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402 Part III Esophagus
FIGURE 18-24 Lateral view of the blunt dissection posterior to the esophagus in the chest. A sponge stick is used, as it may be dicult to insert
one’s hand completely through the cervical incision.
diovasc Surg. 1978;76:643.)
(Redrawn, with permission, from Orringer MB, Sloan H. Esophagectomy without thoracotomy. J orac Car-
heart, there must be constant communication between the
surgeon and the anesthesiologist. Hypotension often results
from compression of the left atrium and impairment of left
ventricular lling. It is wise to have the arterial line tracing
and numbers in direct view of the surgeon; the surgeon’s eyes
should be on these numbers as he/she performs the blind dissection with his/her ngers.
Dissection anterior to the esophagus is then performed
in nearly identical fashion. e palmar aspect of the hand
is again kept directly against the esophagus (Fig. 18-25). As
dissection approaches the carina from below, the surgeon
will note an increase in the tenacity of the anterior attachments to the esophagus. Dissection must be gentler in this
area. A gentle side-to-side motion of the ngertips will also
separate the trachea from esophagus. Eventually the ngertips from both hands are united. Once the anterior and posterior dissection has been completed, the lateral attachments
are then divided. From the neck incision, as much blunt dissection of the lateral attachments as possible is performed
under direct vision. Next the surgeon’s hand is introduced
anterior to the esophagus with the palmar aspect of the hand
facing the esophagus. e hand is inserted until the rst and
second ngers are above the level of dissection of the lateral attachments. ese attachments are pressed against the
spine, and using a raking motion the surgeon pulls his hand
back toward the abdomen, releasing the lateral attachments
(Fig. 18-26). Care must be taken in the region of the azygos
vein and its branches.
FIGURE 18-25 Anterior blunt dissection of the esophagus in the chest. Dissection must be gentle and deliberate around the level of the carina
to avoid tracheal as well as azygos vein injury.
Chapter 18 Surgical Procedures to Resect and Replace the Esophagus 403
TECHNIQUE
e most versatile thoracoabdominal approach involves
positioning the patient in the right lateral decubitus position
with the hips rotated posteriorly 45 degrees. A left sixth
interspace thoracotomy is performed beginning at the tip of
the scapula and extending across the costal margin toward the
abdominal midline. e latissimus is divided and the serratus
is spared. e costal margin is divided with a rib cutter. e
left lung is deated. e diaphragm is incised circumferentially 2–3 cm away from the chest wall (Fig. 18-27). Doing so
avoids injury to the radial branches of the phrenic nerve. e
abdomen is explored for metastatic disease. Cautery is used
FIGURE 18-26 e esophagus has been freed from the trachea,
and the lateral attachments are avulsed from a cranial to caudal
direction.
to divide the inferior pulmonary ligament. e mediastinal
pleura overlying the esophagus is incised, and the esophagus
is encircled in the lower chest including all tissue from the
aorta to the pericardium. e esophagus is dissected proximally behind the inferior pulmonary vein. A proximal gross
in situ margin of 10 cm is ideal, though lesser margins, if
conrmed negative by frozen section, may be adequate. A
e remainder of the operation, including the anastomosis,
is identical to that of the tri-incisional technique. After
removing the specimen, it is wise to pack the mediastinum
with a lap pad (without compressing the heart) to facilitate
hemostasis. Prior to drawing the conduit into the neck, a nal
inspection is made for hemostasis and for entry into either
point of division of the proximal esophagus is identied and
mobilization above this point is minimized to preserve blood
supply to the anastomosis. e thoracic duct can be located at
this level and ligated if desired.
e incision permits excellent exposure of the short gastric
vessels, which are ligated starting at the hiatus. Care is taken
pleural space. If either pleural space is entered, a chest tube
should be placed.
Left Thoracoabdominal Approach
CONSIDERATIONS
Limited resection of the distal esophagus via left thoracotomy
is almost always a compromise procedure. Only the distal
esophagus is readily accessible via the left chest, as the aortic arch obscures much of the upper esophagus. A tumor that
extends more proximally than 30 cm should not be approached
through the left, as a dicult dissection behind the aortic arch
will be required. In addition, placement of the esophagogastric anastomosis low in the left chest can be associated with
severe GE reux. is approach is best reserved for a GE junction cancer that involves a signicant portion of the proximal
stomach and when there is concern that the residual stomach
may be of insucient length to reach the neck.
A variety of incisions or a combination of left thoracic
and abdominal incisions can be used for this approach. An
upper midline laparotomy can be extended across the costal margin. is is the least versatile approach and its use is
limited to instances in which use of the esophagus is unexpected, as with proximal extension of a gastric tumor. A second approach involves placing the patient in full right lateral
decubitus position and taking the diaphragm down in radial
fashion 2–3 cm from the chest wall to gain exposure to the
abdomen. is approach permits good exposure to the upper
abdomen, although exposure to the pylorus and duodenum
may be dicult.
FIGURE 18-27 Left thoracoabdominal approach; dotted lines
delineate the circumferential diaphragmatic incision as well as the
hiatal margin incision. A Penrose drain encircles the esophagus above
the tumor.
404 Part III Esophagus
along the greater curvature, where the short gastric vessels end
and the right gastroepiploic vessel begins. e right gastroepiploic artery is preserved. e gastrohepatic ligament is divided.
e left gastric artery is identied and all celiac lymph nodes
are swept up onto the specimen. e stomach is retracted anteriorly and the left gastric artery is divided with a vascular endoscopic stapler. e gastric tube is constructed by sequential res
of GIA staplers starting at the fundus and extending down to
the crow’s foot of veins. Six centimeters of distal margin is desirable. A Kocher maneuver and pyloroplasty or pyloromyotomy
are performed, and the tube is passed through the enlarged
hiatus into the chest. e anastomosis is typically constructed
inferior to the aortic arch and may be hand-sewn as described
in the previous section or stapled.
If needed, the dissection can be carried to the neck with
this incision with some diculty. e proximal esophagus can
be dissected bluntly under the aortic arch, and provided the
neck has been prepped into the eld, a left cervical incision is
made as in the tri-incisional technique and the conduit pulled
into the neck. Closure begins with careful reapproximation
of the diaphragm with interrupted horizontal mattress 0 silk
sutures followed by solid reapproximation of the costal margin with gure-of-eight wire or heavy nonabsorbable suture
such as no. 1 Prolene. Some surgeons prefer not to divide the
costal margin and, instead, perform all intra-abdominal work
through the divided diaphragm.
LEFT COLON
After completion of the thoracic phase of the operation,
the patient is placed in the supine position and a midline
laparotomy is performed. After a careful search for metastatic
disease, the left colon is mobilized by dividing the white line
of Toldt and by dividing the attachments to the spleen and
omentum. e colon is freed proximal to the hepatic exure.
A careful inspection is made of the vascular supply, including the marginal artery of Drummond (Fig. 18-28). A pulse
should be palpable in the left colonic artery as well as the
marginal artery. e middle colic artery supplying the hepatic
exure is clamped with a soft bulldog clamp and its perfusion
is inspected for 10 minutes.
Prior to conduit isolation, the GE junction is isolated and
the cardia and lesser curvature are dissected with division of
the phrenoesophageal ligament and the gastrohepatic ligament. e stomach is divided using a GIA stapler. A pyloric
drainage procedure is performed. e length of colon needed
is estimated by placing an umbilical tie along the proposed
route of colonic interposition. is tie is placed alongside the
colon and the length of required colon is determined.
After ensuring adequate blood supply to the conduit, the
marginal artery is ligated distal to both branches of the left
colic artery. e middle colic artery is divided near its origin. e mesentery is scored and divided between clamps.
e colon is divided with GIA staplers and the conduit is
packed in moist gauze. e colocolonic anastomosis is most
ALTERNATIVE METHODS OF
RECONSTRUCTION: COLON
AND JEJUNUM
Colonic Interposition
e stomach is the preferred organ for esophageal replacement because of its blood supply, the resistance of these vessels
to atherosclerotic disease, the need for a single anastomosis,
and the ability of the stomach to reach the neck without difculty. Prior gastric surgery, scarring from peptic ulcer disease
or involvement with tumor may preclude use of the stomach as a conduit. In this instance, colon interposition may
be employed. e left colon is preferred over the right colon
for several reasons. Its diameter more closely resembles that
of the esophagus, its vascular supply has less variation, and
greater length can be obtained. Unfortunately, atherosclerotic
disease most commonly aects the inferior mesenteric artery,
and the left colon is often more aected by diverticular disease than the right.
Preoperative preparation includes colonoscopy or barium
enema to ensure normal anatomy and the absence of any
intrinsic colonic disease. Patients older than 40 years or any
patients with atherosclerotic risk factors should undergo
mesenteric angiography. Signicant vascular disease of the
conduit vessel would preclude its use as a conduit. A complete bowel prep and oral antibiotics are necessary prior to
operation.
FIGURE 18-28 e mobilized colon is elevated, and the arterial
supply and venous drainage are examined. e arterial and venous
ligation sites and the mesenteric incision lines are illustrated for an
isoperistaltic conduit based on a left colic artery supply.
Chapter 18 Surgical Procedures to Resect and Replace the Esophagus 405
FIGURE 18-29 Lateral view of the colonic conduit in the posterior mediastinal esophageal bed. Cervical esophagocolonic and posterior cologas-
tric anastomoses are shown. Inset: Neck incision marked and left colon conduit mobilized on the anterior chest wall, based on the marginal artery
pedicle of left colonic artery and placed in isoperistaltic position.
easily stapled in side-to-side functional end-to-end fashion.
e mesenteric defect is closed with a running suture to avoid
internal herniation. e esophagus is identied in the neck
and the esophagectomy is completed as previously described
in the tri-incisional esophagectomy section.
pulled into the abdomen; if it remains in the chest, obstruction may result. e colon is sutured to the left crus of the
diaphragm at the hiatus using seromuscular sutures in a twothird circumferential fashion in order to prevent herniation
of abdominal contents into the chest.
e colon can be brought to the neck via either the
anterior mediastinum (substernal) or the in situ route (bed
of the resected esophagus). e in situ route is preferred,
as it provides the shortest route to the neck (Fig. 18-29).
In instances of prior infection or scarring (as seen with
gastric conduit necrosis or leak), the in situ route may be
scarred and unusable. e substernal route may then be
used with resection of the manubrium required to prevent
acute angulation and possible obstruction in the neck. e
colon is oriented in isoperistaltic position and drawn to the
neck in an endoscopic camera bag as described previously.
e proximal anastomosis is most easily performed using a
single-layer interrupted technique with ne 4-0 silk sutures.
An EEA or functional end-to-end stapled anastomosis is also
acceptable. e nasogastric tube is guided through prior to
completion of the anastomosis. e cologastric anastomosis
is then performed onto the posterior aspect of the stomach.
e easiest method of anastomosis employs an EEA stapler.
e handle is placed through an anterior gastrotomy and
creates the anastomosis in the posterior wall of the stomach. e gastrotomy is then closed with a TA stapler. e
nasogastric tube must be guided through the anastomosis
into the stomach. Any excess length in the conduit should be
RIGHT COLON
ere are numerous conditions that may make the left colon
unsuitable as a conduit, including extensive diverticular disease, stricture from ischemia or infection, atherosclerotic
occlusion of the inferior mesenteric artery, or splenic vein
thrombosis and thrombosis of the inferior mesenteric vein.
In these instances the right colon may be used as a conduit
to reach the neck. e right colon is mobilized by lysis of its
retroperitoneal attachments. e length of colon needed is
estimated with an umbilical tape as described previously. e
greater omentum is removed from the hepatic exure and
proximal half of the transverse colon. Its mesentery is transilluminated revealing the ileocolic, right colic, middle colic,
and marginal arteries. e ileocolic and right colic arteries
are clamped in preparation for division of these vessels and
mobilization of the conduit based on the middle colic artery.
If perfusion appears adequate, these vessels are ligated. e
peritoneum overlying the base of the mesentery is scored, and
the remainder of the mesentery is divided between clamps
and ligated. e proximal and distal ends of the conduit are
divided with a linear cutting stapler. Some incorporate the
406 Part III Esophagus
ileocecal valve and distal ileum in the conduit because the
diameter of the ileum closely approximates that of the esophagus. Others prefer not to use distal ileum in the anastomosis,
as the valve may contribute to dysphagia.
e colocolonic anastomosis is performed with staplers.
e right colon conduit is then rotated in clockwise fashion (as the surgeon looks into the abdomen) in preparation
for isoperistaltic transfer into the chest. As stated previously,
the preferred route is via the esophageal bed. is route is
often unavailable for use in colon transposition, as one of the
most common indications is a failed gastric conduit placed
in the esophageal bed. e retrosternal route is most often
used. e diaphragm is bluntly detached from its inferior
sternal attachments, and blunt dissection with the hand is
performed to enlarge the tract. Division of cartilaginous
attachments behind the manubrium is also necessary. e
conduit is drawn into the neck via a plastic endoscopy bag
as described previously. If the thoracic inlet is thought to be
too constricting, the head of the clavicle, manubrium, and
anterior aspect of the rst rib may be resected. e proximal and distal anastomoses are performed as described for
left colon conduits. e conduit may also be passed to the
neck via the transpleural or subcutaneous route (with great
cosmetic deformity).
FIGURE 18-30 Roux-en-Y jejunal replacement of the distal
esophagus.
Jejunal Interposition
Jejunal interposition may be applied as a free graft, pedicled
graft, or Roux-en-Y replacement. Jejunum is often the third
choice (after stomach and colon) for esophageal replacement, because it cannot replace the entire esophagus to the
neck, but can be used to replace a portion of the distal or
proximal esophagus. When distal esophagectomy is necessary
for peptic stricture, jejunum or colon interposition is preferred, as both conduits are relatively resistant to reux. e
isoperistaltic conduits are believed to have a lower incidence
of recurrent reux than the simple gastric pull-up procedure.
Free jejunal grafts are used in limited reconstructions of the
cervical esophagus. Patients undergoing jejunal interposition
should receive preoperative antibiotics. Although a mechanical bowel preparation is not needed, it should be used if it is
possible that colon may be needed.
ROUX-EN-Y REPLACEMENT
Roux-en-Y replacement is most commonly used after total
gastrectomy and distal esophagectomy (Fig. 18-30). Unlike
stomach, it will not reliably reach to the cervical esophagus.
e jejunum is divided approximately 20–30 cm beyond the
ligament of Treitz. e jejunum and its mesentery are held
up and its arcade is transilluminated. e proposed point
of division is identied, as are the mesenteric vessels to be
divided. e rst few arcades are not divided to preserve blood
ow to the native jejunum. Up to 60 cm of jejunum can be
mobilized using this technique. e mesentery is scored and
these vessels are clamped near their origin from the superior
mesenteric artery with soft bulldog clamps. e conduit is
observed for about 10 minutes for evidence of ischemia. e
vessels are then ligated and divided. A hole is made in the
transverse mesocolon to the left of the middle colic artery,
just large enough to pass the jejunum and its mesentery. For
replacement after total gastrectomy, the proximal anastomosis
is made to the very distal esophagus in the upper abdomen.
If resection of the distal esophagus is required, the incision is
usually extended across the costal margin to the sixth or seventh interspace. If additional length is needed on the conduit,
the next vessel in the arcade is identied, test-clamped, and
then divided. e anastomosis can be performed by stapled or
hand-sewn technique. e stapled anastomosis is most easily
performed with an EEA stapler. e largest EEA stapler possible should be used for the anastomosis. e distal esophagus
may rst be dilated with a lubricated metal dilator. A fullthickness 2-0 Prolene suture is used to create a purse string in
the distal esophagus. e shaft may be introduced by opening
the stapled end of the jejunum. It can then be passed out the
side of the jejunum and united with the anvil. Care must be
taken not to occlude the ongoing lumen of the jejunum with
the stapler. Two full-thickness anastomotic doughnuts should
be veried. After removing the stapler, the jejunal end is closed
with a TA 60 stapler. A hand-sewn anastomosis in one or two
layers can also be performed. e jejunum is tacked to the
hiatus at several points using interrupted silk sutures. is
prevents herniation of abdominal contents into the chest and
limits tension on the esophagojejunal anastomosis. Likewise,
defects in the colonic mesentery should be closed to prevent
an internal hernia. e distal anastomosis can be hand-sewn
Chapter 18 Surgical Procedures to Resect and Replace the Esophagus 407
or more rapidly performed with a side-to-side functional endto-end stapled anastomosis.
PEDICLED JEJUNAL INTERPOSITION
Pedicled jejunal interposition is most often used to replace
a strictured distal esophagus (Fig. 18-31). A left thoracoabdominal incision is employed with a left seventh interspace
incision extended across the costal margin and rectus mus-
A
cle. e jejunum is transilluminated and an appropriate
length of jejunum is selected, beginning 20 cm beyond the
ligament of Treitz. A single large vessel is chosen as the conduit feeder vessel. e jejunum is transected proximally and
distally using a GIA stapler, and the mesentery is divided
down each side toward the feeder vessel (Fig. 18-32A). e
jejunum is reconnected using a side-to-side functional endto-end stapled anastomosis (Fig. 18-32B). e pedicled
jejunum is tunneled through the colonic mesocolon and
brought up to the left chest through an enlarged hiatus.
(Fig. 18-33) e proximal anastomosis can be constructed
with an EEA stapler (usually 28 cm in size, but a larger anastomosis may be more resistant to postoperative stricture).
e jejunogastric anastomosis is easily performed using an
EEA stapler (inserting the handle through a separate gas-
FIGURE 18-32 A. e jejunum is prepared in an isoperistaltic
fashion (arrows) based on a distal mesenteric branch and proximal
marginal arcade. e dotted line illustrates the line of resection of
mesentery and the division of vessels. B. After dividing the mesentery and preserving the pedicle, jejunal continuity is restored and the
mesenteric defect closed.
B
trotomy). A two-layered hand-sewn anastomosis may also
be used.
FIGURE 18-31 Pedicled jejunal replacement of the distal esopha-
gus. e jejunum is brought through an incision in the transverse
mesocolon.
FIGURE 18-33 Jejunal interposition graft to reconstruct the lower
esophagus. An end-to-side esophagojejunostomy is performed to avoid
tension on the vascular pedicle. A posterior jejunogastric anastomosis
avoids tortuosity of the conduit while an 8- to 12-cm segment of the
jejunal graft situated below the hiatus aids in the control of reux.
408 Part III Esophagus
FREE JEJUNAL TRANSFER
Free jejunal transfer is needed if the pedicle is not of sucient
length, such as in replacement of a portion of the cervical
esophagus for benign disease. It is not clear whether use of a free
jejunal transfer is preferable to total esophagectomy and gastric
pull-up. e use of jejunum does carry a lower incidence of
postoperative reux and avoids dissection of the thoracic esophagus; however, there is increased risk of graft ischemia and gangrene. Two anastomoses are required and there is an increased
risk of anastomotic leak. As with a pedicled jejunal graft, a short
segment of jejunum is chosen for harvest. A left cervical incision is made, and the esophagus as well as the carotid artery and
jugular vein are isolated. A dominant feeder vessel in the jejunal
segment is identied and divided with a scalpel. e artery and
vein are ushed with heparinized saline. e proximal anastomosis is constructed rst and is performed with a two-layer endto-side hand-sewn anastomosis. An operating microscope is
then used to perform the arterial and venous anastomosis to the
carotid artery and jugular vein with 9-0 or 10-0 Prolene suture.
e distal anastomosis is then performed in fashion identical to
the proximal anastomosis (Fig. 18-34). Typically, a meshed skin
graft is placed over the conduit for continuous postoperative
monitoring. A feeding jejunostomy tube is placed as with every
case of esophageal replacement.
A
COMPLICATIONS AND HOW
TO AVOID THEM
Anastomotic Leak
e incidence of anastomotic leak is higher following cervical anastomosis (10–15%) than intrathoracic anastomosis
(5–10%).
the cervical position for several reasons. First, increased length
is needed and this may place increased tension on the anastomosis. e tip of the stomach, which is used in the cervical anastomosis, may have a more tenuous blood supply, as it
is farther from the gastroepiploic artery. Additionally, venous
engorgement due to a tight thoracic inlet may impair blood
supply. An analysis of anastomotic leaks found that albumin
level below 3 g/dL, positive margins, and cervical anastomosis were risk factors for anastomotic leak following esophagectomy.
anastomosis in 102 patients undergoing Ivor Lewis esophagectomy did not show any signicant dierence in the incidence
of anastomotic leak. e incidence was 5% after a single-layer
monolament anastomosis and 2% after a stapled anastomosis.
e incidence of leak following hand-sewn anastomosis is
more operator-dependent, and those who perform few of these
procedures may wish to use a stapled technique.
feared complication that in the past was associated with a 50%
mortality rate. Centers that routinely employ this technique
have rened their techniques, resulting in very low leak rates
in the 2% range. Early detection and aggressive management
22,30,31
e incidence of leak is believed to be higher in
32
A randomized comparison of hand-sewn versus stapled
33
Anastomotic leak following Ivor Lewis esophagectomy is a
B
FIGURE 18-34 Free jejunal graft used as a cervical esophageal
replacement. It is typically covered with a meshed skin graft so that
conduit health can be observed postoperatively.
can reduce the high mortality rate usually associated with this
complication. Unexplained fever, elevated white cell count,
respiratory failure, delirium, hypotension, or low urine output
may signal the onset of an intrathoracic leak. Conrmation
is usually possible by Gastrogran swallow or instillation of
Chapter 18 Surgical Procedures to Resect and Replace the Esophagus 409
contrast through the nasogastric tube. Immediate intervention is required, and attempts at direct repair with muscle ap
reinforcement and wide drainage are often successful. Patients
who are unstable or severely ill should be diverted with a spit
stula, and either excluded at the hiatus, or have the conduit
closed and returned to the abdomen. In rare instances, a clinically silent, small, contained leak that is not adjacent to vital
structures such as the trachea or aorta may be observed and
treated with strict NPO status and enteral feeds.
Although leak is more common following cervical anastomosis, it is rarely life-threatening. Occasionally a cervical
anastomosis may leak into the chest and must be treated like
an intrathoracic leak. Initially, mortality from a cervical leak
was estimated at 20%, though recent series have shown that
34
the mortality is much lower.
Cervical anastomotic leak is
usually signaled by fever, erythema, and uctuance in the
neck incision. Opening of the neck incision and probing
down to the prevertebral fascia (with placement of a drain)
is usually all that is needed. Patients can be allowed clear liquids by mouth and may be fed via jejunostomy tube until the
leak is sealed. Barium swallow following esophagectomy may
miss 10% of cervical leaks. Giving patients purple grape juice
to drink and observing the drain during swallow may detect
leaks missed by barium swallow.
Anastomotic Stricture
e same risk factors that predispose to anastomotic leak also
predispose one to stricture. Indeed, it is very common to present with stricture following treatment for an anastomotic leak.
Retrospective meta-analyses have shown that the incidence
of stricture is higher after cervical reconstruction (28%) than
after Ivor Lewis reconstruction (16%).
stricture is not precise and is usually determined by the need
for intervention (ie, dilation). As some surgeons are more
aggressive than others with regard to dilation, this value may
be misleading. A retrospective analysis of transhiatal esophagectomy patients revealed that the use of a stapled anastomosis, anastomotic leak, and the presence of cardiac disease were
the only risk factors associated with the development of stric-
35
Other studies have mentioned intraoperative blood loss
ture.
and poor conduit vascularization as risk factors. A unifying
theme in anastomotic stricture (other than mechanical stapler
issues) is impaired blood supply to the region of anastomosis. In an eort to avoid ischemia, it is wise not to place the
anastomosis too close to the tip of the gastric conduit. Careful
handling of the gastroepiploic artery, ensuring systemic oxygen delivery, and avoidance of congestion all are important in
avoiding anastomotic leak and stricture.
Mechanical factors may also contribute to development
of stricture, especially when an EEA-stapled anastomosis is
performed. In a randomized evaluation of the EEA stapler
for Ivor Lewis anastomosis, the incidence of stricture was
found to be 40% with a stapled anastomosis versus 9% with a
hand-sewn anastomosis. When a small (25-mm) EEA stapler
was used, the incidence of stricture was 43% as opposed to a
22
e denition of
12.5% incidence with a 29-mm stapler, and no strictures was
seen with a 33-mm stapler.
33
Postoperative strictures may nearly always be managed
by bougie dilation. Often, repeat dilations are needed. In
the aforementioned study of strictures following Ivor Lewis
esophagectomy, 53% of patients needed one dilation, 20%
required two, 12% required three, and 8% required four.
No patient was treated with reoperation. In Honkoop and
associates’ study of anastomotic stricture following transhiatal
esophagectomy, the average patient required three dilations
to achieve normal swallowing. Perforations occurred in 2 of
the 519 patients requiring dilation.
35
Recurrent Laryngeal Nerve Injury
e clearest risk factor for recurrent nerve injury is cervical anastomosis. In a retrospective analysis, the incidence of
recurrent nerve injury with a cervical anastomosis was double
(11%) that for intrathoracic anastomosis (5%).
rent nerve can be injured at any point, from its “recurrence”
from the vagus nerve (around the subclavian artery on the
right and around the aortic arch on the left), to its course in
the tracheoesophageal groove, to its insertion into the larynx.
Although an Ivor Lewis resection should not touch the recurrent nerve, traction or cautery injury to the vagus nerve may
cause injury to the recurrent nerve.
A left neck incision is often used to approach the cervical
esophagus. e right recurrent nerve is farther from the esophagus than the left, and it is easier to avoid the right nerve from
a left neck incision than it is to avoid the left nerve from a
right neck incision. During neck dissection, it is important to
stay immediately against the esophagus in order to avoid injury
to the nerve. In a review of tri-incisional esophagectomy by
Swanson and colleagues, renements in technique resulted in a
reduction of recurrent nerve injury from 14% to 7%.
Brigham and Women’s Hospital technique, the vagus nerves
are divided at the level of the azygos vein, and cranial dissection
of the esophagus proceeds within the nerves. A Penrose drain is
used to surround the esophagus and is positioned in the neck
for later retrieval during the cervical phase of the operation to
ensure isolation of the esophagus inside the recurrent nerves.
Early recognition and aggressive treatment is necessary
to minimize respiratory complications from recurrent nerve
injury. Recurrent nerve injury prevents cord apposition, making an eective cough impossible and interfering with protective reexes involved in swallowing. Hoarseness is present with
recurrent nerve injury but may be present after any intubation.
Loss of eective cough is another hallmark of recurrent nerve
injury but may not be present immediately following extubation, because there may be swelling of the cords after use of
a double-lumen tube, a prolonged operation, and large uid
shifts. Eective cough may be lost between 24 and 48 hours
after extubation as cord swelling decreases. Any patient with
hoarseness and ineective cough should undergo beroptic
laryngoscopy. Immediate injection of the aected cord with gelfoam will allow an eective cough and clearance of secretions.
22
e recur-
36
In the
410 Part III Esophagus
Respiratory Complications
In early series, anastomotic leak and infection were the
most common cause of death following esophagectomy. In
modern series, the most common cause of death is respiratory failure. e incidence of pneumonia following esopha-
26,31,37
gectomy ranges from 2 to 57%.
e assumption that
the incidence of pneumonia is higher with transthoracic
esophagectomy than with transhiatal esophagectomy has not
been denitively borne out by the literature. A large metaanalysis by Rindani and coworkers showed no dierence
in incidence of pneumonia between the two techniques.
22
Two randomized trials, one by Goldmine and associates
and one by Chu and colleagues, also showed no dierence
24,25
in the incidence of pneumonia.
A larger randomized
trial comparing tri-incisional, en bloc esophagectomy with
transhiatal esophagectomy did show a higher incidence of
combined atelectasis and pneumonia in the tri-incisional
group (57%) versus the transhiatal group (27%). e unexpectedly high incidence of pulmonary complications in
the transthoracic group should, however, be questioned, as
reported rates are typically around 20–35%.
20,21
A variety of modications and maneuvers can be employed
to limit the incidence of pulmonary complications. All
eorts must be made to spare injury to the recurrent nerve,
and, if injured, aggressive intervention including cord
medialization is necessary. Eorts at limiting pain associated
with thoracotomy, including a limited muscle-sparing thoracotomy, are helpful. e use of thoracic epidurals has been
shown to decrease the incidence of pulmonary complications
in thoracotomy patients. Early ambulation and aggressive
pulmonary toilet are necessary.
Bleeding
Bleeding following esophagectomy occurs about 5% of the
time regardless of the technique used. Meta-analyses have
shown that estimates of blood loss are slightly higher with
the transthoracic group as opposed to the transhiatal group.
Preoperatively, antiplatelet agents should be stopped well in
advance of surgery. Low-lose subcutaneous heparin or lowdose low-molecular-weight heparin should not increase the
incidence of perioperative bleeding. Intraoperatively, arterial
branches from the aorta to the esophagus should be clipped
whenever possible. If blunt dissection is used, staying immediately against the esophagus should help avoid larger arteries, as the esophageal arterioles tend to form a ne plexus
of vessels approximately 1–2 cm away from the wall of the
esophagus. A notorious site of bleeding during the transhiatal dissection is the azygos vein or one of its branches. is
bleeding usually occurs at about the level of the carina, and,
as always, extra care should be taken at this level. A common
site of bleeding after any thoracotomy is the chest wall itself,
including intercostal vessels; these should be inspected after
removing the retractor.
23
Chyle Leak
e thoracic duct enters the chest through the aortic hiatus
and lies between the spine, azygos vein, and aorta at the level
of the diaphragm. At approximately the T6 level, it crosses
to the left side and eventually empties into the left subclavian
vein. e incidence of chyle leak following esophagectomy
ranges from 2 to 10% and is at greatest risk during en bloc
resection. If the thoracic duct is taken during en bloc dissection, the duct is ligated at the hiatus and inspected for leak.
It is wise to inspect the area of the thoracic duct at the end
of any transthoracic dissection of the esophagus. Often, clear
uid (in the unfed patient) can be seen welling up in the area
and may lead one to a laceration of the thoracic duct. In such
instances, the leak should be repaired directly with pledgeted
4-0 Prolene sutures. Prophylactic ligation of the thoracic
duct following esophagectomy is sometimes performed. In
this maneuver, all tissue between the aorta, spine, and azygos
vein at the level of the hiatus is ligated with a large (0 or 1)
ligature.
e diagnosis of a thoracic duct leak should be suspected
if chest tube output remains high (>800 mL/d) in a patient
despite a normal volume status. Denitive diagnosis may be
dicult, because chyle is not milky unless the patient has been
fed fats. Fluid should be sent for Gram’s stain, triglyceride level,
cell count, and cholesterol level. A triglyceride level greater
than 1 mmol/L is strongly suggestive of a chyle leak, as is a
lymphocyte count greater than 90%. If chylomicrons can be
conrmed by electrophoresis, the diagnosis can also be established. A good bedside test involves feeding the patient cream
enterally 200–300 mL over 2 hours and observing for a change
in character of chest tube euent, from serous to milky white.
Chyle leak following esophagectomy must be repaired.
ese patients are recovering from major surgery and most are
malnourished. e loss of protein and lymphocytes associated
with a chyle leak may be associated with infections and may
interfere with healing. Once the diagnosis is conrmed, or
even if it is strongly suspected, patients should be brought to
the operating room and the thoracotomy incision reopened.
e patient is given enteral cream 1 hour before the procedure
to help locate the leak. e defect is repaired with a pledgeted
4-0 or 5-0 Prolene suture. A careful inspection for other leaks
should be performed before closure, and mass ligation of the
duct at the hiatus should be considered as well.
CT or MRI-guided noninvasive methods have been
proposed for repairing chyle leaks. e cisterna chyli can sometimes be located under CT guidance, cannulated, and injected
with either coils or glue. In a published trial of 42 patients
(including 9 postesophagectomy patients), the thoracic duct
could be embolized in 26 and 16 of these cases were cured.
Impaired Conduit Emptying
Numerous factors aect conduit emptying postesophagectomy.
ese include vagotomy, drainage through the pylorus, width
38
Chapter 18 Surgical Procedures to Resect and Replace the Esophagus 411
of the conduit, redundancy and/or kinking of the conduit, and
postoperative swelling. Studies objectively looking at conduit
emptying following esophagectomy give conicting results as
to the eect of pyloroplasty on gastric conduit emptying time.
A prospective trial studied 200 patients and randomized half to
pyloroplasty and half to no pyloroplasty following Ivor Lewis
39
esophagectomy.
e average daily postoperative nasogastric
drainage was no dierent between the two groups. irteen
patients who did not undergo pyloroplasty had symptoms from
delayed gastric emptying, and two died of aspiration pneumonia. ere were no complications from the pyloroplasty procedure. Six months after the procedure, gastric emptying was
6 minutes in the pyloroplasty group versus 24 minutes in the
group without pyloroplasty. ese patients had more symptoms attributable to delayed emptying as well. e same group
conducted a randomized trial of pyloroplasty versus pyloromyotomy and found both to be equally eective and safe.
Width of the gastric conduit may also aect emptying.
A thin gastric tube has been shown to have a lower incidence of symptoms related to poor gastric emptying (3%)
than patients either with the whole stomach (38%) or distal
40
two-third stomach (14%) acting as the conduit.
A conduit
diameter of 5–6 cm is probably ideal. Excess conduit length
or angulation may also impair emptying, and excess colon
conduit length or angulation is known to cause immediate or
delayed problems with emptying. However, a conduit that is
too thin can lead to an increased anastomotic leak rate.
41
CONCLUSION
Esophagectomy can be a technically challenging operation.
Mortality rates can vary greatly with experience. Hospital volume and surgeon experience play signicant roles. Analysis
of the relationship between volume and mortality shows a
large variance in mortality from almost 25% in low-volume
and low-experience centers to as low as 2.5% in high-volume
42,43
centers.
With improvements and increased penetration of
minimally invasive techniques, mortality has been reported as
41
low as 1.4 %.
Careful patient selection, preoperative preparation, and choice of operation, as well as meticulous surgical
technique, excellent anesthetic and intensive care, and aggressive management of postoperative complications can limit
the morbidity and mortality of this operation.
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