The management of esophageal cancer has evolved tremendously over the past decade. Increasingly, patients are treated with an aggressive multimodal approach including neoadjuvant chemoradiotherapy followed by surgical resection.1 Despite these changing trends in the treatment paradigm for esophageal cancer, esophagectomy remains the crucial component to long-term survival.
The key to success in managing patients with esophageal cancer is surgeon experience.2 There are numerous approaches to esophageal resection and replacement, both open and minimally invasive, but all have the potential for a high rate of morbidity and mortality. Each esophageal surgeon must develop and refine a technique of resection that is safe and expeditious to minimize morbidity while aggressively pursuing standard oncologic principles including adequate resection margins and complete lymphadenectomy to help assure long-term survival.
The selection of operative approach is based on numerous factors: type and location of the lesion, extent of invasion, stage of disease, need for lymphadenectomy, history of previous surgeries, and type of conduit chosen for esophageal replacement (i.e., stomach, colon, or jejunum). Surgeon preference and experience plays an important role in the selection of the operation. Popular methods of esophageal resection in the United States are based on methods developed by Ivor Lewis and McKeown, among others.3–5 They differ by the approach, number of incisions, and location of the anastomosis (intrathoracic or cervical) (Table 17-1). The three-hole esophagectomy at the Brigham and Women’s hospital has evolved over time and is designed specifically to limit morbidity by assimilating the best elements of each of the predecessor surgeries in a safe and expeditious procedure.6–9 This chapter will delineate the conduct of the operation and establish principles that can be applied to any approach for esophagectomy whether open or minimally invasive.
Good exposure for GEJ tumors
High risk of postoperative reflux
|Proximal margin limited by aorta||GEJ|
|Transhiatala||Upper midline laparotomy|
|No thoracotomy||Limited lower mediastinal lymphadenectomy|
Blind midthoracic dissection
|Benign disease, high-grade dysplasia, GEJ and lower esophageal tumors|
|Ivor Lewisb||Right thoracotomy|
|Direct-vision thoracic dissection|
Limited proximal margin
Increased risk of postoperative bile reflux
|Middle and lower thirds|
|Modified McKeownc||Right thoracotomy|
|Good proximal margin|
Direct-vision thoracic dissection
Exposure to right RLN during dissection
Increased incidence of postoperative reflux
|Brigham THEd||Muscle-sparing right thoracotomy|
Simultaneous abdominal and left cervical
|Unlimited proximal margin|
Direct-vision esophageal dissection
Cervical anastomosis avoids morbidity of an intrathoracic leak and anastomosis located out of potential radiation field
Reduced risk of postoperative reflux
RLN avoided from left approach
Serratus muscle-sparing thoracotomy
Expeditious two-stage procedure
Upper and middle thirds if neoadjuvant therapy is given
+/- left cervical
Reduced postoperative pain
More rapid recovery
Even for experienced centers, esophagectomy is a difficult procedure to perform and is associated with a considerable risk of morbidity and mortality (Table 17-2). Careful preoperative assessment, as well as the prevention, detection, and early treatment of procedure-specific complications, is essential to an excellent outcome. The Brigham three-hole esophagectomy is conducted in two stages. First, the thoracic dissection is conducted under direct vision by means of a limited right muscle-sparing posterolateral thoracotomy. The patient then is moved from the left lateral decubitus position to the supine position for the second stage of the procedure, beginning with simultaneous upper midline and left cervical incisions.
The operation allows direct visualization of the entire esophagus for resection with ample longitudinal margins and the ability to perform a complete lymphadenectomy in both the chest and abdomen. The specimen and surrounding lymph tissues are removed en bloc before the conduit is fashioned and placed. We prefer to use a gastric conduit whenever feasible, but other conduits may be used (i.e., colon or jejunum). The operation is completed with a cervical anastomosis, which is easy to care for in the event of postoperative leak and associated with a lower incidence of recurrent gastric reflux than operations requiring an intrathoracic anastomosis.
The three-hole esophagectomy is ideal for patients with upper, middle, or lower third esophageal lesions. It is also suitable for patients with bulky tumors or with dense adhesions secondary to radiation therapy or caustic injuries, since the dissection is enhanced by the direct vision afforded by thoracotomy. Patients with a history of preoperative neoadjuvant radiation, in whom there is an increased expectation of inflammation and fibrosis of the mediastinal structures, likewise do well with this surgery. The procedure is preferred for malignant disease because it ensures excellent circumferential visualization and dissection.
Preoperative Assessment and Perioperative Care
Before the patient is considered for resection, diagnostic studies include esophagogastroduodenoscopy to evaluate the extent of proximal and distal disease along with endoscopic ultrasound and a PET/CT scan to complete clinical staging and rule out distant metastases. The majority of patients with stage II or III disease are considered for neoadjuvant therapy. It is important to restage patients following neoadjuvant treatment with CT scan or PET/CT to identify those patients who may have progressed on therapy.
All patients are screened carefully for cardiopulmonary reserve. Patients identified as high risk on the basis of cardiopulmonary screening may undergo additional optimization procedures such as cardiac revascularization, valve repair or replacement, smoking cessation, or cardiopulmonary rehabilitation.
Our preference is to use the stomach for reconstruction for its ease of use, need for only one anastomosis, and reliable blood supply. For patients who have had previous abdominal surgery, specifically gastric resections that might compromise the vascular supply of potential conduits, we routinely obtain preoperative angiograms to evaluate the vascular anatomy.
Forty-eight hours before surgery, all patients receive a course of oral antibiotics and mechanical bowel cleanout. An epidural catheter is placed for postoperative analgesia to reduce pulmonary complications secondary to pain. Preinduction intravenous antibiotics are administered prophylactically.
The patient is induced with general anesthesia and intubated with a double-lumen tube to allow for single left lung ventilation. (For a detailed description of anesthetic technique, see Chapter 5.) For those patients with upper or middle third tumors, we first perform a bronchoscopy through a single-lumen endotracheal tube to assess the posterior membranous wall of the airway for tumor invasion.
The patient is turned to the left lateral decubitus position. A limited right posterolateral thoracotomy incision is made in the fifth interspace, sparing the serratus anterior muscle (Fig. 17-1). The fifth interspace is opened, and the sixth rib is shingled to permit better access to the thoracic cavity (Fig. 17-2). The ribs were spread using gentle retraction.
The lung is retracted anteriorly and the inferior pulmonary ligament is divided. The posterior mediastinal pleura is opened from the apex of the chest to the diaphragm at the level of the vertebral bodies thereby exposing the esophagus (Fig. 17-3). The esophagus is then mobilized in a region above the tumor. A 1-cm Penrose drain is passed around the esophagus and used for gentle retraction during the remainder of the thoracic dissection. Retracting the esophagus in this manner permits evaluation of the tumor for resectability from its surrounding structures. The azygos vein is usually divided using a 30-mm endovascular stapler to improve access to the upper thoracic esophagus (Fig. 17-4). If the tumor is deemed to be resectable, the surgeon proceeds with near-total esophagectomy, carrying the dissection cephalad along the esophagus toward the apex of the chest using a combination of electrocautery and blunt dissection with constant traction from the Penrose drain, and countertraction provided by the first assistant’s sponge stick. For mid- and distal esophageal tumors, the dissection of the upper thoracic esophagus proceeds close to the esophagus to avoid injury to the right laryngeal nerve, which recurs around the subclavian artery. Finger dissection is used to define the plane between the trachea and the esophagus at the level of the thoracic inlet, and the finger dissection is carried up to the level of the clavicle (Fig. 17-5).
After packing the apex of the chest with a laparotomy sponge to minimize bleeding, the dissection proceeds caudad between the aorta and esophagus, where the arterial branches are divided. A second Penrose drain can be placed around the lower esophagus, distal to the tumor if possible, to provide countertraction for the posterior dissection. Any pericardium that adheres to the tumor is removed as well as adherent pleura along both sides of the mediastinum. A small rim of diaphragm is incised circumferentially around the esophageal hiatus. The peritoneal cavity is entered posteriorly, and the posterior wall of the stomach is palpated by the surgeon’s finger. In particular, when the lesion is at the carina and densely adherent, using the two Penrose drains above and below the lesion allows safe access to the most densely adherent level where the tumor abuts the posterior wall of the airway and anterior wall of the aorta.
At this point, the first upper Penrose drain is loosely knotted around the esophagus and pushed up into the left neck just beneath the omohyoid muscle, where it can be retrieved later during the cervical dissection (Fig. 17-6). By encircling the midesophagus well below the recurrent nerves, the drain will be inside the nerves when it is retrieved in the neck, minimizing traction or direct injury to the recurrent nerve. The second Penrose drain is loosely knotted around the lower esophagus and passed into the peritoneal cavity to be retrieved at the time of the laparotomy to facilitate dissection of the gastroesophageal junction (Fig. 17-7). Although the goal is to resect the nodal tissue en bloc with the esophagus, any nodal tissue that has not been dissected with the specimen is resected separately and labeled appropriately. The region of the thoracic duct is identified near the aortic hiatus and ligated with a 0 silk suture to prevent chyle leak. If the duct cannot be visualized easily, a mass ligature is placed around all of the tissue between the spine and the aorta at the level of the diaphragm. Hemostasis is achieved, and a straight 28 French chest tube is placed in the posterior chest to the apex and brought out through a separate inferior stab incision. The thoracotomy is closed in layers in typical fashion after reapproximating the ribs with interrupted suture.
After the esophagus has been dissected to the level of the clavicle, the end of the Penrose drain is knotted and pushed behind the esophagus up through the thoracic inlet for use later in the cervical dissection.