The worldwide estimate for new cases of esophageal cancer was 482,300 in 2008.¹ In 2012 over 17,500 new cases of esophageal cancer were diagnosed in the United States alone, with over 15,000 deaths. Despite advances in chemotherapeutic agents and radiation therapy, surgery remains the core component of treatment of this disease. Especially in early-stage disease, surgery is still offered as definitive therapy. The incidence of esophageal adenocarcinoma has been increasing steadily in the United States.^2,3 Adenocarcinoma of the esophagus develops predominantly in a segment of intestinal metaplasia, and thus the increased incidence of esophageal adenocarcinoma translates into an increasingly prevalent disease in the distal third of the esophagus.⁴ Given the anatomic configuration of the esophagus within the thoracic cavity, no one surgical incision provides uniform access to the entire esophagus. The surgical approach therefore must be tailored to the individual patient, permitting adequate exposure to the diseased region of the esophagus with the least amount of invasiveness.

Although resection of the distal esophagus via a left transthoracic incision was first described in the 1930s, the increasing prevalence of distal esophageal cancer has renewed interest in this surgical approach.

Likewise, for Barrett esophagus and high-grade dysplasia, the left transthoracic approach can be optimal allowing a safe complete resection through a single incision with much shorter operating times (about 2 hours).⁵

The advantage of left transthoracic esophagectomy is readily apparent in that it affords a surgical resection with a single incision. In addition to the obvious advantage of decreasing the patient’s discomfort, the left transthoracic esophagectomy also can be performed in much less time than the Ivor Lewis or McKeown esophagectomy, with operative time averaging 2 to 3 hours.⁶ The left transthoracic approach does have a number of disadvantages that should be noted. First, although the division of the diaphragm provides excellent visualization of the left upper quadrant of the abdomen via the left chest, the remainder of the abdomen cannot be accessed using this approach. As a result of the limited abdominal exposure, adequate dissection of the pylorus cannot be achieved to perform pyloromyotomy. Many surgeons profess that gastric drainage is an essential component of esophageal reconstruction with gastric conduit placement after esophagectomy and identify the inability to perform a drainage procedure as a significant limitation of the left transthoracic approach. Evidence for the vital role of gastric drainage, however, is lacking. A meta-analysis of randomized controlled trials revealed that although pyloric drainage decreased the incidence of early gastric drainage dysfunction, the incidence of gastric drainage dysfunction in patients not receiving pyloric drainage was only 10%.⁷ Results from this study that suggest a trend toward increased bile reflux in patients treated with pyloric drainage have led some surgeons to question, in general, the value of pyloric drainage in esophageal reconstruction.

A further limitation of the left transthoracic approach is the lack of adequate exposure to perform a feeding jejunostomy. Early enteral nutrition has been demonstrated in some studies to be associated with improved outcome after esophagectomy in comparison with parenteral nutrition.⁸ Although jejunostomy is not easily accomplished via the left chest approach, enteral nutrition still may be possible using a nasojejunal feeding tube. To prevent inadvertent anastomotic injury from a blind tube insertion, the nasojejunal tube may be placed at the time of surgery using direct visualization to guide the tube through the anastomosis and endoscopic guidance to position the tube within the jejunum. The position of the nasal feeding tube within the jejunum may be secured using an endoscopic clip to fix the tube to the bowel wall. Alternatively, enteral access may be achieved laparoscopically using a jejunostomy tube or a percutaneous jejunal feeding tube placed under radiologic guidance.

A more subtle limitation of the left transthoracic approach is the technical challenge of performing the esophageal anastomosis within the left chest. Considering the relationship of the distal esophagus to the heart and great vessels within the left thorax, right-handed surgeons may experience some increased technical difficulty when performing the hand-sewn anastomosis from this exposure. The initial technical challenge of performing an esophagogastric anastomosis within the left chest arises from the unfamiliar angle of approach to the operative field for most right-hand dominant surgeons. This can be overcome with experience in this approach. The exposure and approach are identical with the left chest approach for Heller myotomy and Belsey repair. Finally, if a resection requires more extensive dissection, and a left neck anastomosis is thought to be the best approach, the mobilization can be completed under the aortic arch and the conduit prepared for a separate new approach by repositioning the patient.

In fact, in Asia, most surgeons perform total esophagectomies for squamous cell cancer through a sole left thoracotomy approach. Recently, there has been adoption of the standard Ivor Lewis approach in China, as a way of accomplishing a more extensive lymph node dissection. Still, many Asian surgeons perform the resection through the classical Ellis approach.

The limited exposure of the abdomen and thorax resulting from the left thoracotomy approach increases the importance of thorough preoperative staging to rule out metastatic disease. CT scanning, PET scanning, and endoscopic ultrasound (EUS) are essential components of preoperative staging. Any evidence of metastatic disease identified by CT, PET, or EUS is further investigated using EUS-guided fine-needle aspiration if accessible. At our institution, we continue to pursue an aggressive approach to surgical staging of all patients with esophageal cancer using laparoscopic and thoracoscopic staging for any patient evidencing a suggestion of advanced disease on CT, PET, or EUS. With the advent of more successful EUS-FNA of thoracic lymph nodes, the number of node-negative patients subjected to surgical staging has dropped to about 25%. In patients requiring laparoscopic staging because of suspicion of advanced disease, a jejunal feeding tube may be placed laparoscopically at the time of staging to facilitate perioperative alimentation.

In addition to oncologic staging and standard preoperative testing, preoperative cardiac stress testing and pulmonary function testing should be obtained to confirm the patient’s ability to tolerate single-lung ventilation. The patient is placed on a full liquid diet 48 hours before surgery, advancing to a clear liquid diet 24 hours before surgery. Some surgeons still use an antibiotic bowel preparation with oral neomycin and erythromycin base the day before surgery.

After placing a dual-lumen endotracheal tube in the correct position, as confirmed by bronchoscopy, an 18F nasogastric tube is placed. The patient is placed in the right lateral decubitus position with the arm positioned such that it is flexed 45 to 90 degrees at the shoulder and elbow. The bed is then flexed at the patient’s hips to widen the intercostal spaces. The surgeon stands to the patient’s left side with the assistant to the patient’s right side (Fig. 22-1).

The patient’s skin is prepared and draped widely to the right of the midline in the event that a laparotomy or thoracoabdominal incision is required. The eighth rib is identified by counting the ribs from caudad to cephalad by palpation. The skin is incised over the seventh intercostal space from 4 cm lateral to the costal margin to the posterior axillary line. The latissimus dorsi muscle is divided, but care is taken to preserve the serratus anterior muscle by freeing the inferior attachment of the muscle and thus allowing the muscle to be retracted superiorly. The ribs are again counted to confirm the position of the eighth rib. The seventh intercostal space is entered along the superior edge of the eighth rib. For patients who receive preoperative chemotherapy and radiation, the seventh intercostal muscle bundle is harvested during entry into the thorax to buttress the esophageal anastomosis.