and GE junction cancers includes a thorough history and physical examination, esophagogastroduodenoscopy with biopsy for diagnosis. Esophageal nodules may be adequately staged by endoscopic mucosal resection, whereas larger tumors require endoscopic ultrasound and PET-CT imaging for complete clinical staging. Bronchoscopy should be considered for patients with squamous cell carcinomas, lesions involving the proximal third of the thoracic esophagus, and respiratory symptoms such as cough or hemoptysis.
Before proceeding with esophageal resection, the patient’s medical condition and nutritional status should be considered carefully as patients with poor nutritional status and multiple comorbid medical conditions are subject to increased perioperative complications. Thorough cardiovascular and respiratory evaluations are particularly important and objective testing such as cardiac stress tests, echocardiography, and pulmonary function tests should be obtained liberally if there are concerns. Smoking cessation and a daily walking program should be strongly encouraged as these lifestyle modifications significantly reduce pulmonary complications, and enteral tube feedings via nasogastric or jejunal feeding tubes should be considered in patients with significant weight loss or other signs of severe malnutrition.
Patients should be administered a mechanical bowel preparation on the evening prior to surgery in the rare event that esophageal reconstruction with a colon interposition is necessary. Appropriate prophylactic antibiotics are administered intravenously prior to incision. Sequential compression devices and subcutaneous heparin are used for deep vein thrombosis prophylaxis.
The patient is placed in the supine position with the arms tucked at the sides. A nasogastric tube is placed to decompress the stomach and aid in identification of the esophagus during mediastinal mobilization. A roll is placed behind the shoulders to facilitate neck extension, and the head is turned to the right and supported on a soft head ring. The neck, anterior chest, and abdomen are prepped and draped from the mandible to pubis.