For surgeons familiar with the unique and extraordinary challenges presented by surgery of esophageal malignancy, the words of Ivor Lewis appear as valid today as they were when first written over 50 years ago: “There is little doubt that the successful outcome of radical curative surgery for esophageal carcinoma remains one of the great challenges of surgical practice.”¹ A satisfactory result necessitates optimization of the patient’s physical state and tumor staging, a high degree of surgical skill and experience, and teamwork involving close coordination of the surgical, anesthetic, physiotherapeutic, and nursing modalities of treatment.

The procedure first described in 1946 by Ivor Lewis now represents the middle road between “minimal” transhiatal esophagectomy without radical lymph node dissection, as described by Orringer et al.,² and extensive radical resection combined with three-field lymphadenectomy, as described by Akiyama et al.³ The operation combines an extended resection of the esophagus with either standard or extensive thoracic and abdominal lymph node dissection under direct vision through a combined abdominal and thoracic approach. For this reason, the Ivor Lewis esophagectomy is a preferred approach in many centers for patients with resectable tumor of the middle to lower third of the esophagus and gastroesophageal junction.

The procedure has several drawbacks that, in our view, confine its use to a select group of patients. The operation may limit the proximal extent of the esophageal resection, which can be a major concern in the case of skip lesions or tumors that spread through the submucosa. By terminating the dissection at the apex of the chest, one may not appreciate the presence of positive lymph nodes in the neck or reap the potential benefits of a third-field lymphadenectomy. Indeed from our own experience in a series of 174 patients with three-field lymphadenectomy,⁴ we observed that 23% of patients with adenocarcinoma (distal third or gastroesophageal junction) and 25% with squamous cell carcinoma presented with positive cervical lymph nodes. Unforeseen changes in the TNM classification because of such lymph node involvement were observed in 12% of patients. Five-year survival in patients with middle-third esophageal squamous cell carcinoma was 27.7%, and 4- and 5-year survival in patients with distal-third adenocarcinoma was 35.7% and 11.9%, respectively. Finally, the intrathoracic anastomosis, as compared with the cervical anastomosis, is thought to be associated with a higher risk of life-threatening sepsis in the event of leak. For these reasons, we reserve the Ivor Lewis technique for patients with resectable tumors in whom a neck anastomosis is contraindicated. This category includes patients with a past history of cervical malignancy that has been treated by either radical radiotherapy or major surgery and patients with other contraindications to surgery in the cervical region.

The preoperative evaluation should establish the histologic diagnosis and extent of local and distant disease, as well as the patient’s physiologic status, which should be improved preoperatively if necessary. Esophagoscopy should be performed to obtain tissue diagnosis and to document the precise location of the tumor and the presence of associated findings (e.g., Barrett esophagus). A bronchoscopy is mandatory in all proximal- and middle-third tumors to evaluate airway invasion or a synchronous second primary. Endoscopic ultrasound has been established as key to evaluating the depth of tumor penetration and involvement of regional lymph nodes. Endoscopic ultrasound also offers the possibility of fine-needle aspiration biopsy for suspicious lymph nodes, especially nodes of the celiac trunk.

Barium swallow is used to document the location and extent of the lesion. CT scan of the chest and abdomen is also obtained routinely, although CT is not as effective as endoscopic ultrasound for determining the extent of intra- and transmural penetration or nodal involvement. CT is more valuable for assessing tumor extension into adjacent structures, such as the aorta, and for the detection of visceral and occult metastasis, especially in combination with a PET scan.

The role of thoracoscopy and laparoscopy in the evaluation of tumor resectability, staging of local and distant lymph nodes, identification of peritoneal implants, and detection of liver or lung metastasis is less clear mainly because of the expense, technical difficulty, and time associated with these procedures.

Careful preoperative assessment of pulmonary and cardiovascular function is mandatory. Routine investigations also include a full blood count, urea and electrolytes, liver function tests, and tumor markers. Physiotherapy is instituted to improve the patient’s mobility and pulmonary function, as well as to enhance the patient’s general condition. Adequate levels of nutrition and hydration also must be ensured. If necessary, the patient should be begun on nutritional supplements or total parenteral nutrition.

Anesthesia

The anesthetic technique must be of the highest standard. All patients undergoing the Ivor Lewis procedure should have an epidural catheter placed whenever possible to obtain satisfactory levels of analgesia postoperatively, thereby facilitating physiotherapy and respiratory function. A double-lumen endotracheal tube permits single-lung ventilation, which is required to obtain proper visualization and radical resection of the area concerned. Arterial and central venous pressure lines are inserted. Urinary output should be monitored with a Foley catheter. A gastric tube is placed to ensure adequate drainage during the procedure. The patient is positioned with the aid of a vacuum beanbag during thoracotomy. Twenty-four-hour antibiotic prophylaxis is instituted before incision.

Surgical Management

The Ivor Lewis esophagectomy is a two-stage procedure consisting of laparotomy for gastric mobilization and tubularization, followed by a right thoracotomy for esophageal resection and reconstruction. A radical lymphadenectomy is performed in the upper abdomen and chest. During the procedure, careful dissection is mandatory to avoid bleeding, limit the need for transfusion, and minimize manipulation of the heart.

Abdominal Dissection

The patient is positioned in a supine manner for laparotomy, and an upper midline incision is performed. Full abdominal exploration ensues with special attention to evidence of tumor dissemination in the form of unforeseen peritoneal or serosal implants, liver metastasis, or both. An abdominal self-retaining retractor is useful. The left lobe of the liver can be retracted cephalad and to the right after dividing the triangular ligament.

The dissection of the stomach starts by entering the lesser sac at a point well away from the gastroepiploic artery. The greater omentum is divided along the greater curvature by ligating and transecting the branches of the gastroepiploic arteries to the epiploon. During this maneuver, great care is taken to protect the gastroepiploic vessels needed for future vascularization of the stomach. The short gastric vessels are ligated sequentially and divided as close to the spleen as possible to avoid interrupting the epiploic arcade, thus preserving the circulation to the gastric fundus. Injury to the fundus of the stomach is assiduously avoided because this will serve as the site of the future anastomosis. While dissecting the gastrocolic omentum toward the duodenum, the stomach is lifted upward to allow the various adhesions between the stomach and pancreas down to the posterior surface of the first part of the duodenum to be transected. At this point in the operation the right gastroepiploic artery origin or venous communicating branch to the mesocolon is most vulnerable to injury. The duodenum is mobilized generously with a Kocher maneuver, and any loose adhesions between the duodenum and gallbladder fundus are divided.

Attention is turned to the lesser omentum, which is divided close to the undersurface of the left liver lobe up to the esophageal hiatus. The vagal branches to the liver are transected, and if a left liver lobe artery is found, care is taken to preserve this artery if at all possible. The right gastric vessels are identified, dissected, ligated sequentially, and divided approximately 1 inch proximal to the pylorus. The stomach is lifted up by the assistant, bringing into the surgeon’s view a bundle of tissue connecting the lesser curvature to the posterior abdominal wall (i.e., the celiac trunk). Palpation confirms pulsation of the left gastric artery within this tissue. Careful dissection permits the artery and vein to be visualized individually and tied off. The surrounding fat and lymph nodes are also removed during this maneuver. The left gastric artery is divided and ligated close to its origin from the celiac axis. The remaining loose adherent tissue, which contains a few small vessels, is divided, bringing the crura of the diaphragm into view. Gentle posterior pressure between the two pillars permits access to the posterior mediastinum, where loose areolar tissue can be broken down with gentle dissection. The phrenoesophageal ligament is transected around the esophagus to complete the mobilization. During this procedure, a cuff of diaphragmatic muscle can be resected if diaphragmatic invasion is suspected. After opening the diaphragmatic hiatus, access is gained to the fibrofatty and lymphatic tissue that separates the esophagus from the pericardium. This fibrofatty and lymphatic tissue is reflected away from the surrounding structures. In this way, much of the dissection of the lower esophagus can be achieved through the abdomen under direct vision. The gastric tubularization is performed using several linear staplers, starting from the gastric fundus down to the place on the small curvature where the right gastric artery has been ligated. The staple line is placed such that it leaves a gastric tube of 4 to 5 cm in width (Fig. 18-1). The staple line is oversewn in a running fashion, although some surgeons prefer to use interrupted sutures. Thus, by resecting the lesser curvature, all lymphatic tissue in this area is removed. A lymph node dissection along the splenic artery, common hepatic artery, and celiac axis is performed. This also can be done en bloc with the dissection of the left gastric artery. The gastric tube is fixed to this separated lesser curvature by using two stay sutures.

At the end of the first stage of the procedure, it should be possible to place the pylorus at the hiatus, ensuring sufficient length for the reconstruction. Pyloroplasty is not carried out, but digitoclasy of the pylorus may be useful. The abdomen is closed.

Thoracic Dissection

A lateral thoracotomy (which can be extended anteriorly or posteriorly depending on the surgeon’s preference) is performed through the fifth interspace. The serratus muscle is spared if possible.

The right lung is selectively deflated and retracted anteriorly. First, the azygos vein is dissected, ligated, and transected, as well as the underlying intercostobronchial artery. The mediastinal pleura anterior to the esophagus is opened widely from the azygos vein to the top of the chest. The proximal esophagus is dissected circumferentially and looped with an umbilical tape. The dissection is carried cephalad toward the apex of the chest, separating the esophagus from its tracheal and prevertebral attachments using the tape for traction and countertraction. Great care is taken to avoid injury to the membranous part of the trachea.

Similar dissection of the esophagus is achieved by encircling it with a tape distally from the distal pole of the tumor. During this dissection, it is important to remove the esophagus en bloc along with the surrounding tissues, including the thoracic duct and azygos vein, to achieve radical resection, especially if transmural extension is suspected. Dissection of the esophagus proceeds inferiorly, encompassing all tissue between the aorta and pericardium, including all periesophageal and subcarinal nodes. Both vagal nerves are transected.