Adult Chest Surgery

Chapter 19. Left Thoracoabdominal Approach 

 

The thoracoabdominal approach to resection of the esophagus is most useful with tumors of the distal esophagus that lie inferior to the aortic arch as well as lesions of the gastric cardia. Eggers first reported the use of a left thoracoabdominal incision for a partial resection of the esophagus in 1931.Eventual resection of the distal esophagus and replacement with mobilized stomach was described by Adams and Phemister in 1938.Finally, Sweet described the technique of anastomosis based on the principles of meticulous technique and attention to detail.The thoracoabdominal incision provides excellent access to the abdomen. With extension of the incision through the costal arch, left rectus muscle, and diaphragm, the esophagus can be mobilized and replaced with stomach, colon, or jejunum depending on the situation. In addition, with an upward paravertebral extension of the incision and Sweet's double-rib resection, one can reach almost any lesion of the intrathoracic esophagus.3

PREOPERATIVE ASSESSMENT

Because of the magnitude of a thoracoabdominal esophagectomy or any esophagectomy, it is important to engage in a rigorous selection and staging workup before proceeding with surgical intervention. While patients with widely disseminated disease and extreme comorbid illnesses are easily eliminated from surgical consideration, most patients undergo a systematic evaluation of resectability and a review of risk factors.

The initial evaluation of patients with esophageal carcinoma should include a contrast esophagogram and upper gastrointestinal endoscopy. Esophagoscopy with biopsy of the lesion is essential to obtain a tissue diagnosis, to confirm that there is not a second synchronous esophageal carcinoma, and to obtain a more accurate assessment of the extent of the tumor both grossly and microscopically by mucosal biopsy. Endoscopy also permits detection of Barrett's esophagus and evaluation of potential gastric involvement.

Further evaluation by CT imaging of the thorax and abdomen provides information regarding invasion of adjacent structures (e.g., pericardium and diaphragm), tracheobronchial invasion, and mediastinal lymph node involvement. However, recent reports have noted the accuracy of CT imaging for the presence of locoregional disease to be as low as 50%.4,5 CT imaging of the abdomen with contrast material also assists in the detection of hepatic metastasis.

Endoscopic ultrasound (EUS) is used commonly in the staging of esophageal cancer. It provides valuable data regarding the depth of tumor invasion, potential nodal involvement, and the opportunity for fine-needle aspiration of local lymph nodes. Accuracy in predicting T status with EUS in esophageal cancer is greater than 80%, and accuracy in predicting N status ranges around 70%.EUS is clearly superior to CT in T staging, and CT appears more accurate in predicting T4 disease.7

PET imaging is becoming a more valuable tool in the evaluation of distant metastatic disease. PET scans have almost no role in the determination of T status, but with N disease, the results are encouraging, with reports of greater than 90% accuracy.(PET imaging may have a further application in monitoring for disease recurrence.)

An evaluation of preoperative risk factors includes an assessment of pulmonary and cardiovascular function. Pulmonary function testing should be obtained if there are any questions as to the patient's respiratory status. Smoking should be stopped well in advance of surgery. A cardiovascular assessment also should be performed with a history and physical examination, as well as an ECG and, if deemed necessary, a stress test or cardiac catheterization.

TECHNIQUE

All esophagectomy procedures, including thoracoabdominal esophagectomy, begin with endoscopy in the OR. Repeat endoscopy provides confirmation of the location of the tumor and evaluation of the esophagus for a second lesion or extension into the stomach. With tumors of the middle and upper thirds of the esophagus, bronchoscopy also should be performed. A double-lumen endotracheal tube is placed, permitting deflation of the left lung during the thoracic dissection, and broad-spectrum antibiotics are given before surgical incision and may need redosing during the procedure.

The patient is positioned in the right lateral decubitus position, which permits access to both the left side of the chest and the upper abdomen. The initial step is an exploration of the abdomen through the medial portion of the incision. This permits inspection of the liver, palpation of the celiac nodes, and further evaluation of the stomach. With no metastatic disease identified, the incision is carried into the chest over the seventh or eighth rib (Fig. 19-1). The higher the interspace, the easier it is to perform the anastomosis. As the diaphragm is divided, it should be clearly marked with stitches to allow reapproximation at the conclusion of the case.

Figure 19-1.

 

The incision is carried into the chest over the seventh rib. The higher the interspace, the easier it is to perform the anastomosis. As the diaphragm is divided, it should be clearly marked with stitches to allow reapproximation at the close of the procedure.

Thoracic Dissection

Thoracic exploration begins with an inspection of the left lung, diaphragm, pericardium, and pleural space. Opening of the mediastinal pleura permits further inspection of the extent of the tumor, evaluation of possible invasion of the aorta or lung, and determination of metastases to the paraesophageal and paraaortic lymph nodes.

Dissection begins in the chest, freeing the esophagus and draining the nodes in continuity. The descending aorta is completely bared by division of the aortoesophageal branches. Aortic involvement precludes resection. The esophagus is encircled after the dissection is carried medially along the posterior aspect of the mediastinum up to the level of the left main stem bronchus, away from the proximal tumor margin. Gentle traction on the esophagus facilitates dissection of the paraesophageal nodes and fat. The thoracic duct is rarely seen with the left thoracoabdominal approach and is not routinely ligated.

It may be necessary to mobilize the esophagus superior to the level of the aortic arch. Division of aortic intercostal vessels is necessary to gain adequate mobilization of the arch. With mobilization of the arch, the left recurrent nerve must be carefully preserved. In addition, it is at this point that the thoracic duct is most vulnerable to injury, and the left main stem bronchus also must be examined for injury to the membranous wall.

Abdominal Dissection

Mobilization of the stomach begins with the division of the greater omentum. This is performed outside the gastroepiploic arcade formed by the left gastroepiploic artery arising from the splenic artery and the right gastroepiploic artery arising from the gastroduodenal artery at the pylorus. Use of the stomach to replace the esophagus hinges on the patency of the right gastroepiploic artery and the right gastric artery. The transverse colon is placed on stretch, and the lesser sac is entered at the thinnest portion of the omentum. The dissection is carried toward the pylorus, dividing the small omental branches of the epiploic artery. Cautery coagulation is avoided for fear of damaging the gastroepiploic arcade. Dissection then is carried toward the spleen, where the left gastroepiploic artery is ligated at the upper end of the arcade as it arises from the splenic artery. Management of the short gastric arteries deserves special attention, and it must be ensured that the ties on the stomach are secure because they can slip with distention of the stomach within the thorax. Alternative methods for controlling the short gastric vessels include use of the Harmonic Scalpel (Ethicon-Endosurgery, Inc.) or the LDS (US Surgical, Norwalk, CT) stapling device.

At the level of the esophagogastric junction, the reflection of the peritoneum is divided, and the esophagus is encircled. Passage of a Penrose drain allows for upward traction on the abdominal esophagus and dissection of the lesser curve. The thin avascular gastrohepatic ligament is divided, and placement of a second thin Penrose drain around the stomach at the level of the incisura can further assist with dissection of the lesser curve. The gastrohepatic ligament should be inspected for an accessory branch of the left hepatic artery. If one is identified, it should be occluded temporarily with a bulldog clamp and the liver assessed for viability. If concern exists about the vascular supply of the liver, the accessory branch must be preserved. This can be done by skeletonizing the accessory branch to its origin from the left gastric artery and preserving these vessels.

Management of the left gastric artery is best accomplished by exposing it with the greater curve rotated to the right, often with the assistance of the Penrose drains. The filmy retrogastric adhesions can be taken down sharply to the level of the pylorus, and the celiac axis can be identified by palpation. With further dissection, the left gastric artery is exposed, doubly tied, and suture ligated at its origin with 2-0 silk suture. The left gastric vein is also suture ligated and divided. At this point in the operation, the stomach is free except for the pylorus/duodenum and right gastroepiploic artery arising from the gastroduodenal artery.

Transection of the Stomach

For a distal esophagectomy performed for cancer, the celiac axis nodes and the nodes along the left gastric artery should have been swept up with the specimen. The stomach should be transected from a point on the greater curvature opposite the emergence of the left gastroepiploic artery to a point on the lesser curvature below the lowest branch of the left gastric artery. The fundus should be preserved to maximize the length of the gastric tube, and it is important not to assume adequate gastric length and amputate the conduit prematurely (Fig. 19-2). After the stapler is fired and the stomach is divided, the staple line is turned in with 4-0 silk Lembert stitches (Fig. 19-3).

Figure 19-2.

 

The fundus should be preserved (A, solid line) to maximize gastric length, which permits extension of the gastric tube to the neck (a, solid line) if necessary. For a distal lesion where only a portion of the esophagus needs to be resected (b, dashed line), more of the gastric fundus may be taken in creating the gastric conduit (B, dashed line). It is important not to assume adequate gastric length and amputate the conduit prematurely. Thecircles marked A' and B' indicate the proposed esophagogastric site.

 

Figure 19-3.

 

The staple line of the gastric conduit is turned in with interrupted Lembert sutures prior to completing the anastomosis.

 

If required, further mobilization of the stomach is performed via a Kocher maneuver starting at the pylorus and extending around the C curve of the duodenum. Care must be taken to avoid the right gastric artery and the common bile duct during the dissection. The duodenum and pancreas then are swept off the inferior vena cava by blunt dissection. The Kocher maneuver can mobilize the stomach sufficiently to reach to the thoracic inlet, which is rarely needed for the thoracoabdominal approach.

Drainage of the stomach remains controversial. In our opinion, a gastric drainage procedure makes sense from a physiologic perspective; that is, after vagotomy, there is clinical experience to suggest that obstructive symptoms are encountered without a drainage procedure. A pyloromyotomy is preferred because it does not distract from the length of the stomach. The pyloric muscle may retain some of its barrier capacity against bile reflux into the esophagus (Fig. 19-4). Initially, traction sutures are placed on either side of the pyloric vein to facilitate exposure. Once the submucosal plane is reached, the incision is carried onto the first portion of the duodenum and distal stomach. The myotomy is usually limited to 2 cm. If the mucosa is inadvertently violated, the safest course of action is to convert the procedure to a Heineke-Mikulicz pyloroplasty with coverage of the pyloroplasty with omentum.

Figure 19-4.

 

A. A 2-cm incision across the pylorus provides exposure of the muscle for division down to the mucosal layer. B. The principal risk of entry is where the duodenal mucosa covers the undersurface of the pyloric muscle.

Anastomosis

The gastroesophageal anastomosis has been performed at the Massachusetts General Hospital in a two-layer fashion with interrupted 4-0 silk sutures for more than 50 years (Fig. 19-5). Basic principles of performing the anastomosis are (1) to avoid placing crushing clamps on tissue to be included in the anastomosis and (2) to transect the esophagus with a fresh knife blade rather than cautery. There must be no tension on the anastomosis. The interrupted fashion of the anastomosis does not allow for purse-stringing and permits blood vessels to reach the anastomotic edge. If the anastomosis is sufficiently secure after these basic principles are followed, there should be no concern about placing the anastomosis in the mediastinum.

Figure 19-5.

 

A. The first step in the Sweet anastomosis developed at the Massachusetts General Hospital. An end-to-side anastomosis is initiated with excision of a button of gastric wall. This button must not be placed too close to the gastric turn-in. The button actually can be placed quite close to the greater curvature, often between the last two branches of the gastroepiploic arcade. The outer posterior row of the anastomosis is performed with interrupted mattress sutures of fine silk placed across the longitudinal muscle fibers of the esophagus. All these sutures are placed before tying. B. The gastric button has been excised. With the specimen still attached and excluded with the right-angle clamp, the mucosae of the esophagus and stomach are approximated with interrupted fine silk sutures. C. The corner of the anastomosis is turned to begin the anterior row of sutures. These are placed, again in interrupted fashion, with the knots tied on the inside. D. Omentum is brought into the chest and used to wrap the anastomosis.

The anastomosis is performed end (esophagus) to side (gastric tube). A point approximately 2 cm from the gastric suture line is selected, and a small circle of the size of a nickel is scored in the serosa with a knife blade. The small submucosal vessels exposed by this maneuver then are ligated with fine silk. The specimen remains attached to the proximal esophagus and is reflected proximally to expose the planned line of transection. A long right-angled clamp is placed just distal to the planned line of transection. The two-layer anastomosis is performed in the following fashion: The first row of 4-0 silk sutures is placed in a horizontal mattress fashion between the muscularis of the esophagus and the serosa–muscular layer of the stomach. A total of four to six sutures are placed posteriorly and tied while the stomach is brought up to the esophagus (because the esophagus is a fixed structure). This outer posterior layer should cover only one-third of the circumference, which provides exposure for placement of an inner layer.

The esophagus then is opened sharply 4–5 mm distal to the initial row of sutures, and the incision is extended to each corner. The mucosal button of the stomach then is opened, and the inner back row of oiled 4-0 silk sutures is placed. Each stitch is placed approximately 5 mm back from the cut edge. The sutures should include the full thickness of the stomach and submucosa and mucosa of the esophagus. Attempts should be made not to manipulate the mucosa. Elevating the previous stitch guides placement of the next. Once the posterior row is complete, the esophagus can be transected. The nasogastric tube is advanced through the anastomosis to the level of the gastric antrum. The anterior inner row is completed in a similar fashion such that the knots are always within the lumen with complete inversion of the mucosa. The outer layer of horizontal mattress sutures is completed over the remaining two-thirds of the circumference. The stomach is suspended by a series of nonabsorbable sutures to the fascia overlying the thoracic spine. Omentum is brought into the chest and used to wrap the anastomosis.

A jejunostomy tube is placed at the conclusion of the case for feeding purposes to speed recovery to improve nutrition, and to promote healing. Patients are usually discharged on tube feeding and limited oral intake. The jejunostomy tube is usually removed at the first postoperative visit.

POSTOPERATIVE MANAGEMENT

Patients spend the first night in an ICU. With a significant amount of dissection and mobilization of stomach and esophagus, it is important to maintain an adequate volume status and not engage in the use of pressors for the management of blood pressure. This avoids spasm of the right gastroepiploic artery and compromise of the anastomosis.

The nasogastric tube remains in place for several days, and a barium swallow evaluation is performed approximately 1 week after surgery. During the course of the first week, patients are often started on enteral feeds via the jejunostomy tube, and these feedings are increased over the course of several days.

The left chest tube is left in place until drainage slows, which often takes several days. It is not necessary to leave the chest tube in place until the barium swallow is performed, and it is often discontinued between postoperative days 4 and 6.

PROCEDURE-SPECIFIC COMPLICATIONS

Many potential complications exist after a thoracoabdominal esophagectomy, the most dreaded being an anastomotic leak. Smaller anastomotic leaks that appear to drain back into the esophagus can be followed in a conservative manner and should heal. A leak developing after 2–4 weeks may only give rise to a localized empyema, which may be managed initially with percutaneous drains but may need a more definitive procedure. A large intrathoracic leak during the early postoperative period can cause an acute pyopneumothorax, fever, dyspnea, and shock. These patients need to be emergently explored and potentially diverted.

Other potential complications include gastric conduit necrosis, aortoanastomotic fistula, delayed gastric emptying, and anastomotic stricture. Approximately 5–10% of patients develop an anastomotic stricture, and most respond to a single dilation.

Reflux is also a common complaint after esophagectomy and gastric pull-up. It has been demonstrated that the severity of the reflux depends on the height of the anastomosis, with lower anastomoses leading to more reflux. Often conservative measures are sufficient to control reflux, including smaller, more frequent meals, elevation of the head of the bed, and acid suppression.

SUMMARY

Thoracoabdominal esophagectomy is one of several surgical approaches to carcinoma of the esophagus. In a series from the Massachusetts General Hospital, we reported a 2.9% mortality with no anastomotic leaks in 101 patients, thus demonstrating excellent results with a low mortality and morbidity.Before proceeding to surgery, a standard and logical staging evaluation should be completed and clearance obtained from a cardiac and pulmonary perspective. Postoperative care is similar to that for other techniques of esophageal resection, with careful attention paid to pulmonary physiotherapy and early mobilization. Potential complications include anastomotic stricture, anastomotic leak, and reflux.

CASE HISTORY

A 76-year-old man presented with worsening dysphagia and moderate weight loss. His past medical history was significant for coronary artery disease status post coronary artery bypass grafting and diabetes mellitus. Physical examination was unremarkable. An initial barium swallow demonstrated a mass lesion in the distal esophagus. Endoscopy revealed a tumor at 37 cm from the incisors with thickening of the gastroesophageal junction on retroflexed view. Biopsies were read as adenocarcinoma. Further workup included EUS, which staged the tumor as uT2N0, as well as CT scans of the chest and abdomen that were without enlarged lymph nodes and without liver or lung metastases. PET imaging revealed no evidence of metastatic spread. Other preoperative testing included an ECG, a stress test, pulmonary function tests, and a full laboratory evaluation, which were within normal limits. With the tumor located in the distal third of the esophagus, we proceeded with a thoracoabdominal esophagectomy. No metastatic disease was found at the time of surgery, and the patient underwent a complete lymph node dissection. A hand-sewn esophagogastric anastomosis was performed. Pathology returned a T2 tumor with no evidence of metastatic disease in 28 lymph nodes sampled.

The patient was extubated in the OR and transferred to the surgical ICU after the procedure. He was transferred to the general thoracic surgical floor on postoperative day 1. Physical therapy began immediately to mobilize the patient. With the return of bowel function, tube feeds were started and advanced slowly. A nasogastric tube remained in place. On postoperative day 7, a barium swallow demonstrated no anastomotic leak and adequate gastric emptying. The patient started oral feeding and was discharged on postoperative day 9. At clinic follow-up, he complained of mild reflux symptoms that were controlled adequately with proton pump inhibitors. Follow-up imaging has been negative for recurrence, and the patient has not required subsequent dilations.

EDITOR'S COMMENT

This approach used by the MGH group successfully for several decades is similar to the Ellis left transthoracic in terms of the exposure of the GE junction. It does afford better access to the abdomen and therefore the possibility of doing a pyloroplasty. On the other hand, the transcostal incision is the most painful one in thoracic surgery and should be avoided if at all possible. This is also commonly used in Asia, with thin patients with early tumors even allowing anastomosis above the aortic arch.

–MJK

REFERENCES

1. Eggers C: Resection of the thoracic portion of the esophagus for carcinoma. Surg Gynecol Obstet 52:739, 1931. 

2. Adams W, Phemister D: Carcinoma of the lower thoracic esophagus: Report of a successful resection and esophagogastrectomy. J Thorac Surg 7:621, 1938. 

3. Sweet R: Surgical management of carcinoma of the mid-thoracic esophagus: Preliminary report. N Engl J Med 223:1, 1945. 

4. Wu LF, Wang BZ, Feng JL, et al: Preoperative TN staging of esophageal cancer: comparison of miniprobe ultrasonography, spiral CT and MRI. World J Gastroenterol 9:219–24, 2003. [PubMed: 12532435]

5. Chandawarkar RY, Kakegawa T, Fujita H, et al: Comparative analysis of imaging modalities in the preoperative assessment of nodal metastasis in esophageal cancer. J Surg Oncol 61:214–7, 1996. [PubMed: 8637210]

6. Lightdate C: Staging of esophageal cancer: Endoscopic ultrasonography. Semin Oncol 21:438, 1994. 

7. Riedel M, Stein HJ, Mounyam L, et al: Predictors of tracheobronchial invasion of suprabifurcal oesophageal cancer. Respiration 67:630–7, 2000. [PubMed: 11124645]

8. Himeno S, Yasuda S, Shimada H, et al: Evaluation of esophageal cancer by positron emission tomography. Jpn J Clin Oncol 32:340–6, 2002. [PubMed: 12417599]

9. Mathisen DJ, Grillo HC, Wilkins EW Jr, et al: Transthoracic esophagectomy: A safe approach to carcinoma of the esophagus. Ann Thorac Surg 45:137–43, 1988. [PubMed: 3277551]



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