Advertisement

Technique of Open Ivor Lewis Esophagectomy

  • Carolyn E. Reed
    Correspondence
    Address reprint requests to Carolyn E. Reed, MD, Division of Cardiothoracic Surgery, Medical University of South Carolina, 25 Courtenay Drive, Suite 7018, Charleston, SC 29425
    Affiliations
    Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
    Search for articles by this author
      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.
      • Lewis I.
      The surgical treatment of carcinoma of the oesophagus with special reference to a new operation for growths of the middle third.
      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.
      • Lanuti M.
      • de Delva
      • Maher A.
      • et al.
      Feasibility and outcomes of an early extubation policy after esophagectomy.
      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
      • Rentz J.
      • Bull D.
      • Harpole D.
      • et al.
      Transthoracic versus transhiatal esophagectomy: A prospective study of 945 patients.
      • Visbal A.L.
      • Allen M.S.
      • Miller D.L.
      • et al.
      Ivor Lewis esophagectomy for esophageal cancer.
      • Karl R.C.
      • Schreiber R.
      • Boulware D.
      • et al.
      Factors affecting morbidity, mortality, and survival in patients undergoing Ivor Lewis esophagogastrectomy.
      • Hulscher J.B.F.
      • van Sandick J.W.
      • de Boer A.G.E.M.
      • et al.
      Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus.
      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%.
      • Rentz J.
      • Bull D.
      • Harpole D.
      • et al.
      Transthoracic versus transhiatal esophagectomy: A prospective study of 945 patients.
      • Visbal A.L.
      • Allen M.S.
      • Miller D.L.
      • et al.
      Ivor Lewis esophagectomy for esophageal cancer.
      • Karl R.C.
      • Schreiber R.
      • Boulware D.
      • et al.
      Factors affecting morbidity, mortality, and survival in patients undergoing Ivor Lewis esophagogastrectomy.
      Anastomotic leak has been detected in 3% to 8%.
      • Rentz J.
      • Bull D.
      • Harpole D.
      • et al.
      Transthoracic versus transhiatal esophagectomy: A prospective study of 945 patients.
      • Visbal A.L.
      • Allen M.S.
      • Miller D.L.
      • et al.
      Ivor Lewis esophagectomy for esophageal cancer.
      • Karl R.C.
      • Schreiber R.
      • Boulware D.
      • et al.
      Factors affecting morbidity, mortality, and survival in patients undergoing Ivor Lewis esophagogastrectomy.
      • Hulscher J.B.F.
      • van Sandick J.W.
      • de Boer A.G.E.M.
      • et al.
      Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus.
      Mortality has varied between 1.4% and 10%.
      • Rentz J.
      • Bull D.
      • Harpole D.
      • et al.
      Transthoracic versus transhiatal esophagectomy: A prospective study of 945 patients.
      • Visbal A.L.
      • Allen M.S.
      • Miller D.L.
      • et al.
      Ivor Lewis esophagectomy for esophageal cancer.
      • Karl R.C.
      • Schreiber R.
      • Boulware D.
      • et al.
      Factors affecting morbidity, mortality, and survival in patients undergoing Ivor Lewis esophagogastrectomy.
      • Hulscher J.B.F.
      • van Sandick J.W.
      • de Boer A.G.E.M.
      • et al.
      Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus.
      It is also known that esophagectomy is a procedure that is affected by hospital and surgeon volumes.
      • Dimick J.B.
      • Wainess R.M.
      • Upchurch G.R.
      • Iannettoni M.D.
      • Orringer M.B.
      National trends in outcomes for esophageal resection.
      • Casson A.G.
      • Van Lanschot J.J.B.
      Improving outcomes after esophagectomy: The impact of operative volume.
      • Chang A.C.
      • Birkmeyer J.D.
      The volume-performance relationship in esophagectomy.
      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.

      Operative Technique

      Figure thumbnail gr1
      Figure 1(A, B) The Ivor-Lewis esophagectomy is performed through an upper midline laparotomy and then a thoracotomy (A) and typically includes a two-field lymphadenectomy (B) encompassing periesophageal, subcarinal, superior mediastinal, diaphragmatic, paracardial, lesser curvature, and celiac axis lymph nodes (levels 2, 3, 4, 7, 8, 9, 15, 16, 17, and 20). The operation begins with an esophagoscopy to confirm the extent of tumor. On opening the abdomen, the right gastroepiploic artery is palpated and its fitness as the blood supply for the gastric conduit is confirmed. Abdominal exploration should confirm absence of liver metastases, extensive nodal disease, omental metastases, etc. v. = vein.
      Figure thumbnail gr2a
      Figure 2(A-C) The left triangular ligament is divided and the left lobe of the liver is retracted (A). The gastrohepatic ligament is incised as close to the liver as possible. One should always look for a replaced left hepatic artery, especially if a vessel appears unusually large. Further dissection may be needed before ligating such a vessel (see legend to Fig. 5). The phreno-esophageal ligament is incised and the esophagus is circumferentially dissected (B, C). The hiatus is widened by incising the crura. If the tumor is bulky, a cuff of diaphragm can be included with the specimen. lig. = ligament.
      Figure thumbnail gr2b
      Figure 2(A-C) The left triangular ligament is divided and the left lobe of the liver is retracted (A). The gastrohepatic ligament is incised as close to the liver as possible. One should always look for a replaced left hepatic artery, especially if a vessel appears unusually large. Further dissection may be needed before ligating such a vessel (see legend to Fig. 5). The phreno-esophageal ligament is incised and the esophagus is circumferentially dissected (B, C). The hiatus is widened by incising the crura. If the tumor is bulky, a cuff of diaphragm can be included with the specimen. lig. = ligament.
      Figure thumbnail gr3
      Figure 3The esophagus is encircled with a large penrose drain. The lower esophagus can be mobilized under direct vision transhiatally to confirm resectability of the tumor. The hiatus is enlarged to fit four fingers of a size 7 gloved hand.
      Figure thumbnail gr4
      Figure 4Before mobilizing the greater curvature of the stomach, two laparotomy pads are placed behind the spleen to lift the spleen forward. The lesser omental sac is entered at least 2 cm beyond the right gastroepiploic artery (usually at the midpoint of the stomach where the omentum is most transparent). Using the Harmonic Wave (Ethicon Endo-Surgery, Inc., Guaynabo, Puerto Rico), the dissection is carried to the level of the pylorus and proximally to the first short gastric vessel. Care must be taken to avoid any injury to the right gastroepiploic artery, and one must be particularly vigilant in obese patients as the omentum thickens and the left transverse colon encroaches on the stomach as the “bare area” is approached. The short gastric vessels are either individually ligated or secured with the harmonic scalpel. The author prefers to work from the most proximal short gastric distally to the bare area. The vascular reflection of the peritoneum at the esophagogastric junction is incised (meeting the penrose drain). At times short vessels from the splenic artery run to the back of the cardia and must be ligated. The entire greater curvature should now be mobilized. Hemostasis is assured in the splenic bed and the laparotomy pads behind the spleen are removed. a. = artery.
      Figure thumbnail gr5
      Figure 5The stomach is now held up out of the incision and cephalad to expose the celiac axis. Small vessels and lymphatics superior to the pancreas are carefully clipped as dissection of the areolar tissue proceeds. It is important to avoid injury to the pancreas as well as the splenic artery, which is often very tortuous. The left gastric (coronary) vein is identified and ligated. The left gastric artery coursing directly superiorly to the stomach is identified and dissected. All lymph nodal tissue at the celiac trifurcation is swept upward to be included en bloc with the specimen. The left gastric artery can be tied and suture ligated proximally or frequently easily secured with an endovascular stapler. Before securing the left gastric artery, the surgeon should look for an accessory hepatic artery or left hepatic artery arising from the left gastric. Such a finding necessitates ligation closer to the stomach. a. = artery.
      Figure thumbnail gr6
      Figure 6The lesser curvature of the stomach is mobilized from the hiatus to the right gastric artery. The entire gastrohepatic ligament is included with the specimen to resect lesser curvature lymph nodes. Posterior dissection continues along and often includes part of the left crus to the hiatus. A generous Kocher maneuver is then performed. IVC = inferior vena cava; lig. = ligament.
      Figure thumbnail gr7
      Figure 7A pyloric drainage procedure is now performed. Choices include pyloromyotomy, pyloroplasty, and more recently botox injection. Some perform no drainage procedure. Pyloromyotomy was the author's preferred procedure, but recent experience with botox injection has been satisfactory. Two hundred units of botox is mixed in 5 mL of normal saline and approximately 1.25 mL is injected into the pyloric muscle at the one o'clock, 3 o'clock, 6 o'clock, and 9 o'clock positions. To aid in the resection of the proximal stomach when drawn into the right chest, the gastrohepatic tissue at the point of resection of the distal lesser curvature is cleared. This point is about six vascular arcades distal to the esophagogastric junction. The celiac axis is marked with a long stitch to aid pathologic examination. A jejunostomy tube is then placed 30 to 40 cm beyond the ligament of Treitz. The abdomen is closed.
      Figure thumbnail gr8
      Figure 8The patient is placed in the left lateral decubitus position, prepped, and draped. A right posterolateral thoracotomy incision is made, and the fifth intercostal space is entered. The lung is deflated using the double lumen endobronchial tube placed at the beginning of anesthesia. The azygos vein is divided using the endo GIA 30, 2.5 stapler (Endo GI Universal, US Surgical, Norwalk, CT). The pleura is scored with the electrocautery from posterior to the azygos down to the hiatus. The inferior ligament is incised and the pleura scored back to the cut azygos vein. Boundaries of dissection are now marked. The esophagus is then dissected and encircled with a large penrose drain at the level of the arching azygos vein. Care must be taken with this maneuver to avoid entering the esophageal muscularis propria as the posterior muscle fibers are often “splayed” deep into the mediastinum. v. = vein.
      Figure thumbnail gr9
      Figure 9Using the penrose as a traction device, the esophagus and the attached lymphoareolar tissue are mobilized from the mediastinal bed. Aortic branches are clipped. The dissection includes mobilization of the subcarinal lymph node packet, which is kept intact with the specimen and marked with a double stitch. The pericardium is “bared.” The vagal nerve trunks are cut as the esophagus is mobilized from the lower superior mediastinum. Once the hiatus is reached, final attachments are released. Level 15 (diaphragmatic) lymph nodes are carefully identified and resected. The thoracic duct is purposely ligated at this level by mass ligature of all tissue between the aorta, spine, and azygos vein using a 0-silk tie.
      Figure thumbnail gr10
      Figure 10The nasogastric tube that was placed after the endoscopy is withdrawn to the thoracic inlet. The esophagus is stapled above the azygos vein using a GI stapler with a “green load” (such as PI 30 mm stapler; US Surgical).
      Figure thumbnail gr11
      Figure 11With care to preserve proper orientation, the stomach is delivered through the hiatus into the chest. The gastric conduit is formed by several applications of the ILA 100-mm stapler (US Surgical) or use of the 60-mm endostapler (Endo GIA Universal, US Surgical). The previously cleared portion of the distal lesser curvature serves as a distal marker. The highest point of the fundus is easily identified when the stomach is put on “stretch.” If the tumor is at the gastroesophageal junction, a more “V-shaped” staple line will increase the radial gastric margin. The highest point of the staple line is oversewn with a 3-0 silk horizontal mattress suture as well as where staple lines have crossed each other. GE jct = gastroesophageal junction.
      Figure thumbnail gr12
      Figure 12While awaiting for the results of the frozen section examination of the esophageal plus/minus gastric margins, a superior mediastinal lymph node dissection is done, and levels 2 and 4 lymph nodes sent for permanent pathologic examination. Once the margins are clear, the anastomotic setup is commenced. The esophagus is circumferentially dissected proximally 3.5 to 4 cm from the staple line. The esophagus is then laid on the surface of the stomach, which has been placed in the previous esophageal bed. The esophagus is secured by four 3-0 silk sutures as illustrated. A small V-shaped esophagotomy is made in the midpoint of the staple line. A 3-0 silk suture is placed through the upper “lip” of the esophagotomy, including both muscle and mucosa, and is tagged. A small gastrotomy is made with the electrocautery. Another 3-0 silk suture is placed catching the posterior “lip” of the esophagotomy and posterior margin of the gastrotomy. These sutures are guiding sutures for the arms of the endostapler used for the anastomosis.
      Figure thumbnail gr13
      Figure 13The endostapler [author uses the 35-mm endoscopic articulating linear cutter (Ethicon Endo-Surgery, Cincinnati, OH) with the blue load] is opened and the larger arm is inserted into the esophagus. The other arm is inserted into the stomach via the gastrotomy. The guiding sutures are gently tugged downward to assure full insertion of both arms of the stapler. The stapler is closed, fired, and released. The stapler forms a side-to-side functional end-to-end anastomosis. The nasogastric tube is passed into the distal stomach. The esophagotomy and gastrotomy are closed with interrupted full-thickness sutures of 3-0 silk. To help avoid delayed emptying, excess conduit is placed back into the abdomen, and the conduit is gently “tugged” to make it as straight as possible. Tacking sutures are not used. The right pleural cavity is irrigated with normal saline; chest tubes are placed (posterior straight chest tube and right-angle tube over the diaphragm), and the thoracotomy is closed in standard fashion.

      References

        • Lewis I.
        The surgical treatment of carcinoma of the oesophagus with special reference to a new operation for growths of the middle third.
        Br J Surg. 1946; 34: 18-31
        • Lanuti M.
        • de Delva
        • Maher A.
        • et al.
        Feasibility and outcomes of an early extubation policy after esophagectomy.
        Ann Thorac Surg. 2006; 82: 2037-2041
        • Rentz J.
        • Bull D.
        • Harpole D.
        • et al.
        Transthoracic versus transhiatal esophagectomy: A prospective study of 945 patients.
        J Thorac Cardiovasc Surg. 2003; 125: 1114-1120
        • Visbal A.L.
        • Allen M.S.
        • Miller D.L.
        • et al.
        Ivor Lewis esophagectomy for esophageal cancer.
        Ann Thorac Surg. 2001; 71: 1803-1808
        • Karl R.C.
        • Schreiber R.
        • Boulware D.
        • et al.
        Factors affecting morbidity, mortality, and survival in patients undergoing Ivor Lewis esophagogastrectomy.
        Ann Surg. 2000; 231: 635-643
        • Hulscher J.B.F.
        • van Sandick J.W.
        • de Boer A.G.E.M.
        • et al.
        Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus.
        N Engl J Med. 2002; 347: 1662-1669
        • Dimick J.B.
        • Wainess R.M.
        • Upchurch G.R.
        • Iannettoni M.D.
        • Orringer M.B.
        National trends in outcomes for esophageal resection.
        Ann Thorac Surg. 2005; 79: 212-218
        • Casson A.G.
        • Van Lanschot J.J.B.
        Improving outcomes after esophagectomy: The impact of operative volume.
        J Surg Oncol. 2005; 92: 262-266
        • Chang A.C.
        • Birkmeyer J.D.
        The volume-performance relationship in esophagectomy.
        Thorac Surg Clin. 2006; 16: 87-94