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Ростовский Государственный Медицинский Университет

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■Asmall-caliberbougiedilator(44Fr)inthe

esophagusfacilitatestactilelocalizationofthe esophagusduringbluntdissection.

Reconstruction ■Graftfailureandanastomoticleakresultfrom

ischemia,whichisaconsequenceofinadequate bloodsupply,venouscongestion,tensiononthe anastomosis,orhypoperfusionintheearly postoperativeperiod.Thesefactorsshouldbe avoided.

■Properorientationoftheconduitwithpreventionof

twistingismadeeasierbydrawingparallellineson thePenrosedrainandmakingsurethedraindoes nottwistasitispulledoutthrutheneckdelivering theconduittothecervicalincision.

Anastomosis ■Properorientationofthecervicalanastomoticstaple

linesshouldbemaintainedtomaximizeperfusion ofthegastricwall.Thisisaccomplishedbykeeping theesophagogastrostomystaplelineasfaraway fromtheconduitlessercurvaturestapleline.

■Whenplacingtheanastomosisbackintheneck,it

shouldbestraightenedbyreducingredundancyof theconduitbycaudaltractionontheconduitatthe hiatus.Avoidplacingtensionontheanastomosis.

POSTOPERATIVECARE

■ Patientsrecoverintheintensivecareunituntilacutecardiac,respiratory,and volumestatusissuesareresolved.

■ Ashypoxiaandhypotensioncanleadtohypoperfusionofthereconstruction withanastomoticleakor,intheworstscenario,conduitnecrosis,this shouldbeavoidedandquicklyremediedifclinicallyencountered.

■ Asrespiratoryfailureandpneumoniaarethemostcommoncomplications encountered,aggressivepulmonarycareisrequired.Earlyambulationis mandatory.

■ Fluidoverloadcanleadtohypoxia,pulmonaryedema,anddysrhythmia(most oftenatrialfibrillation).

■ Entericnutritionisbegunslowlyonpostoperativeday1.

■ Patientsshouldbecarefullyfollowedforsignsofpostoperativecomplications (seethefollowingtext)andevaluationandmitigationstrategiesemployedat thefirstsignofsuchissues.

■ Ifthepatientismedicallystabletoconsideroralintake,awater-solublecontrast studyfollowedbybariumisdoneonthefourthpostoperativedaytomake surethereisnosignificantanastomoticleakandtheconduitempties adequatelyintothesmallintestine.

■ Ifok,aliquiddietisstartedandcontinuedfor2weeksatwhichtimethepatient istransitionedtoasoftdietforanadditional2weekspriortoresuminga normaldiet.Therationaleforthisapproachistoavoidfoodimpactionduring thecriticalperiodofanastomotichealing.Thesurgicaldrainisremovedafter anegativestudyandnoevidenceoforalfluidsinthedrainwithin48hoursof oralliquidintake.

■ Thefeedingtubeisdiscontinuedwhenthepatientisabletotakeadequateoral intake,usuallywithinthefirsttosecondweekfollowingsurgery.

■ Patientsshouldbecounseledastohowtooptimizetheirfluidandnutritional intakeduringthisperiodoftransitiontoregulardietandmanagedumping symptomswithdietaryandlifestylemodification.

■ Patientsshouldbeadvisedastotheearlysignsofanastomoticstrictureandneed

foresophagealdilation.

OUTCOMES

■ THEisaverymorbid,high-riskprocedurewithveryhighassociatedoperative morbidityandmortality(seethefollowingtext).

■ Regardingfunctionaloutcome,thebestdataavailablearereviewsfrompatients whounderwentthisprocedureforbenignindicationsandearlystagecancer giventhelongersurvivalinthesepatientscomparedtopatientswith cancer.

11,12

■ Symptomsofphysicalimpairment,includingGEreflux,dumping,and dysphagia,areverycommonaftersurgerybutshowgradualimprovement towardbaselineoverthefirstyear,notquitereachingbaseline.Long-term physicalimpairmentislesscommonafterTHEcomparedtoTTE.

■ Overallhealth-relatedqualityoflife(abilitytowork,socialinteraction,daily activities,emotionalfunction,perceptionofhealth,energylevel,and mentalhealth)decreasesaftersurgerybutreturnstobaselinenational normswithin1yearofsurgery.

■ Regardingcancer-specificoutcome,long-termsurvivalisafunctionofthe underlyingbiologyandstageofthetumorratherthansurgicalapproach.

13,14

COMPLICATIONS

■ Perioperativecomplicationsoccurin40%to50%ofpatientsandfallinto specificcategoriesdependingonthepointoftimeinwhichtheyappear followingsurgery.Reportedoverall30-daymortalityforTHErangesfrom 1%inselectsinglecenterreportsto10%innonselectiveadministrative databasereports.

13,15,16

■ Earlypostoperativeperiod(0to2days)

■ Technicalcomplications

■

Bleeding

■ RLNinjurywithresultanthoarseness(unilateral)andairwayobstruction (bilateral)

■ Pleuralviolationwithpneumothoraxorpleuraleffusion

■ Conduitnecrosisrequiringremovalofconduitandcervicalesophagostomy

■

Medicalcomplications

■ Respiratorycomplications(respiratoryfailure,pneumonia)

■ Cardiaccomplications(dysrhythmia,myocardialinfarction,heartfailure)

■ Urinarytractcomplications(renalfailureorinsufficiency)

■ Intermediatepostoperativeperiod(2to14days)

■

Technicalcomplications

■ Anastomoticleakmanifestascervicalwoundinfectionanddrainageor drainageoforalsecretionsviaclosedsuctiondrain.

■ Conduitnecrosisrequiringremovalofconduitandcervicalesophagostomy

■ Thoracicductinjurywithchyleleak,usuallymanifestbypleuraleffusionat onsetofentericororalnutrition.

■

Medicalcomplications

■ Respiratorycomplications(respiratoryfailure,pneumonia)

■ Cardiaccomplications(dysrhythmia,myocardialinfarction,heartfailure)

■ Urinarytractcomplications(renalfailure/insufficiency,urinarytract infection)

■ Infectiouscomplications,(lineinfection,organspaceinfection,wound infection)

■ Latepostoperativeperiod(after14days)

■

Technicalcomplications

■ Anastomoticstricture

■ Delayedgastricemptying

■ Dumpingsyndrome

■

Medicalcomplications

■ Malnutrition

■ Cancerrecurrence

REFERENCES

1.EdgeSB,ByrdDR,ComptonCC,etal.AJCCCancerStagingManual.7thed.NewYork,NY:

Springer;2010.

2.AjaniJA,BarthelJS,BentremDJ,etal.Esophagealandesophagogastricjunctioncancers.JNatl

ComprCancNetw.2011;9(8):830–887.

3.BirkmeyerJD,SiewersAE,FinlaysonEV,etal.Hospitalvolumeandsurgicalmortalityinthe

UnitedStates.NEnglJMed.2002;346(15):1128–1137.

4.BirkmeyerNJ,GoodneyPP,StukelTA,etal.DocancercentersdesignatedbytheNational

CancerInstitutehavebettersurgicaloutcomes?Cancer.2005;103(3):435–441.

5.DimickJB,WainessRM,UpchurchGRJr,etal.Nationaltrendsinoutcomesforesophageal

resection.AnnThoracSurg.2005;79(1):212–216;discussion217–218.

6.CataifeG,WeinbergDA,WongHH,etal.TheeffectofSurgicalCareImprovementProject

(SCIP)complianceonsurgicalsiteinfections(SSI).MedCare.2014;52(2Suppl1):S66–S73.

7.AryaS,MarkarSR,KarthikesalingamA,etal.Theimpactofpyloricdrainageonclinical outcomefollowingesophagectomy:asystematicreview[publishedonlineaheadofprintFebruary24, 2014].DisEsophagus.doi:10.1111/dote.12191.

8.HondaM,KuriyamaA,NomaH,etal.Hand-sewnversusmechanicalesophagogastric anastomosisafteresophagectomy:asystematicreviewandmeta-analysis.AnnSurg.2013;257(2):238–

248.

9.PriceTN,NicholsFC,HarmsenWS,etal.Acomprehensivereviewofanastomotictechniquein 432esophagectomies.AnnThoracSurg.2013;95(4):1154–1160;discussion1160–1161.

10.PetersJH,KronsonJW,KatzM,etal.Arterialanatomicconsiderationsincoloninterposition

foresophagealreplacement.ArchSurg.1995;130(8):858–862;discussion862–863.

11.deBoerAG,vanLanschotJJ,vanSandickJW,etal.Qualityoflifeaftertranshiatalcompared withextendedtransthoracicresectionforadenocarcinomaoftheesophagus.JClinOncol. 2004;22(20):4202–4208.

12.DarlingGE.Qualityoflifeinpatientswithesophagealcancer.ThoracSurgClin. 2013;23(4):569–575.

13.ChangAC,JiH,BirkmeyerNJ,etal.Outcomesaftertranshiatalandtransthoracic esophagectomyforcancer.AnnThoracSurg.2008;85(2):424–429.

14.HulscherJB,vanSandickJW,deBoerAG,etal.Extendedtransthoracicresectioncompared withlimitedtranshiatalresectionforadenocarcinomaoftheesophagus.NEnglJMed.2002;347(21): 1662–1669.

15.OrringerMB,MarshallB,ChangAC,etal.Twothousandtranshiatalesophagectomies: changingtrends,lessonslearned.AnnSurg.2007;246(3):363–372;discussion372–374.

16.RentzJ,BullD,HarpoleD,etal.Transthoracicversustranshiatalesophagectomy:aprospective studyof945patients.JThoracCardiovascSurg.2003;125(5):1114–1120.

Chapter13

IvorLewisEsophagectomy



RobertE.Merritt

DEFINITION

■ AnIvorLewisesophagectomyisdefinedasaresectionoftheesophagealtumor usingalaparotomyincisionandarightthoracotomy.Theesophagogastric anastomosisisperformedintherightthoraciccavity.Thissurgicalapproach isappropriateforpatientswithresectabletumorsinthemiddleanddistalthird oftheesophagusaswellasthegastroesophagealjunction.

PATIENTHISTORYANDPHYSICALFINDINGS

■ Patientswhopresentwithesophagealcarcinomashouldundergoacomplete historyandphysicalexamination.

■ Patientsoftencomplainofdysphagiatosolidfoodandliquids.Thissymptomis relatedtoesophagealobstructionfromabulkytumor.

■ Barrett’sintestinalmetaplasiaorgastroesophagealrefluxdisease(GERD)may precedethediagnosisofesophagealcancer.

■ Significantweightlossisacommonsymptomofpatientswithesophageal cancer.Theweightlossmaybesecondarytopoororalintakerelatedto

dysphagiaorcancercachexia.

■ Thecervicallymphnodesandsupraclavicularlymphnodesshouldbe thoroughlyexaminedduringphysicalexamination.Thecervicaland supraclavicularlymphnodesareacommonsiteformetastaticspreadfrom esophagealcarcinoma.

IMAGINGANDOTHERDIAGNOSTICSTUDIES

■ Anesophagogastroduodenoscopy(EGD)shouldbeperformedoneverypatient withesophagealcarcinoma(FIG1).Upperendoscopyallowsaccesstothe tumorfordiagnosisanddeterminationofthehistologicsubtype (adenocarcinomavs.squamouscellcarcinoma).Thelocationofthetumoris alsoimportanttodeterminewhetheranIvorLewisesophagectomywouldbe feasible.Esophagealtumorsintheproximalthirdoftheesophaguswould requireatranshiatalorthree-fieldesophagectomywithacervical esophagogastrostomyanastomosis.

■ Endoscopicultrasound(EUS)isacriticalstagingtechniqueforesophageal cancer(FIG2).TheEUSdeterminesthedepthofinvasionofthetumorinto theesophagealwall(Tstage).Esophagealtumorsthatpenetratethroughthe esophagealwallareconsideredlocallyadvancedandhaveahighpropensity tometastasizetolocoregionallymphnodes.Periesophageallymphnodesthat

areenlargedcanbevisualizedwithEUSandfineneedleaspirationbiopsycan beperformedtodeterminelocoregionallymphnodeinvolvement.Patients withbiopsy-provenlymphnodeinvolvementwilltypicallybereferredfor preoperativechemotherapyorcombinedchemoradiation.

■ Allpatientswhoarebeingconsideredforesophagectomyshouldundergoa computedtomography(CT)scanofthechest,abdomen,andpelvisto evaluatetheprimarytumorintheesophagusandthelocoregionallymph nodes.Theliver,celiaclymphnodes,bone,andadrenalglandsarecommon sitesformetastaticdiseasesecondarytoesophagealcarcinoma.Positron emissiontomography(PET)isanessentialstagingtechniqueforesophageal carcinoma(FIG3).PETscanscandetectoccultmetastaticdiseasethatwas notidentifiedonstandardCTscansinabout10%to15%ofcases.This detectionofoccultmetastaticdiseasewillpreventpatientswithstageIV

esophagealcarcinomafromundergoinganunnecessaryesophagealresection.

SURGICALMANAGEMENT

PreoperativePlanning

■ AnypatientwhoisbeingevaluatedforanIvorLewisesophagectomyshould undergoacompleteandthoroughcardiopulmonaryevaluationpriortothe operation.Cardiacdiseaseandrespiratorycompromiseshouldbeidentifiedin thepreoperativeperiodtoproperlyaccessperioperativeriskofcomplications andmortality.

■ Pulmonaryfunctiontestsshouldbeobtainedtomeasuretheforcedexpiratory volumein1second(FEV1)anddiffusioncapacity.Patientswithahistoryof

chronicobstructivepulmonarydisease(COPD)willhavediminishedvalues forFEV1anddiffusingcapacityoflungforcarbonmonoxide(DLCO);

therefore,theywillbeatincreasedriskforperioperativerespiratory complications.

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