Esophagectomy for an esophageal cancer: General considerations and choice of an operation

Surgery remains the mainstay of treatment for esophageal carcinoma in conjunction with preoperative chemoradiation
therapy.  Available data and National Comprehensive Cancer Network (NCCN) guidelines favor preoperative
chemoradiation therapy fo all cases of esophageal carcinoma except for low rist cases of T1-T2 tumors, as it improves
survival and local control.

            The number of esophagectomies performed has been rising steadily over the last decade. While the trends
show that increasing numbers of esophageal resections are performed as minimally invasive (MIE) and robotic-assisted
(RAE) surgery, over 50% of esophagectomies in 2010–2015 were performed as open surgery.3 All techniques have
comparable postoperative survival. MIE and RAE esophageal resections are reported to have a higher lymph node
counts than open approaches (15 and 17, respectively, versus 13)1.

           Choice of the approach for esophagectomy (Open vs MIE and Ivor Lewis vs McKeown vs Transhiatal
esophagectomy) depends on location of the tumor, prior operations, radiation treatment, body habitus, and surgeon
preference. The transthoracic approach (Ivor Lewis and McKeown) allows dissection of the esophagus under direct
vision, allows a more radical lymphadenectomy, and can improve radial margin for the midesophageal tumors.

Intrathoracic anastomosis (Ivor Lewis esophagectomy) has lower leak rate than a cervical anastomosis (McKeown and
Transhiatal), but intrathoracic leaks are associated with higher morbidity.

            Existing data suggests that for distal esophageal and gastroesophageal junction carcinomas, these
approaches provide overall comparable results.

Flexible endoscopy performed by the surgeon is essential for preoperative planning prior to esophageal resection. At
least a 5 cm longitudinal resection margin is required for carcinomas of the esophagus. Carcinomas located above 30 cm
may involve the trachea or left main stem bronchus and are less favorable for a transhiatal approach. This mandates
preoperative bronchoscopy to rule out airway involvement. Tumors above 25 cm are best approached with cervical
anastomosis and may require laryngectomy.

            The three-incision esophagectomy, also known as Mckeown’s esophagectomy, allows a direct approach for
dissection of the intrathoracic esophagus during a right thoracotomy (or thoracoscopy), similar to the Ivor Lewis
esophagectomy. However, during Mckeown’s esophagectomy the esophagus above the azygous vein is completely
mobilized and separated from the trachea. An additional cervical (“third”) incision allows for the greater length of the
proximal esophageal resection, and anastomosis is performed in the neck. Thus, many surgeons prefer this approach
for middle and upper esophageal lesions.

The option of a thoracoscopy is appropriate for most uncomplicated cases, including neoadjuvant chemoradiation
therapy. Thoracotomy is preferred for bulky tumors or mediastinal lymphadenopathy or if time lapse after radiation is
over 3–5 months. 

            The stomach is the most commonly used conduit for esophageal reconstruction. In some patients, the
stomach may not be available (esophagogastrectomy) or not suitable to be used for replacement (previous gastric
resections, damage to right gastroepiploic vessels, caustic injury, or other unfavorable situations). In such cases, the
colon can be used (transhiatal esophagogastrectomy with colon interposition ).

            At the University of Iowa, transhiatal esophagectomy is the preferred approach to distal esophageal
carcinomas. The operation, as popularized by Dr. Orringer 2, can be done efficiently with minimal blood loss and sound
oncologic principles in experienced hands. The transhiatal approach has been criticized for limited exposure,
hemostasis, and lymph node harvest. We developed a lighted transhiatal retractor that greatly improved visibility in
the mediastinum due to wider exposure and use of a light source. The improved exposure of the mediastinum allows us
to dissect the esophagus using a combination of suction tips, ringed forceps, and energy devices under direct vision up
to the level of tracheal bifurcation. This also allows us to resect or sample subcarinal and lower periesophageal lymph
nodes and assure the hemostasis. Blood transfusions are decreased to 6% of cases. The median lymph node harvest
with the specimen is 17 at our institution.  The median duration of postoperative hospital stay is 8 days.

            We perform the three-incision (Mckeown’s) esophagectomy for bulky mid-esophageal carcinomas or those
with the presence of mediastinal lymphadenopathy. We reserve Ivor Lewis esophagectomy for cases in which the length
of the gastric conduit is not sufficient to reach the neck for the anastomosis or those with unfavorable cervical
anatomy (prior radiation, severe cervical spine arthritis).

 
PERTINENT ANATOMY

Approaches to the Esophagus

 Cervical esophagus is approached via the left neck. Omohyoid and strap muscles stretch across its projection.
The left recurrent laryngeal nerve is located in the tracheoesophageal grove inferior to the inferior thyroid
artery.

 The upper thoracic esophagus is exposed through the right chest. It is located behind the trachea, carina and
left atrium. The azygos vein arches over it. The aorta ascends along the esophagus and feeds it with several
esophageal branches.

 The lower thoracic esophagus (as it courses to the left) and hiatus may be exposed through the left chest to
repair esophageal perforation or reduce diaphragmatic hernia.

 The abdominal esophagus is short and is accessible through the abdomen. It is mobilized with the division of the
phrenoesophageal ligament.

Blood Supply

 Right gastroepiploic vessels and right gastric vessels are the only vessels supplying the gastric conduit after
esophagectomy.

 Other vessels include left gastric vessels and left gastroepiploic vessels.

 The posterior gastric artery may originate from the splenic artery and supply the posterior wall of the gastric
fundus.

 A replaced or accessory left hepatic artery may originate from the left gastric artery.Inferior phrenic vessels
additionally supply lower esophagus.

Lymphatics

 There is an extensive network of lymphatics in submucosa allowing tumors to spread long distances intramurally
without penetrating the muscular coat.
  Thera are no chains of lymphatic and lymph nodes around and along the esophagus, as commonly described in
anatomical atlases.

 There are accumulations of larger lymph nodes in the area of the tracheal bifurcation and smaller nodes in the
neck and cardia regions.

 Lymphatic drainage of the esophagus above tracheal bifurcation occurs cephalad, while areas below carina drain
to lower mediastinal and perigastric lymph nodes.

 The thoracic duct originates at the cisterna chyli at the level of L1–2 vertebrae to the right and behind the
aorta. It enters the chest via the aortic hiatus and travels between aorta, esophagus, and azygos vein.

 At the T5 level the thoracic duct crosses to the left and ascends behind the trachea and esophagus to the left
neck above the clavicle. It drains into the junction of left subclavian vein with the internal jugular vein.

       

Innervation

 Vagal nerves are found on the sides of the esophagus. At the gastroesophageal junction, the left vagus nerve
deviates anteriorly and the right one posteriorly, and both descend onto the stomach.

 Division of the vagal nerves during esophagectomy requires drainage procedure on pylorus to facilitate gastric
emptying

PREOPERATIVE PREPARATION

Evaluation

 Multidisciplinary evaluation of all esophageal cancer patients

 Flexible esophagogastroduodenoscopy to establish the location and size of the tumor and associated mucosal
lesions with tissue diagnosis

 Determination of Siewert category for the gastroesophageal junction (GEJ ) tumors.

 Endoscopic ultrasound imaging to evaluate T and N stage (unless tumor is obstructing)

 Endoscopic resection to differentiate T1a versus T1b tumors

 Chest and abdominal computed tomography (CT) with per os (PO) and intravenous (IV) contrast

 PET CT if no evidence of M1 disease

 Biopsy of suspected metastatic lesions as clinically indicated

 Bronchoscopy if tumor is at or above carina with no evidence of M1 disease

 Complete blood count and comprehensive metabolic panel

 Assessment of exercise tolerance meeting 4 metabolic equivalents (METS) (or ability to walk 2–3 flights of
stairs)

 Pulmonary function test for patients with chronic obstructive pulmonary disease

 Cardiac stress test in patients with known coronary artery disease

 Screening for family history

 In patients with history of prior gastric surgery, colonoscopy is performed in advance to assess the colon as a
potential conduit. Bowel preparation is performed the day prior to esophagectomy in such cases.

Neoadjuvant Chemoradiation Treatment (nCRT)

 T1b–T4a, N0–N+ tumors should receive preoperative chemoradiation therapy.

o Note: T1b – T2, N0 low - risk lesions (well differentiated and < 2 cm ) - proceed to esophagectomy
without nCRT
  Esophagectomy is ideally performed within 35 days after completion of nCRT to prevent postoperative morbidity,
assuming patient is fit for surgery.

 Surgery is delayed as needed to improve nutritional and performance status.

Patient Preparation

 Complete abstinence from smoking for 2–3 weeks prior to the operation is of paramount importance.

 Nutritional assessment and counselling

 Nasogastric feeding tube or jejunostomy when esophageal obstruction is high grade and precludes adequate oral
calorie intake. Gastrostomy tube is not advised to preserve intact stomach for subsequent conduit.

Potential Complications

 Anastomotic leak

 Anastomotic stricture

 Recurrent laryngeal nerve injury

 Splenic injury

 Gastric conduit necrosis

 Hiatal hernia

 Injury to the tracheobronchial tree

 Delayed gastric emptying

 Reflux and dumping syndrome

 Aspiration pneumonitis