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Left thoracic subtotal esophagectomy

Jun-Feng Liu

HISTORY

More than 100 years ago, esophagectomy began to be used for obstructive esophageal diseases. Czerny resected the cervical esophagus for a 50-year-old woman with esophageal cancer in 1877, and she survived for 15 months. Jejunal interposition was performed in a patient with benign esophageal stricture by Roux and Herzen in 1907. Kelling was the first to use colon as a substitute for the esophagus in 1911. The first successful thoracic esophagectomy was undertaken by Torek in 1913. No attempt was made to perform a reconstruction and the patient fed herself through a gastrostomy until she died from a stroke 13 years later. Ohsawa performed a gastroesophagostomy using an abdominal approach after resection of a cardiac cancer in 1932. Adams and Phemister performed a left thoracic subtotal esophagectomy for cancer in 1938 and undertook an esophagogastric anastomosis in the thorax. A combined left thoracoabdominal subtotal esophagectomy for cancer was initially reported by Sweet in 1945. Lewis undertook a three-stage esophagectomy first in 1946, and three-field esophagectomy was first used in the treatment for esophageal cancer by Akiyama in 1981.

PRINCIPLES AND JUSTIFICATION

Indications

This operation provides a means for resecting the thoracic esophagus, with anastomosis of the esophagus to the fundus of the stomach in the thorax or in the neck from the left side. The principal indication for this approach is resection of tumors of the thoracic esophagus and cardia, but it is also applicable to resection of a benign esophageal stricture. The main advantages of this method of subtotal esophagectomy are that it permits exploration of the tumor, dissection of the esophagus, and mobilization of the stomach through a single thoracotomy incision. This is quicker and simpler than a right-sided three-stage approach—that is laparotomy, right thoracotomy, and right neck incision—and it permits dissection of the tumor and its lymphatic or other extensions under direct vision. In general, indications for surgical therapy of esophageal carcinoma are dictated by cancer stage and fitness of patients for surgery. The stages 0, I, II, and T₃N₁M₀ of stage III disease can be radically resected. Palliative resection is usually performed for a T₃ intrathoracic esophageal cancer, but with supraclavicular and/or upper abdominal lymph node metastasis. Although there is a steady increase in surgical mortality with advancing age and a precipitous rise in mortality over the age of 75, left thoracic subtotal esophagectomy can be well tolerated by patients whose age is close to 80 years if they have no obvious cardiopulmonary problems.

Contraindications

The contraindications to this approach are when a tumor is located at the cervical esophagus (judged by barium swallow and not endoscopy) and when the upper part of the stomach is involved by tumor and there is insufficient stomach to reach the anticipated anastomotic site. It is also contraindicated when patients are cachectic, or have significant comorbid disease and are judged unfit to withstand the operation. Clinical factors, which indicate an advanced stage of carcinoma, are recurrent laryngeal nerve paralysis, Horner’s syndrome, persistent spinal pain, paralysis of the diaphragm, fistula formation, and malignant pleural effusion, and these indicate inoperability. Factors that make surgical cure unlikely are a tumor greater than 8 cm in length, abnormal axis of the esophagus on barium roentgenograph, enlarged lymph nodes, invasion of aorta or trachea on computed tomography (CT), and a weight loss greater than 20%.

PREOPERATIVE ASSESSMENT

Routine investigations

Investigations before operation are designed to assess the patient’s fitness for operation and to determine whether there is spread of the tumor beyond the limits of surgical resection. Routine investigations include hematological and biochemical tests and measurement of renal and hepatic function. Cardiac status is assessed by chest radiography, electrocardiography, and additional tests if indicated. Respiratory assessment includes routine spirometry, with full tests of respiratory function and blood gases if significant abnormalities are found. Possible spread of the tumor is investigated by barium swallow, esophagoscopy, and biopsy, CT, and/or ultrasonography in all cases, as well as positron emission tomography scan if available, and bronchoscopy, indirect laryngoscopy, lymph node biopsy, cytology of effusions, and other tests as indicated by symptoms or the findings on physical examination.

Nutritional assessment

Since the predominant symptom of esophageal carcinoma is difficulty in swallowing, most patients are nutritionally depleted. The nutritional status of the patients is important in predicting the outcome. A poor nutritional status decreases host resistance to infection and affects healing of an anastomosis. Physical examination should look for peripheral edema, specifically in the feet and flanks which, if present, gives an initial clue for very poor nutritional status of the patient. Measurement of the serum albumin is a more objective estimate of the status of the patient. A low value of serum albumin (<34 g/L) increases the risk of surgical complications, including anastomotic leakage. A positive nitrogen balance is important for the patient’s safe passage through the rigors of this major operation and postoperative stress. Hyperalimentation may be necessary for patients with poor nutritional status before surgery. Albumin or blood plasma can be given to supplement nutrition in patients with hypoproteinemia.

Pulmonary assessment

In addition to the effects of thoracotomy on pulmonary function, the intrathoracic stomach takes up room in the thorax after esophagectomy, and this adversely affects pulmonary function. Thus, pulmonary function should be meticulously assessed before resection of the esophagus. Pulmonary complications, including retained secretions, atelectasis, pneumonia, and respiratory failure, are the most severe problems following thoracic surgical procedures. Patients who are heavy smokers have a significantly increased risk of postoperative complications. The ability to cough is important because cough helps avoid postoperative atelectasis. Preoperative pulmonary function testing is undertaken routinely. The tests range from the simplest medical assessment (history taking, particularly of past pulmonary disease; physical examination; and stair climbing) to the most sophisticated exercise testing, and even analysis of blood gases. After deep inspiration, the ability to breath hold for more than 30 seconds suggests normal lung function. A value less than 20 seconds implies a high risk for thoracotomy. After climbing stairs of three stories, a pulse rate of more than 120 beats per minute indicates a high risk for esophagectomy. In my experience, a patient with a maximum volume ventilation (MVV) and vital capacity (VC) more than 70% of predicted values will tolerate a transthoracic esophagectomy; however, if the MVV and VC are less than 50% of predicted values, forced expiratory volume in 1 second (FEV1)/forced vital capacity less than 60%, and oxygen saturation (SO₂) less than 90% after exercise, surgery is contraindicated.

Cardiovascular assessment

The risk of both morbidity and mortality from thoracic surgery increases exponentially in patients with respiratory and significant cardiovascular disease. It is important to have an accurate cardiac history and know all cardiovascular medications used. If there is concern, a detailed assessment of the cardiac state should be undertaken in consultation with a cardiologist within a formal risk assessment protocol, such as the New York Heart Association (NYHA) Functional Classification published in 1928 (see Table 33.1)

In general, patients with class I or II cardiac function can tolerate esophagectomy well. Class III cardiac function is a relative contraindication for esophagectomy and such patients need to be prepared meticulously to recover their cardiac function to class II before surgery. Class IV cardiac function is a contraindication for esophagectomy. In our experience, heart infarction is a contraindication for the surgery except for inferior wall myocardial infarction, which can tolerate the surgery if more than half a year has elapsed since the heart incident. Although angina rarely undermines heart function, it should be stable for at least 3 months before the surgery. Hypertension and heart arrhythmias are not contraindications for esophageal resection, but should be effectively controlled before surgery.

Preparation

Adequate preoperative management will improve the ability of the patient to tolerate the operation. Smoking is stopped for at least 2 weeks before the operation, and all patients are instructed by an experienced respiratory physiotherapist in the breathing and coughing techniques that will be required after operation and in the use of incentive spirometry. Cessation of smoking, aggressive bronchopulmonary toilet, and bronchodilators may improve a marginal FEV1. Patients with chronic lung disease do better if their operations are scheduled for the afternoon, thus allowing them to ambulate and cough up secretions that have accumulated in the lung overnight. For the patients complicated with infectious respiratory diseases such as asthma or chronic obstructive pulmonary disease, intravenous use of antibiotics and mucus thinner—Ambroxol—and inhalation of bronchodilator and inhaled corticosteroids are needed. As discussed earlier, most esophageal cancer patients have difficulty swallowing, so preoperative nutritional support is important. Oral intake is usually inadequate in patients with advanced esophageal cancer, and hyperalimentation may be necessary. Enteral alimentation via a nasogastric tube and intravenous hyperalimentation are selected according to the status of the patients.

In resection of the esophagus, the mediastinum is extensively dissected and the bacteriologically contaminated esophagus is opened. Therefore, it is necessary to use prophylactic antibiotics to reduce the incidence of wound infection and anastomotic breakdown. Adequate doses of a broad-spectrum antibiotic with adequate Gram-positive and Gram-negative coverage is prescribed intravenously. A nasogastric tube is placed before surgery. Washout of esophageal content through the nasogastric tube is necessary for patients who have severe obstruction of the esophagus.

ANESTHESIA

After the administration of general anesthesia and endotracheal intubation with a singleor double-lumen tube (the latter is preferable), the patient is placed in the right lateral decubitus position with the arm flexed at the elbow and shoulder. The table is flexed or a soft pad is placed under the right chest to widen the operative field.

OPERATION

Incisions

1. The site of the incision is decided according to the anatomical level of the tumor and the anticipated site of anastomosis. If the tumor is in the cardia or the lower third of the esophagus and the anastomosis is constructed below the aortic arch, the incision is made through the seventh intercostal space or by resection of the seventh rib. When the tumor is in the middle or upper third of the esophagus and the anastomosis is to be constructed above the aortic arch or in the neck, the incision is made through the sixth intercostal space or by resection of the sixth rib. Usually, the sixth or seventh rib is identified as the standard left thoracotomy incision, including anterior and posterior extensions when necessary. The basic incision is made from the level of the costal cartilage in front to the paravertebral region at the angle of the scapula behind.

It may be extended upward between the scapula and the vertebral column to the level of the posterior end of the fourth rib. This allows the transaction of a higher rib, usually the fifth at the costal end, giving access for a supra-aortic dissection of the esophagus, and it also permits an easier high intrathoracic anastomosis. A left thoracoabdominal incision is usually used for resection of the proximal stomach or for obese patients. With the patient in the right lateral position, an oblique lateral incision is made, starting in the left hypochondrium and continuing over the costal margin and along the line of the seventh rib to the angle of the rib posteriorly. The incision on the abdomen is the oblique extension of the thoracic incision to the edge of the rectus sheath. The peritoneum is opened in the line of the incision, which provides excellent access to the upper abdominal organs (see Figure 33.1.)

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