Adult Chest Surgery

Chapter 15. Three-Hole Esophagectomy: The Brigham and Women's Hospital Approach 

 

Surgery is the mainstay of treatment for esophageal cancer. Numerous surgical approaches to esophageal resection and replacement have evolved since esophageal resection was introduced in the late 1800s. All these operations gain access to the esophagus through the abdomen, with additional exposure through the thorax and/or neck. The selection of approach is based on numerous factors: type and location of the lesion, submucosal extent, invasion of or adherence to surrounding structures, stage of disease, need for lymphadenectomy, history of previous surgeries, type of conduit chosen for esophageal replacement (i.e., stomach, colon, or jejunum), and neoadjuvant treatment (i.e., chemotherapy, radiotherapy, or both). Surgeon preference and experience often dictate the selection of approach. Popular methods of esophageal resection in the United States for lesions that lie below the thoracic inlet are based on methods developed by Ivor Lewis and McKeown, among others.1–3 They differ by the approach, number of incisions, and location of the anastomosis (intrathoracic or cervical) (Table 15-1). With rare exception, we prefer a three-incision transthoracic approach to esophagectomy. The three-hole esophagectomy developed at Brigham and Women's Hospital was designed specifically to limit morbidity by assimilating the best elements of each of the predecessor surgeries in a safe, expeditious procedure.4–7

Table 15-1. Popular Methods of Esophageal Resection and Replacement in the United States

Technique

Incision(s)

Advantages

Disadvantages

Lesions

LTE

Left thoracoabdominal

Good exposure for GEJ tumors

Single incision

High risk of postoperative reflux

Proximal margin limited by aorta

GEJ

Transhiatala

Upper midline laparotomy

Left cervical

No thoracotomy

Precludes lymphadenectomy

Blind midthoracic dissection

Benign tumor, high-grade dysplasia, malignant

Ivor Lewisb

Right thoracotomy

Laparotomy

Direct-vision thoracic dissection

Lymphadenectomy

Thoracotomy

Limited proximal margin

Intrathoracic anastomosis/leak

Increased risk of postoperative bile reflux

Middle and lower thirds

Modified McKeownc

Right thoracotomy

Midline laparotomy

Right cervical

Good proximal margin

Direct-vision thoracic dissection

Lymphadenectomy

Cervical anastomosis

Thoracotomy

Three incisions

Exposure to right RLN during dissection

Increased incidence of postoperative reflux

Middle third

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

Complete lymphadenectomy

Thoracotomy

Three incisions

Middle third

Upper and middle thirds if neoadjuvant therapy is given

MI-THE

Right thoracoscopy

Laparoscopy

Right cervical

No thoracotomy

Reduced postoperative pain

More rapid recovery

Longer operation, prolonged anesthesia

More expensive than open procedure

 

 

Abbreviations: LTE = left thoracoabdominal esophagectomy; RLN = recurrent laryngeal nerve; GEJ = gastroesophageal junction; THE = three-hole esophagectomy; MI = minimally invasive.

aOrringer MB, Sloan H: Esophagectomy without thoracotomy. J Thorac Cardiovasc Surg 76:643, 1978.

bLewis I: The surgical treatment of carcinoma of the esophagus with special reference to a new operation for growths of the middle third. Br J Surg 34:18, 1946.

cModified McKeown K: Trends in oesophageal resection for carcinoma. McKeown first described the operation with a right thoracotomy and a left paramedian abdominal incision. The Modified McKeown is the right thoracotomy with a midline laparotomy. Ann R Coll Surg Engl 51:213, 1972.

dSwanson SJ, Batirel HF, Bueno R, et al: Transthoracic esophagectomy with radical mediastinal and abdominal lymph node dissection and cervical esophagogastrostomy for esophageal carcinoma. Ann Thorac Surg 72:1918, 2001.

GENERAL PRINCIPLES

Even for experienced centers, esophagectomy is a difficult procedure to perform and is associated with a considerable risk of morbidity and mortality. Careful preoperative assessment, as well as prevention, detection, and early treatment of procedure-specific complications, is essential to outcome. The Brigham three-hole esophagectomy is conducted in two stages. 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 midline abdominal and left cervical incisions. The operation allows direct visualization of the entire esophagus for resection and ample longitudinal margins. The ability to perform a complete lymphadenectomy is advantageous for patients undergoing neoadjuvant regimens. 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 (e.g., colon, jejunum, and less commonly, tubularized skin graft conduits). 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 middle to upper-third esophageal lesions, for which the proximal margin would be compromised with an intrathoracic anastomosis performed through a limited Ivor Lewis or transhiatal approach. It is also suitable for patients with bulky tumors or with dense adhesions secondary to radiation therapy or caustic injuries, in whom 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.

PERIOPERATIVE ASSESSMENT AND CARE

Table 15-2. Before the patient is considered for resection, the pathologic distinction between esophageal malignancy (i.e., adenocarcinoma or squamous cell carcinoma) and high-grade dysplasia (i.e., in situ or early) must be made by two independent pathologists. Diagnostic studies include esophagogastroduodenoscopy and endoscopic ultrasound for staging. A CT scan, PET/CT scan, or both are obtained to rule out distant metastases. A head CT scan may be ordered for suspicion of brain metastases. A bone scan is used occasionally if clinically indicated. All patients are screened carefully for cardiopulmonary status. Patients identified as high-risk on the basis of cardiopulmonary screening may undergo additional optimization procedures, such as valve repair/replacement or other cardiopulmonary bypass procedures. For patients who have had previous surgery or procedures that might compromise the vascular supply to potential conduits, we routinely obtain preoperative angiograms to evaluate the vascular anatomy. Additional chemoradiation also may be a part of the preoperative routine if there is advanced local disease that prevents immediate resection. Patients who demonstrate a positive result to treatment are restaged for possible esophagectomy.

Table 15-2. Procedure-Specific Complications

·   Pulmonary

·   Anastomotic leak

·   Conduit necrosis

·   Anastomotic stricture

·   Recurrent gastric acid reflux

·   Tracheoesophageal fistula

·   Injury to recurrent laryngeal nerve

 

 

Forty-eight hours before surgery, all patients receive a course of oral antibiotics and mechanical bowel cleanout. Preinduction intravenous antibiotics are administered prophylactically. An epidural catheter is placed for postoperative analgesia to reduce pulmonary complications secondary to pain. A jejunostomy is performed routinely during surgery for postoperative feeding and to provide access for enteral nutrition if problems with oral feeding occur postoperatively. Thoracostomy drainage is used for thoracotomy, and Jackson-Pratt drains are used for the cervical anastomosis. All thoracic, abdominal, and cervical tubes are left in place for drainage of fluid collections or leaks that may arise in the postoperative period. Intraluminal drainage tubes are also left in place to aid in gastrointestinal tract decompression.

SURGICAL TECHNIQUE

Right Posterolateral Thoracotomy

Before the operation begins, the patient is induced with general anesthesia, and a single-lumen endotracheal tube is placed in preparation for bronchoscopy to assess the airway and tumor. If the airway is clear, nasogastric and double-lumen endotracheal tubes are placed to enable decompression of the proximal esophagus and single right lung ventilation. (For a detailed description of anesthetic technique, see Chap. 5.)

The patient is turned to the left lateral decubitus position. A limited right posterolateral thoracotomy incision is made at the fifth interspace, sparing the serratus anterior muscle (Fig. 15-1). The ribs are spread using gentle retraction. The fifth interspace is opened, and the sixth rib is removed or "shingled" to permit access to the thoracic cavity (Fig. 15-2). The lungs are retracted anteriorly and medially, after which the inferior pulmonary ligament is located and divided. The posterior mediastinal pleura is opened over the esophagus from the apex of the chest to the diaphragm at the level of the vertebral bodies (Fig. 15-3).

Figure 15-1.

 

A muscle-sparing right posterolateral thoracotomy incision is made at the fifth interspace.

 

Figure 15-2.

 

The fifth interspace is opened, the sixth rib is removed or "shingled," and the ribs are gently retracted.

 

Figure 15-3.

 

The posterior mediastinal pleura is opened over the esophagus from the apex of the chest to the diaphragm.

Thoracic Dissection

The esophagus is mobilized in a region of normal tissue above the tumor. Alternative methods of esophageal mobilization using thoracoscopy and laparoscopy may be used. A 1-cm Penrose drain is passed around the esophagus and used for retraction during the thoracic dissection (Fig. 15-4). 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. If the tumor is deemed to be resectable, the surgeon proceeds with the total esophagectomy, carrying the dissection cephalad along the esophagus toward the apex of the chest using electrocautery, constant traction from the Penrose drain, and countertraction provided by the first assistant's sponge stick. Only a minimal amount of periesophageal lymph node tissue is found above the azygos vein. For this reason, the dissection 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 (Fig. 15-5), and the finger dissection is carried up to the level of the clavicle. At this point, the Penrose drain is knotted and pushed up into the left neck just beneath the omohyoid muscle, where it can be retrieved later for the cervical dissection (Fig. 15-6). By placing the drain around the esophagus in the midchest, well below the recurrent nerves, it will be inside the nerves when it is retrieved in the neck, avoiding traction or direct injury.

Figure 15-4.

 

A 1-cm Penrose drain is passed around the esophagus and used for retraction during the thoracic dissection. The azygos vein is divided using a 30-mm endovascular stapler.

 

Figure 15-5.

 

Finger dissection is used to develop the plane between the trachea and esophagus at the level of the thoracic inlet up to the level of the clavicle. The dissection proceeds close to the esophagus to avoid injury to the right laryngeal nerve, which recurs around the subclavian artery.

 

Figure 15-6.

 

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.

 

After packing the apex of the chest with a small sponge to minimize bleeding, the dissection proceeds between the aorta and esophagus, where the arterial branches are divided. Large esophageal branches from the aorta are clipped or tied and smaller ones are cauterized. A second Penrose drain is placed around the esophagus distal to the tumor 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 2-cm 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. The second Penrose drain is knotted and passed into the peritoneal cavity to be retrieved at the time of the laparotomy to facilitate dissection of the gastroesophageal junction (Fig. 15-7). At this point, any nodal tissue that has not been swept up onto the specimen is dissected out separately, such as nodal tissue found in the subcarinal space and in the area of the inferior pulmonary ligament. The thoracic duct is identified near the esophageal hiatus and ligated. A prophylactic 0 silk suture is placed around the thoracic duct at the level of the aortic hiatus to prevent a chyle leak. If the duct cannot be visualized here, a mass ligature is placed around all of the tissue between the spine and the aorta. Hemostasis is achieved, and a straight 28F 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 with absorbable running suture in typical fashion after reapproximating the ribs with stout absorbable interrupted suture.

Figure 15-7.

 

A second Penrose drain is knotted around the lower esophagus and pushed into the peritoneal cavity for use later in the laparotomy and dissection of the gastroesophageal junction.

Abdominal and Left Cervical Dissections

The patient is repositioned from left lateral decubitus to supine position for the abdominal and left cervical dissections. At this juncture, the double-lumen tube is replaced with a single-lumen tube to avoid the complications associated with replacing the tube after the cervical anastomosis has been created. The patient's head is rotated 45 degrees to the right, and a shoulder roll is placed between the scapulas. Both upper midline laparotomy and left cervical incisions can be created from this position, and the procedures are performed simultaneously (Fig. 15-8).

Figure 15-8.

 

After the thoracic dissection is complete, the patient is placed in the supine position, and different surgical teams working simultaneously make two incisions, a midline abdominal incision and a left cervical incision.

Upper Midline Laparotomy Incision

After the upper midline incision is created, the abdomen is explored for resectability. With the availability of improved CT and PET/CT technology for preoperative surgical staging, it is unlikely at this stage to find any evidence of metastatic disease. In the event that metastatic disease is identified and a palliative resection deemed inadvisable, the patient is closed after removing the packing and Penrose drains. Nothing further is required because the esophagus has a rich longitudinal submucosal blood supply and will continue to survive. Palliative resection would not be indicated, for example, in patients with stage IV esophageal cancer, who typically have a less than 6-month survival rate. A feeding tube should be installed if not already in place before closure.

After dividing the triangular ligament to the left lobe of the liver, the left lobe is folded down and retracted to the right with a moist lap pad and a deep self-retaining retractor. Upper-hand and Balfour retractors are placed to provide exposure after taking down the triangular ligament. The Penrose drain placed during thoracotomy is identified and used for retracting the esophagus at the level of the gastroesophageal junction (Fig. 15-9). Adequate pulse is confirmed in the right gastroepiploic artery, after which the surgeon proceeds to locate the short gastric vessels. If the spleen is located superiorly such that it limits visualization of the gastric vessels, a laparotomy pad can be placed behind the spleen to bring the short gastric vessels into view. Once the short gastric vessels are identified, the surgeon dissects, clips, and divides them with the aid of an automatic clip applier and scissors beginning at the gastroesophageal junction and progressing to the separation between the left and right gastroepiploic arcades (Fig. 15-10). The dissection of the right gastroepiploic arcade is carried 2 cm distal (or lateral) to the right gastroepiploic pedicle to avoid injury. Clamps and 2-0 silk are used to divide the greater omentum. The dissection is continued to the level of the pylorus. The posterior attachments to the pancreas are sharply divided. A generous Kocher maneuver is carried out to mobilize the duodenum to the midline. Optionally, a pyloromyotomy or Heineke-Mikulicz type of pyloroplasty using a single layer of 3-0 silk is created to provide egress from the conduit (Fig. 15-11).

Figure 15-9.

 

The abdomen is explored for resectability through the midline incision. Upper-hand and Balfour retractors are placed to provide exposure after taking down the triangular hepatic ligament. The second Penrose drain that was placed during thoracotomy is identified.

 

Figure 15-10.

 

The short gastric arteries are dissected, clipped, and divided.

 

Figure 15-11.

 

The duodenum is mobilized using a Kocher maneuver. A pyloromyotomy or Heineke-Mikulicz type of pyloroplasty using single layer of 3-0 silk is done to create the egress from the conduit.

 

At this point, all nodal tissue is gathered up onto the specimen. The stomach is reflected superiorly and to the right to expose the left gastric artery and vein. The left gastric pedicle is palpated at its takeoff from the celiac axis and ligated with a single firing of the endovascular 30-mm stapler. Before firing the stapler, it is important to recheck the pulse of the right gastroepiploic pedicle to be sure that the celiac axis itself has not been clamped (Fig. 15-12). The lesser omentum is released from the abdominal viscera with clamps and ties, and the gastric conduit is now ready to be brought up into the neck.

Figure 15-12.

 

The stomach is reflected superiorly and to the right, exposing the left gastric vein and artery, which are ligated using an endostapler near their origin in the celiac axis.

Left Cervical Incision

The cervical incision is performed simultaneously with the upper midline laparotomy by a separate surgical team. A short left neck incision is created along the anterior border of the sternocleidomastoid muscle (Fig. 15-13). The sternocleidomastoid muscle is mobilized laterally along with the carotid sheath. Dissection is deepened lateral to the thyroid gland. The middle thyroid vein may need to be divided. Care is taken on this side not to impinge on the left recurrent nerve with retractors. The use of self-retaining metal retractors should be avoided to prevent recurrent laryngeal nerve injury and carotid artery lesions, particularly if carotid plaques are suspected. The omohyoid muscle is mobilized or divided with electrocautery. Using gentle blunt finger dissection, the surgeon proceeds posteriorly, anterior to the cervical bodies of the vertebrae, where the Penrose drain is stored, and the drain is brought into the wound site. Traction from the Penrose drain permits mobilization of the esophagus. Because of the left cervical approach, the right recurrent laryngeal nerve is completely avoided during the neck dissection.

Figure 15-13.

 

While the first team mobilizes the esophagus below the diaphragm, the second team creates a short left cervical incision along the anterior border of the sternocleidomastoid muscle and locates the first Penrose drain.

 

At this point the surgical team prepares to divide the esophagus. The anesthesia team withdraws the nasogastric tube just proximal to the division of the cervical esophagus. The cervical esophagus is divided with a linear cutter 75-mm stapler (Fig. 15-14). A long, stout silk suture is placed in the distal esophageal staple line. In this manner, the silk tie accompanies the specimen as it is pulled into the abdomen. Later it will be used to guide the gastric conduit up through the mediastinum into the neck. The esophagus is divided, and the specimen is removed through the abdominal incision (Fig. 15-15).

Figure 15-14.

 

The cervical esophagus is divided with a linear cutter, 75-mm (GIA) stapler.

 

Figure 15-15.

 

A long, heavy silk suture is attached to the cervical end, and the specimen is brought down through the abdominal incision and removed.

 

With the specimen delivered into the abdomen, a linear cutter 75-mm stapler may be used both to divide the stomach in an appropriate location and to fashion a tube-shaped conduit, preserving perfusion through the gastroepiploic arcade. The outline for the conduit begins along the greater curvature of the stomach, high on the fundus, and is drawn toward the lesser curvature just above the crow's foot. The staple line along the gastric conduit is reinforced with separate invaginating stitches (Fig. 15-16).

Figure 15-16.

 

A linear cutting stapler is used to create the gastric conduit. The conduit is fashioned by creating a semicircular line along the greater curvature of the stomach beginning high on the fundus and ending at a point along the lesser curvature just above the crow's foot.

 

Maintaining a narrow conduit is important physiologically because it will ensure adequate emptying of the neoesophagus. The hiatus is dilated manually to permit four fingers to be placed through it. An additional suture can be placed just superficial to the aorta in the hiatus if there is any concern about the integrity of the thoracic duct.

A Foley catheter with a 30-mL balloon is attached to the distal end of the silk tie that was placed during the neck incision to mark the posterior mediastinum (Fig. 15-17). The balloon is attached to an arthroscopic camera bag. The bag is unfolded, and the gastric conduit is placed inside. The Foley catheter, camera bag, and gastric conduit are passed through the abdominal incision, through the mediastinum, and out of the left cervical incision.

Figure 15-17.

 

The silk tie is attached to the port of a 30-mL Foley balloon catheter, and the catheter is pulled up until it is partway through the neck incision.

 

The end of the bag is placed at the level of the pyloroplasty if a pyloroplasty has been created. Applying suction through the Foley catheter can help to maintain traction through negative pressure between the plastic camera bag and the gastric conduit (Fig. 15-18). The conduit should be gently pushed or fed up the mediastinum rather than "pulled up" to prevent injury to the walls of the conduit or the vascular pedicle. Care is taken to prevent twisting of the conduit. Suction is discontinued through the Foley catheter. The bag is gently cut away. When oriented properly, the gastric staple line lies on the right side of the neck incision from the patient's perspective, and the pylorus sits at the hiatus (Fig. 15-19). The esophagogastric anastomosis can be performed in one of two ways: hand sewn or with automatic sutures (staplers). The proximal esophageal staple line is cut off. A gastrotomy is made 3 cm below the tip of the conduit. When the gastrotomy is performed by hand, a single layer of 3-0 silk sutures is placed first in the back row with the knots inside (Fig. 15-20). The nasogastric tube is passed transanastomotically to the distal gastric tube. The front row of sutures is performed with the knots outside. There are two nasogastric tube placement options with hand-sewn anastomoses. A nasogastric tube can be placed through the remaining cervical esophagus, through the anastomosis, and down into the gastric conduit. Alternatively, a sterile (Levine) nasogastric tube is brought to the sterile field. A gastrostomy is placed 3 cm from the tip of the conduit. A purse-string suture is placed around the gastrostomy tube. This is brought out through the incision and secured to the skin, thus avoiding the morbidity and discomfort of a nasogastric tube.

Figure 15-18.

 

The other end of the Foley catheter is attached to an arthroscopic camera bag. The neoesophagus is placed into the folded bag, being careful to ensure proper axial orientation (i.e., the neoesophagus is oriented with the staple line on the patient's right side). A Yankauer suction device is attached to collapse the bag around the neoesophagus.

 

Figure 15-19.

 

The gastric conduit is pulled through the posterior mediastinum into the cervical wound.

 

Figure 15-20.

 

An end-to-side anastomosis is created with a single layer of interrupted 3-0 silk suture. The anastomosis is created on the posterior aspect of the gastric conduit to ensure more favorable drainage.

 

The anastomosis also can be created with staplers, using a linear cutting and thoracoabdominal-30 (TA-30) stapler to make a functional end-to-end (side-to-side) anastomosis (Fig. 15-21). A Jackson-Pratt 10-mm closed suction drain is passed posteriorly and to the left of the anastomosis at the level of the thoracic inlet and brought out through a small lateral stab incision. This tube prevents seroma and provides an outlet for drainage in the event of a defect in the anastomosis. Usually the tube is left in place for 5 days.

Figure 15-21.

 

Alternative technique using a stapler to create the cervical anastomosis.

PROCEDURE-SPECIFIC COMPLICATIONS

Complications of this procedure can be categorized as technical or as aberrations in cardiopulmonary status (Table 15-3). Prevention, early detection, and rapid treatment of these conditions are essential to outcome.

Table 15-3. Strategies for Prevention of Complications

Preoperative strategies

Preoperative cardiopulmonary screening to identify risk factors

·   Surgical and medical optimization for select patients, e.g., aortic valve replacement, coronary artery bypass graft surgery

Previous surgery

·   Preoperative angiogram to assess condition and availability of conduits

Preoperative measures 48 hours in advance of surgery

·   Mechanical bowel cleanout

·   Oral antibiotics

Preinduction

·   Preinduction intravenous prophylactic antibiotic administration

·   Epidural catheter placement for postoperative pain control to reduce cardiopulmonary

 

Intraoperative strategies

·   Intraoperative

·   Jejunostomy tube placement for postoperative feeding and access for parenteral nutrition if needed.

·   Thoracostomy drainage for each thoracotomy

·   Jackson-Pratt drain for cervical anastomosis.

 

 

Technical Complications

ANASTOMOTIC LEAK

Chief among the complications of esophagectomy is the anastomotic leak. This is most serious when the leak is intrathoracic, because the mortality rate remains very high. Most leaks manifest within 10 days of surgery. General factors that influence the development of an anastomotic leak include tension on the anastomosis, quality of the arterial and venous blood supplies, location of the anastomosis, manner in which it was performed, and surgeon experience. Ease of maintenance and repair of anastomotic leak in the cervical region, in our view, outweighs the complications of caring for an intrathoracic leak.

ESOPHAGEAL STRICTURE

Tension and inadequate blood supply can lead to esophageal stricture months after surgery. Dysphagia is the first sign of esophageal stricture, and patients should be evaluated with a barium swallow, endoscopic ultrasound, and abdominal and chest CT. Benign strictures can be treated with dilation. Stenting is contraindicated for cervical esophageal anastomoses because of the risk of creating a tracheal perforation. Anastomotic stricture is a common problem in the cervical anastomosis. Serial dilatation is usually sufficient and resolves the problem without the need for reoperation.

HEMORRHAGE

There are many potential sources for hemorrhage after esophagectomy, including unrecognized or poorly controlled injury to the spleen, azygos vein, intercostal vessels, omentum, right gastric artery, and lung parenchyma. Traction injuries of the heart and pericardium can lead to cardiac tamponade. Injury to the phrenic veins during mobilization of the left lateral segment of the liver extending to the vena cava also can give rise to internal bleeding. Patients with unsuspected cirrhosis can have bleeding of the esophageal varices intraoperatively. Prevention of intraoperative bleeding requires close attention to technique and vigilant examination of all potential bleeding sites before closure. Postoperative hemorrhage requires urgent reexploration and occurs with an incidence of 3–5%. Diagnosis of postoperative bleeding is usually delayed by 12–24 hours. Unexpected tachycardia and decreased urine output are early signs of a developing problem. Since esophagectomy patients have sizable fields of dissection, where the blood can "hide," they generally require large-volume blood replacement. After patients are resuscitated with blood products to correct coagulopathies, they are reexplored. This source of bleeding usually can be prevented with meticulous surgical technique.

CHYLOTHORAX

The thoracic duct follows a similar course to the esophagus and comes in close proximity to the aorta and vertebral bodies. Hence patients undergoing esophagectomy are at risk for developing a chyle leak, or chylothorax, during the thoracic dissection. It occurs with an incidence of 1–5%. Diagnosis is made on demonstration of a pleural effusion consisting of a milky white fluid with high triglyceride and lymphocyte counts. It is identified on postoperative inspection of chest tube drainage or chest radiographs. Suspicion should be high if the chest tube output remains elevated beyond postoperative day 4 or if a pleural effusion develops in the first postoperative week. The fluid may be clear and have a low triglyceride level if the patient has been NPO for a few days. Although chylothorax can be managed conservatively with hyperalimentation and restriction of oral intake, the course is prolonged. For this reason, if it persists by the seventh postoperative day or if the chest tube output increases with enteral feeds, then, we treat the chylothorax more aggressively, with surgical exploration conducted through the right side of the chest and mass suture ligation of the thoracic duct at the site of leak. Others favor interventional radiology techniques to embolize the thoracic duct in the area of leak. However, the thoracic duct is visible on direct inspection, and with careful surgical technique, thoracic duct leaks can be readily identified and repaired during the esophagectomy procedure, before they develop into a complicated postoperative problem.

PLEURAL EFFUSION AND PNEUMOTHORACES

Other possible complications of esophagectomy include pleural effusion and pneumothoraces, resulting from injury to the pleura on the contralateral hemithorax, which permits drainage of air or fluid from the field of dissection into the pleura. These conditions can be managed conservatively with percutaneous drainage or thoracostomy after other causes have been eliminated, including hemorrhage, chylothorax, conduit leak, metastatic disease, and airway injury.

RECURRENT LARYNGEAL NERVE INJURY

A serious complication of esophagectomy is recurrent laryngeal nerve palsy. This injury affects the vocal cords and the ability to prevent life-threatening aspirations. It occurs with an incidence of 10–20% in patients receiving a cervical anastomosis.Treatment consists of temporary medialization with Gelfoam to give the nerve a chance to recover, followed by permanent medialization with a prosthesis if recovery does not ensue.

AIRWAY INJURIES

Rarely, a tracheobronchial injury arises intraoperatively that leads to a postoperative neoesophageal-to-bronchial fistula. Airway injuries of the membranous trachea also have been described. We routinely perform bronchoscopy after thoracic dissection to look for tracheal injuries. This is an important safeguard because small injuries that heal without treatment can lead to the development of a neoesophageal fistula postoperatively that requires more extensive treatment with stenting or operative repair for resulting respiratory compromise from recurrent pneumonia or empyema. The risk of injury to the membranous wall of the trachea is minimized when the dissection is carried out under direct vision, as afforded by the THE. If such an injury does occur, it can be repaired primarily and buttressed with pericardium, omentum, and/or muscle patches.

DELAYED GASTRIC EMPTYING

Up to 10% of patients undergoing esophagectomy experience delayed gastric emptying in the postoperative period. However, patients undergoing three-hole esophagectomy exhibit lesser rates of reflux presumably because of the cervical anastomosis and use of a gastric conduit. In the past, we routinely performed a prophylactic pyloromyotomy or pyloroplasty for all patients undergoing esophagectomy to avoid this disabling complication, but recently this practice has been largely abandoned, and the problem can be managed with balloon dilatation if needed in the postoperative period.

Cardiopulmonary Aberrations

Many esophagectomy patients are elderly, malnourished individuals with a positive history for smoking and alcohol abuse. Often they have comorbid conditions that compromise their cardiovascular and cardiopulmonary status, prolonging recovery and complicating postoperative management. These complications include myocardial infarction, arrhythmias, congestive heart failure, deep venous thrombosis, and pulmonary embolism. Although the incidence of cardiovascular complications is relatively low, occurring in 5–10% of patients in most large series,the most common is atrial fibrillation. Pulmonary complications after esophagectomy include pneumonia, aspiration, and respiratory failure requiring prolonged intubation. The incidence of pulmonary complications occurs at a rate of 20–30% at high-volume centers.8

Other Late Sequelae

It is important for the surgeon to educate the patient and family to recognize some of the late complications that can occur because these may not readily be identified by the primary care physician. These include anastomotic stricture, paraesophageal hernia, intestinal motility problems (e.g., dumping syndrome), bile reflux esophagitis, and postthoracotomy pain syndrome.

SUMMARY

The mortality rate for esophagectomy is proportional to experience. Mortality ranges from a high of 10% at low-volume centers to a low of 2–3% at high-volume centers. Attention to all aspects of the procedure includes careful patient selection, meticulous surgical technique, and diligent perioperative care.7,8 A high suspicion for procedure-specific complications yields a safe procedure with acceptable morbidity and mortality when the surgery is performed by an experienced surgical team (Table 15-4). Highlights of the most important technical aspects of this approach include use of a muscle-sparing left posterolateral thoracotomy, direct vision for the thoracic dissection, complete thoracic lymphadenectomy for staging (which yields the best chance for cure and guidance for neoadjuvant regimens), and an unlimited proximal margin. Placing the anastomosis in the left cervical neck provides easy postoperative maintenance, reduces the morbidity of anastomotic leaks in comparison with an intrathoracic anastomosis, and is associated with a lower incidence of postoperative bile reflux. Survival data have not revealed a clear benefit of one surgery over the other in a comparison of the transhiatal and transthoracic techniques. The technical complications are fewer when thoracic esophageal dissection is performed under direct vision rather than with blunt dissection. This is especially the case after caustic injuries and neoajuvant radiation therapy. However, several recent randomized studies have demonstrated a trend toward improved survival with the transthoracic approach.9

Table 15-4. Major Complications of Three-Hole Esophagectomy (N = 250)

Complication

Frequency

n

Recurrent laryngeal nerve injury

14%

35

Chylothorax

9%

22

Anastomotic leak

8%

19

Pneumonia

5%

13

Postoperative bleeding

2%

5

Tracheoesophageal fistula

1%

2

Adult respiratory distress syndrome

1%

2

Empyema

1%

2

Sepsis

0.4%

1

Mediastinitis

0.4%

1

 

Reprinted with permission from reference 4.

EDITOR'S COMMENT

The authors have done a remarkable job of teaching a very difficult technique to two generations of esophageal surgeons. The carefully articulated technical description can be followed meticulously and leads to excellent results. In my own practice, I use this technique routinely whenever a lesion involves the esophagus proximal to 24 cm from the incisors or when it involves laryngeal nerve in the upper thoracic or cervical regions, especially after chemoradiation. There is a benefit of having a neck anastomosis with less resultant morbidity in the case of a leak, but this is balanced with the need to remove the entire organ routinely. I feel this is not needed, as we see more and more distal adenocarcinomas and fewer proximal squamous cancer lesions!

–MJK

REFERENCES

1. Lewis I: The surgical treatment of carcinoma of the esophagus with special reference to a new operation for growths of the middle third. Br J Surg 34:18–31, 1946. 

2. Orringer MB, Marshall B, Iannettoni MD: Transhiatal esophagectomy: Clinical experience and refinements. Ann Surg 230:392–400; discussion 400–3, 1999. 

3. McKeown K: Trends in oesophageal resection for carcinoma. Ann R Coll Surg Engl 51:213–39, 1972. [PubMed: 5083864]

4. Sugarbaker D, DeCamp M, Liptay M: Surgical Procedures to Resect and Replace the Esophagus. Stamford, CT, Appleton & Lange, 1997.

5. Swanson S, Sugarbaker D: The three-hole esophagectomy: The Brigham and Women's Hospital approach. Chest Surg Clin North Am 10:531–52, 2000. [PubMed: 10967755]

6. Swanson SJ, Batirel HF, Bueno R, et al: Transthoracic esophagectomy with radical mediastinal and abdominal lymph node dissection and cervical esophagogastrostomy for esophageal carcinoma. Ann Thorac Surg72:1918–24; discussion 24–5, 2001. 

7. Linden P, Sugarbaker D: Surgical Procedures to Resect and Replace the Esophagus. New York, NY, McGraw-Hill, 2006:885–910.

8. Kuo EY, Chang Y, Wright CD: Impact of hospital volume on clinical and economic outcomes for esophagectomy. Ann Thorac Surg 72:1118–24, 2001. [PubMed: 11603422]

9. Hulscher JB, van Sandick JW, de Boer AG, et al: Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus. N Engl J Med 347:1662–9, 2002. [PubMed: 12444180]



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