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The combination of a laparotomy and right thoracotomy for resection of cancer of the esophagus was proposed in 1946 at the Royal College of Surgeons' Hunterean Lecture by Ivor Lewis. As originally described, the Ivor Lewis esophagectomy was a two-stage procedure.
The first stage consisted of a laparotomy and mobilization of the stomach, and the second stage performed 10 to 15 days later was a right thoracotomy, resection of the esophagus, and esophagastric anastomosis. The operation was successful in five of seven patients, which was a tremendous feat for this era. Over time, the combined approach evolved into a single procedure, and the Ivor Lewis esophagectomy continues to be widely used.
The Ivor Lewis esophagectomy is appropriate for tumors of the distal esophagus and gastroesophageal junction. For cancer located at or above the carina, the author prefers the three-field (McKeown) approach. The Ivor Lewis esophagectomy is the author's first choice for T2N0 and T3N0 or TanyN1 lesions following induction therapy located below the carina. Although early T1 tumors and high-grade dysplasia in Barrett's are amenable also to this process, the author tends to use more minimally invasive approaches.
The advantages of the Ivor Lewis esophagectomy include excellent visualization of all parts of the operation, ability to perform two-field lymphadenectomy, lower leak rate, and lower chance of injury to the recurrent laryngeal nerves.
The disadvantages include the pain associated with a right thoracotomy, potential for higher respiratory complications, and increased toxicity if a leak occurs. If the anastomosis is performed high in the right chest, there is not a huge gain in esophageal length resected for a “routine” cervical anastomosis.
There are several components of the Ivor Lewis esophagectomy that may differ from surgeon to surgeon. These include the following: technique of pyloric drainage (pyloromyotomy versus pyloroplasty versus Botox injection versus none); inclusion of jejunostomy; width of the gastric tube; technique of anastomosis (mechanical versus hand sewn); etc. What follows is a technique that has evolved over time, can be taught to surgical residents, and has produced satisfactory patient results.
Postoperative care after Ivor Lewis esophagectomy should be directed at prevention of respiratory complications, pain control, careful attention to fluid fluxes, identification and treatment of atrial arrhythmias, and maintenance of nutrition, especially after induction therapy. Respiratory complications are an important source of morbidity and, more importantly, mortality. The author routinely uses a thoracic epidural catheter to reduce thoracotomy pain and promote respiratory toilet. The Massachusetts General Hospital thoracic surgeons promulgate early extubation as a means to decrease pneumonia.
Acute respiratory distress syndrome on postoperative days 1 or 2 is especially devastating. The author believes that preoperative micro-aspiration and the tremendous systemic inflammatory response engendered by esophagectomy are culprits. The role of preoperative chemoradiotherapy to morbidity remains controversial. Acute respiratory distress syndrome carries a very high risk of mortality (at least 50%). Further investigative studies into its inciting factors, early identification, and aggressive intervention measures are critical to decreasing mortality.
Comparison of outcomes after Ivor Lewis esophagectomy with the transhiatal or other approaches is hindered by the lack of prospective randomized trials, the different time periods, the proportion of patients undergoing induction treatment, and the lack of consistent staging. Length of intensive care unit stay or median hospital stay cannot be used as surrogate measures of morbidity because not all surgeons have access to specialized nursing floors, step down units, etc. Median length of stay is dependent on the physician's philosophy regarding timing of Gastrografin/barium swallow and initiation of diet. The author obtains a swallow on postoperative day 6. Most patients are discharged home on nighttime jejunostomy tube feedings and a soft diet a few days later.
Atrial arrhythmia is the most common complication in the author's series. It is usually easily controlled with amiodarone.
The technical complications include chylothorax, anastomotic leak, staple line leaks, anastomotic stricture, and dreaded gastric tip necrosis. Injury to recurrent laryngeal nerve should be infrequent unless an aggressive upper mediastinal lymph node dissection is performed. Since adopting an endostapler anastomosis, a true anastomotic leak has been rare. However, small leaks from the gastric staple line or at the site of closure of the esophagotomy/gastrotomy do occur. These leaks can almost always be addressed by computed tomographic directed percutaneous catheter drainage and conservative management. The author routinely ligates the thoracic duct just above the diaphragm.
Comparison of complications reported in a recent series
is hindered by the lack of uniform definitions of complications, the nonreporting of events, and the mixture of surgical approaches in some of the reports. The incidence of pneumonia has varied from 8% to 26%.
Recently, minimally invasive Ivor Lewis esophagectomy has become feasible at certain centers. It is too early to define its role. It is critical that the same oncologic principles be followed, and there is no selection bias present. The open Ivor Lewis esophagectomy will serve as the benchmark.
The surgical treatment of carcinoma of the oesophagus with special reference to a new operation for growths of the middle third.