Transthoracic esophagectomy and an intrathoracic esophagogastric anastomosis was the standard surgical approach to resectable esophageal carcinoma since the late 1930s, when this operation was first performed successfully. For those of us who became accustomed to this operation, postoperative respiratory insufficiency associated with combined thoracic and abdominal incisions in a debilitated patient and mediastinitis associated with an intrathoracic anastomotic leak were well-recognized, all too frequent and dreaded complications. It was a common teaching that the maximally mobilized stomach would reach to the apex of the right chest for a high intrathoracic esophagogastric anastomosis above the divided azygous vein. There was also a prevailing notion that, while the stomach was the preferred esophageal substitute for patients with carcinoma, for those with benign esophageal disease requiring esophageal resection, preservation of the gastric reservoir was important, and a colonic interposition preferred.
In the mid-1970s, the feasibility of transhiatal esophagectomy (THE) without thoracotomy and a cervical esophagogastric anastomosis (CEGA) for both benign and malignant esophageal disease was reported.
1The theoretic advantages of the approach were (1) avoidance of a thoracotomy and (2) placement of the anastomosis in the neck, where a postoperative leak translated to a relatively benign salivary fistula rather than mediastinitis, with its 50% mortality rate. As is often the case with a novel approach to an old problem, the thoracic surgery “establishment” criticized THE for (1) its lack of meticulous hemostasis and (2) its “blind” and therefore “unsafe” mediastinal dissection. At the time, thoracic surgeons were generally not comfortable with a cervical approach to the esophagus and an esophagogastric anastomosis above the level of the clavicles, and there was often expressed skepticism that the stomach would reach to the neck in the majority of patients. It was also fascinating to hear criticism of THE evolve on the basis of it being a poor oncologic operation, since no attempt was made in THE to resect all regional mediastinal lymph nodes. For years, transthoracic esophagectomy had been performed primarily as a palliative operation, with little emphasis on the importance of removing mediastinal lymph nodes other than those directly associated with the esophageal tumor. But as THE emerged as an alternative to transthoracic esophagectomy, those uncomfortable with the concept could challenge its use on the basis of “oncologic surgical principles.”
- Orringer M.B.
- Sloan H.
Esophagectomy without thoracotomy.
J Thorac Cardiovasc Surg. 1978; 76: 643-654
THE and a CEGA—“the gastric pull-up procedure”—has now become a widely used approach to esophageal resection and reconstruction for both benign and malignant esophageal disease. The operative technique described in this article is a culmination of progressive refinements—mobilizing and handling of the stomach, transhiatal mobilizing of the esophagus, preparing the gastric conduit, transposing it through the mediastinum to the neck, and constructing the cervical esophagogastric anastomosis. Although in my experience, this approach has been applicable in 97% of all patients requiring esophageal resection, it is to be emphasized that there are clear contraindications to proceeding with a THE or situations in which gastric replacement of the esophagus is not feasible. In patients with esophageal cancer, tracheobronchial invasion by upper- or mid-third tumors or aortic invasion demonstrated by magnetic resonance imaging, computed tomography, or esophageal endoscopic ultrasonography preclude a THE. Patients with biopsy-proven distant (M1) carcinoma are not candidates for esophagectomy of any type. In patients who have had prior esophageal surgery (fundoplication, esophagomyotomy, perforation repair) the surgeon must be prepared to convert to an open thoracotomy if excessive mediastinal adhesions preclude a transhiatal approach. In those with esophagogastric junction carcinomas which may necessitate resection of a major portion of the stomach, a barium enema to assess the suitability of the colon as an esophageal substitute and a preoperative bowel preparation are indicated. It cannot be overstated that the single most important contraindication to a THE is the surgeon’s assessment at the time of exploration through the diaphragmatic hiatus that there is fixation of the esophagus to adjacent vital structures that renders this approach unsafe; there is no shame in performing a thoracotomy to resect the esophagus.
Careful patient selection and preoperative assessment are vital to a successful esophagectomy. Evaluation of nutritional status, general medical condition, pulmonary function, and cardiac status is particularly important. Improvements in the preoperative preparation of patients undergoing an esophagectomy are as important in decreasing morbidity and mortality as the operation itself. I require that patients (1) abstain from cigarette smoking and alcohol for a minimum of 3 weeks before esophagectomy, (2) use an incentive inspirometer on a regular basis during this time for preoperative pulmonary physiotherapy, and (3) walk 1 to 3 miles per day to condition themselves for early postoperative ambulation. For those with severe dysphagia, liquid diet supplements by mouth or nasogastric feeding tube are administered at home. Patients are admitted for esophagectomy the day of scheduled surgery.
The patient is positioned supine with a small rolled sheet beneath the scapulae to extend the neck. The head is turned toward the right with the occiput stabilized on a head ring. The skin of the anterior neck, chest, and abdomen is prepared and draped from the mandibles to the pubis and anterior to both midaxillary lines. The arms are padded and placed at the sides, with venous and arterial access lines well protected. In patients in whom there is concern that transthoracic mobilization of the esophagus may be required (eg, patients with middle-third esophageal carcinoma or those being operated on after prior esophageal operations), a set of thoracic instruments and retractors are available. However, I prefer the supine position for virtually all patients undergoing an esophagectomy. If it is necessary to perform a thoracotomy, the abdominal and cervical incisions are closed with several interrupted sutures and covered with adherent plastic drapes, and the patient is turned to the appropriate side for a full posterolateral thoracotomy, clearly the best means of obtaining exposure to the esophagus in the posterior mediastinum. Use of a table-mounted, self-retaining (upper-hand) retractor provides ample exposure for a THE. THE is performed in 4 separate phases: abdominal, cervical, mediastinal, and the anastomosis.
The abdomen is entered through a midline supraumbilical incision (Fig. 1, inset). Exploration of the upper abdomen is performed to determine that the stomach is not too extensively involved by tumor or severe adhesions from prior operations to preclude its use as an esophageal replacement. The triangular ligament of the liver is divided, and the left lobe of the liver is retracted to the right with the liver blade of the upper hand retractor. If a previous gastrostomy has been performed, the stomach is “taken down” from the anterior abdominal wall, and the gastrostomy site is temporarily sutured closed, a more thorough and meticulous closure being performed once the stomach is totally mobilized. Attention is turned to the high greater curvature of the stomach. The greater omentum is retracted to the left, and a filmy layer of omentum along the high greater curvature is incised, allowing entry into the lesser omental sac. With the fingers placed within the lesser sac, downward traction on the greater omentum allows sequential identification and division of the high short gastric and left gastroepiploic vessels. This is typically done using 13-in long right-angled clamps and 2-0 silk ties. Rather than proceeding all the way superiorly along the greater curvature of the stomach and dividing the highest short gastric vessels near the spleen, it is best to continue dissection of the greater omentum away from the stomach, moving more distally toward the pylorus. Every effort is made to preserve the communication of the right and left gastroepiploic vessels when it exists; this is not often the case, however. The right gastroepiploic artery is carefully identified and protected throughout the gastric mobilization. The omentum is separated from the right gastroepiploic vascular arcade at least 1.5 to 2 cm inferior to the vessel to avoid injury to the artery. Mobilization of the greater omentum away from the stomach proceeds to a point just proximal to the level of the pylorus. Attention is then redirected to the high greater curvature of the stomach. With retraction of the stomach to the right and the greater omentum to the left, the highest short gastric vessels are identified, clamped, divided, and ligated, taking care to avoid injury to both the spleen and gastric necrosis from ligating these vessels too near the stomach wall. Adhesions between the posterior gastric wall and the retroperitoneum are divided to ensure full gastric mobility.
With separation of the omentum from the greater curvature of the stomach complete, the peritoneum overlying the esophageal hiatus is incised, and the distal esophagus is encircled with a 1-in rubber drain. Mobilization of the lesser curvature of the stomach is begun by placing a hand behind the stomach from the greater curvature side and identifying the filmy gastrohepatic omentum, which is incised with electrocautery. Division of the gastrohepatic omentum is performed to the level of the diaphragmatic hiatus. If an aberrant left hepatic artery is palpated in the process, the vessel is preserved as the left gastric artery is dissected. The mid stomach is then retracted laterally to the left, thereby tensing the soft tissues along the high lesser curvature. The left gastric vein is identified, clamped, divided, and ligated. Lymph nodes surrounding the origin of the left gastric artery from the celiac axis are mobilized and dissected laterally with the stomach. If there is an aberrant left hepatic artery arising from the left gastric artery, the hepatic blood supply is preserved and the left gastric artery divided distal to the origin of the hepatic vessel. If there is no aberrant hepatic artery, the left gastric artery is doubly ligated and divided as close as possible to its origin from the celiac artery. Soft tissue and lymph nodes adjacent to the left gastric artery are mobilized laterally with the stomach. With mobilization of the high lesser curvature and high greater curvature of the stomach completed, attention is turned to the diaphragmatic hiatus. The phrenoesophageal attachments are divided with electrocautery as near as possible to the hiatal musculature, and this fibroareolar tissue is mobilized with the esophagus. If there is tumor fixation at the diaphragmatic hiatus, it may be necessary to resect a rim of diaphragmatic hiatus along with the specimen. Once the phrenoesophageal attachments have been divided, gentle palpation and blunt dissection of the distal esophagus at the level of the diaphragmatic hiatus allow insertion of a narrow Deaver retractor into the hiatus and lower mediastinum. Periesophageal tissues contained within the mediastinal pleura on either side of the distal esophagus are mobilized en bloc with the esophagus. If during this or subsequent portions of the transhiatal mobilization of the esophagus, entry into either pleural cavity is recognized, the nursing staff is notified that a chest tube will be required. The distal 5 to 10 cm of esophagus is freed from the mediastinum using long right-angled clamps inserted into the inferior mediastinum to allow division and ligation of periesophageal soft tissue under direct vision. As the esophagus is progressively freed, its mobility within the posterior mediastinum is assessed by “rocking” the esophagus (and its contained tumor when present) from side to side to demonstrate fixation to the adjacent spine, prevertebral fascia, or aorta. Generally, such direct mobilization of the esophagus and its periesophageal soft tissues is possible nearly to the level of the carina working upward through the diaphragmatic hiatus. After determining that transhiatal esophageal mobilization will likely be possible, the lower mediastinum is packed with an abdominal pack to encourage hemostasis, and attention is turned toward completion of the abdominal phase of the operation.
A generous Kocher maneuver is performed until there is sufficient mobility of the duodenum to allow the pylorus to be displaced from its normal location in the right upper quadrant of the abdomen to the level of the xiphoid process medially. Two 3-0 silk traction sutures are placed through the superior and inferior aspects of the pylorus, which is gently elevated in preparation for performance of a pyloromyotomy. A 1.5 to 2 cm long pyloromyotomy is performed using electrocautery and a fine-tipped vascular mosquito clamp to gently dissect and elevate the pyloroduodenal musculature away from the underlying submucosa. The pyloromyotomy begins on the gastric side, approximately 1.5 cm from the pylorus and extends through the pylorus and onto the duodenum for another 0.5 to 1 cm. If the pyloroduodenal mucosa is violated, the hole is closed with several interrupted 5-0 polypropylene sutures. A hemoclip is placed near the pylorus on each of the 2 previously placed traction sutures, which are then cut. These hemoclips are used to provide radiographic localization of the pylorus in future contrast studies.
A 14F rubber jejunostomy feeding tube is inserted 8 to 10 inches beyond the ligament of Treitz and secured in place using a Weitzel maneuver. The jejunostomy tube protruding from the inferior end of the abdominal incision is covered with a folded towel, which is clamped on either side to the drapes to prevent inadvertent dislodging of the jejunostomy during the subsequent portions of the operation.
Mediastinal (Transhiatal) Dissection
Once the esophagus is divided in the neck, the stapled proximal end is grasped with an Allis clamp, which is elevated and retracted toward the right as the stomach is gently pulled downward and elevated out of the abdominal wound, drawing the attached thoracic esophagus out of the posterior mediastinum through the diaphragmatic hiatus. As soon as the esophagus is delivered out of the posterior mediastinum, a narrow Deaver retractor is inserted into the diaphragmatic hiatus as the Saratoga sump catheter (Argyle) is advanced downward through the cervical incision into the posterior mediastinum. The posterior mediastinum is carefully inspected through the hiatus as blood is evacuated with the sump catheter. Bleeding from an aortic esophageal artery may be identified, controlled with a long right-angled clamp, and the vessel ligated. In addition to looking for any untoward bleeding, either side of the mediastinal pleural is inspected for its integrity both visually and by palpation. If entry into either pleural cavity during the esophageal dissection has occurred, a 28F chest tube is inserted in the appropriate anterior axillary line in approximately the sixth intercostal space, and the tip of the tube is advanced upward to the apex of the chest. The tube is secured to the skin and connected to underwater chest tube suction.
The blades of the upper-hand retractor are removed from the abdominal wound during chest tube insertion to minimize distortion of the proposed entry site of the chest tube. Once the required chest tube(s) is in place, the 2 upper-hand body wall retractor blades are reinserted into the abdominal wound, but the “liver blade” is no longer used, since retraction of the liver upward and to the right draws the lesser curvature of the stomach along with it and minimizes the needed mobility and upward reach of the stomach. With major posterior mediastinal bleeding excluded, 1 large abdominal pack is inserted into the posterior mediastinum through the diaphragmatic hiatus to tamponade minor bleeding during further preparation of the stomach. The hiatus retractor is removed. Through the cervical incision, while simultaneously protecting the tracheoesophageal groove from direct contact, the upper mediastinum is gently packed with 2 smaller gauze packs (thoracic packs). The divided cervical esophagus and cervical wound are covered with a moist pack as attention is redirected to the abdomen.
As the technique of transhiatal esophageal mobilization has been refined, our focus has shifted toward methods of avoiding a subsequent cervical esophagogastric anastomotic leak. Minimizing trauma to the mobilized gastric tip has emerged as the single most important factor in ensuring a healthy, well-vascularized cervical esophagogastric anastomosis. Tracture sutures into the tip of the stomach and suction devices used to pull the stomach through the posterior mediastinum and into the neck wound are therefore avoided. The overarching principle has become that the stomach should be pink and healthy in the abdomen at the completion of gastric mobilization and pink and healthy in the cervical wound when it is time to begin the CEGA, if one hopes to minimize the incidence of anastomotic leak and its substantial late morbidity. Preservation of as much stomach as is possible, rather than attempting to “tubularize” the stomach to more closely approximate the size of the esophagus, is advocated to retain as much of the gastric submucosal collateral circulation as is possible.
While early in my experience, “suspension sutures” between the gastric tip and cervical prevertebral fascia were placed with the intent of eliminating tension on the cervical esophagogastric anastomosis, such sutures are now avoided to minimize both gastric tip trauma and the potential risk of bacterial seeding of a cervical disk and subsequent vertebral osteomyelitis. Once the stomach has been manipulated through the posterior mediastinum, beneath the aortic arch, through the thoracic inlet, and into the cervical incision, its retraction downward into the mediastinum is seldom a problem. Avoidance of torsion of the stomach during its mobilization through the posterior mediastinum is critically important. One must be aware of the proper orientation of the lesser curvature gastric staple suture line on the right side of the intrathoracic stomach and the portion of the stomach mobilized into the cervical wound. In addition, gentle simultaneous palpation of the anterior surface of the stomach through the diaphragmatic hiatus and the cervical incision ensures that no twist has occurred.
To avoid potential infectious complications from contamination of the abdominal wound by oral bacteria, we routinely complete the abdominal phase of the operation before opening the cervical esophagus and beginning construction of the cervical esophagogastric anastomosis. After mobilizing the gastric tip into the cervical incision, a ligated high short gastric vessel is clamped with a hemostat to gently “anchor” the stomach in the neck, and the neck wound is covered with a saline-moistened gauze pack. The color of the stomach within the cervical wound and the position of the hemostat are assessed several times as the abdominal phase of the operation is completed. Inevitably, the diaphragmatic hiatus has been inordinately stretched during the transhiatal mobilization. Before closing the abdomen, the left side of the hiatus is narrowed with one or two #1 silk sutures, so that the hiatus feels loose with 3 fingers alongside the stomach. The edge of the diaphragmatic hiatus is sutured to the anterior gastric wall with one or two 3-0 silk sutures. The previously mobilized left hepatic lobe is returned to its proper location, and the lateral edge of the divided triangular ligament of the liver is sutured to the left side of the diaphragmatic hiatus to further discourage migration of an intestinal loop into the chest through the diaphragmatic hiatus. The pyloromyotomy generally comes to rest 3 to 4 cm inferior to the level of the diaphragmatic hiatus. The feeding jejunostomy tube is brought out through the left upper quadrant of the abdomen, the jejunostomy site is sutured to the anterior abdominal wall, and the tube is secured to the skin with suture. In the event that venous congestion of the gastric tip in the cervical wound develops, the diaphragmatic hiatus should be inspected to be certain that is has not been excessively narrowed, and a crural suture should be removed if necessary. The abdominal incision is then closed, covered with a sterile towel, and excluded from the field as attention is turned to the neck for construction of the cervical esophagogastric anastomosis.
Cervical Esophagogastric Anastomosis
Since 1976, my associates and I have performed approximately 1,950 transhiatal esophagectomies without thoracotomy at the University of Michigan, nearly 80% for carcinoma and 20% for benign disease.
4The patients have ranged in age from 14 to 92 years (average 62 years), one quarter of the patients being 71 years of age or older. The stomach was used as the esophageal substitute in 97% of these patients. Colon was required to replace the esophagus only in those with a history of a prior gastric resection for peptic ulcer disease or a caustic gastric injury resulting in scarring and a contracted stomach. Categorically, the properly mobilized stomach will virtually always reach to the neck for a cervical esophagogastric anastomosis.
- Orringer M.B.
- Marshall B.
- Iannettoni M.D.
Transhiatal esophagectomy clinical experience and refinements.
Ann Surg. 1999; 230: 392-400
There have been 4 intraoperative deaths (<1%) due to uncontrollable mediastinal bleeding during esophageal mobilization. Additional intraoperative complications included the need for a chest tube(s) because of entry into one or both pleural cavities in approximately 75% of patients; a splenectomy (3%); membranous tracheal laceration (<1%); and violation of the gastric or duodenal mucosa during performance of the pyloromyotomy (<2%), managed successfully in all cases by repair with interrupted 5-0 polypropylene sutures and a buttress of the repair with adjacent omentum. Postoperatively, 6 patients (<1%) have required a thoracotomy for control of mediastinal bleeding occurring within 24 hours of THE. Recurrent laryngeal nerve injury occurred in <5% of patients overall, in less than 2% during the past 5 years. The importance of avoiding the placement of a metal retractor against the tracheoesophageal groove during any part of the cervical dissection and construction of the anastomosis is clear. Chylothorax has occurred in <1% of patients and has been successfully managed with an aggressive policy of early ligation of the injured thoracic duct.
5In this large series of esophagectomies, <2% of patients have experienced clinically significant atelectasis or pneumonia, a testimony to improved preoperative preparation (no smoking, walking, and use of an incentive inspirometer), less impairment of pulmonary function with an upper midline abdominal incision than with a combined thoracic and abdominal approach, and use of epidural anesthesia to manage postoperative pain. The overall cervical esophagogastric anastomotic leak rate of 13% in our first 1,000 patients treated with THE has now been reduced to <4% since initiation of the side-to-side stapled CEGA,
- Orringer M.B.
- Bluett M.
- Deeb G.M.
Aggressive treatment of chylothorax complicating transhiatal esophagectomy without thoracotomy.
Surgery. 1988; 104: 720-726
6which is illustrated in this article. Gastric tip necrosis necessitating takedown of the CEGA and construction of a cervical esophagostomy has occurred in <1% of patients.
- Orringer M.B.
- Marshall B.
- Iannettoni M.D.
Eliminating the cervical esophagogastric anastomotic leak with a side-to-side stapled anastomosis.
J Thorac Cardiovasc Surg. 2000; 119: 277-288
7The overall hospital mortality rate has been <4%, and 82% have experienced no postoperative complications.
- Iannettoni M.D.
- Whyte R.I.
- Orringer M.B.
Catastrophic complications of the cervical esophagogastric anastomosis.
J Thorac Cardiovasc Surg. 1995; 110: 1493-1501
In general, the functional results of esophageal replacement with stomach and CEGA have been good, approximately 80% reporting absolutely no symptoms related to eating, or minimal occasional dysphagia, regurgitation, or postvagotomy “dumping” symptoms requiring no treatment; 17%, a “fair” result, requiring an occasional dilatation of a cervical esophagogastric anastomotic stricture or periodic need for medication to control reflux symptoms or dumping; and 3%, a “poor” result, requiring regular dilatation for a severe CEGA stricture or chronic use of medication to control reflux or intractable dumping symptoms.
For patients with esophageal cancer treated with a THE and CEGA, the overall 2-year survival rate has been approximately 48% and the 5-year survival rate 24%. Survival rates for a group of 49 of our patients receiving neoadjuvant chemotherapy and radiation therapy and being complete responders (T0N0) on final pathology were 86% at 2 years and 48% at 5 years. We continue to advocate neoadjuvant chemoradiation therapy before THE in patients with stage II and III esophageal cancer who are less than 75 years of age and physically able to tolerate this treatment.
THE and a CEGA is an effective means of managing the patient with both benign and malignant esophageal disease requiring resection. The advantages of THE over transthoracic esophagectomy have been demonstrated in a recent meta-analysis of 7,527 patients.
8A successful THE requires rather rigid adherence to a series of technical steps outlined in this article. Our patients typically have epidural catheters for postoperative analgesia and are extubated in the operating room after a 3 to 5-hour operation and a chest radiograph that confirms there is no unrecognized hemo- or pneumothorax. They do not go to the intensive care unit but rather directly to our thoracic surgery general care floor, where immediate use of their incentive inspirometer used preoperatively is resumed, and ambulation the next day is begun. The nasogastric tube is discontinued on the third postoperative day, oral liquids are begun on day 4, and diet is progressively advanced to a soft diet by day 7. Jejunostomy tube feeding is begun on postoperative day 3 and is gradually tapered as oral intake improves. A routine barium swallow examination is obtained on day 7 to document (1) integrity of the anastomosis, (2) adequacy of gastric emptying, and (3) any evidence of partial small bowel obstruction at the jejunostomy tube site. Patients are typically discharged from the hospital on the seventh or eighth postoperative day.
- Hulscher J.B.
- Tijssen J.G.
- Obertop H.
- et al.
Transthoracic versus transhiatal resection for carcinoma of the esophagus a meta-analysis.
Ann Thorac Surg. 2001; 72: 306-313
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- Anterior approach to carcinoma of the superior mediastinal and cervical segments of the esophagus.J Thorac Surg. 1957; 33: 663-669
- Partial median sternotomy.J Thorac Cardiovasc Surg. 1984; 87: 124-129
- Transhiatal esophagectomy.Ann Surg. 1999; 230: 392-400
- Aggressive treatment of chylothorax complicating transhiatal esophagectomy without thoracotomy.Surgery. 1988; 104: 720-726
- Eliminating the cervical esophagogastric anastomotic leak with a side-to-side stapled anastomosis.J Thorac Cardiovasc Surg. 2000; 119: 277-288
- Catastrophic complications of the cervical esophagogastric anastomosis.J Thorac Cardiovasc Surg. 1995; 110: 1493-1501
- Transthoracic versus transhiatal resection for carcinoma of the esophagus.Ann Thorac Surg. 2001; 72: 306-313
© 2005 Elsevier Inc. Published by Elsevier Inc.
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