ESOFAGECTOMIA TRASHIATAL

Current Procedures: Surgery > Chapter 5. Transhiatal Esophagectomy >

Indications Resectable esophageal carcinoma. Barrett esophagus with high-grade dysplasia. Carcinoma of the cardia or proximal stomach. Achalasia. Advanced disease (mega-esophagus). Failed esophagomyotomy. Benign (undilatable) stricture. Recurrent hiatal hernia or reflux esophagitis following multiple hiatal hernia repairs.

Contraindications Absolute Biopsy-proven distant metastatic (stage IV) esophageal cancer. Tracheobronchial invasion by upper or mid-third tumors visualized on bronchoscopy. Aortic invasion demonstrated on MRI, CT scan, or endoscopic ultrasound (EUS). Relative Cardiopulmonary comorbidities. Previous esophageal surgery causing excessive mediastinal adhesions. Previous radiation therapy (more than 6–12 months prior) causing mediastinal and esophageal radiation fibrosis.

Informed Consent In our series of patients, overall mortality is 1%, and more than 70% of patients experience no postoperative complications. Expected Benefits Resection of the intrathoracic esophagus and accessible associated adenopathy for definitive therapy or local management of disease, while restoring normal swallowing and digestive function as much as possible. Potential Risks Cervical esophagogastric anastomotic leak (5–10%). Cervical dysphagia or esophageal stricture requiring early postoperative dilation (50–60%). Postvagotomy dumping symptoms (25–50%). Recurrent laryngeal nerve injury (< 5%). Chylothorax (< 2%). Mediastinal hemorrhage (< 1%). Membranous tracheal injury (< 1%). Gastric tip necrosis (< 1%). Surgical site infections and systemic complications common to any major operation (eg, pneumonia, venous thromboembolism, and cardiovascular events).

Equipment A table-mounted "upper hand" retractor facilitates exposure of the operative field. Endoscope for preoperative visualization of the esophageal abnormality and to ensure an adequate normal proximal margin. 14-inch right-angle clamps. Extra-long 16-inch electrocauterizing device. Gastrointestinal anastomosis (GIA) stapler

Patient Preparation Preoperative Planning Thorough preoperative staging evaluation is essential before performing transhiatal esophagectomy for malignancy. Esophagoscopy and biopsy, to establish the location of the tumor and histology. CT scanning, to demonstrate the local extent of the tumor and presence of distant metastatic disease. EUS, to define the depth of tumor invasion within the esophageal wall and surrounding tissues. EUS can also identify dissemination of tumor into regional lymph nodes and can be combined with fine-needle aspiration for confirmation of malignancy. Positron emission tomography has recently become a standard part of the staging evaluation and determines occult distant metastatic disease. For patients with a history of gastric disease or previous gastric surgery, or patients with esophagogastric junction tumors that may necessitate resection of a major portion of the stomach, a barium enema should be performed to assess the colon as an alternate conduit if the stomach is not suitable. Maximizing the patient's preoperative cardiopulmonary status is paramount to successful recovery. Patients should abstain from cigarette smoking and alcohol use for a minimum of 3 weeks before the operation. Patients should use an incentive spirometer on a regular basis (10 deep breaths three times daily), and walk at least 1–3 miles per day. For patients with severe dysphagia, weight loss, or dehydration, liquid supplementation by either oral or nasogastric routes should be considered. Placement of percutaneous gastrostomy and jejunostomy tubes should be avoided for preoperative feeding as they increase the risk of surgical site infection, risk injuring the right gastroepiploic artery, and complicate subsequent mobilization of the stomach at the time of operation. Patients who may require colonic interposition should receive a preoperative bowel preparation. Anesthetic Management Continuous radial intra-arterial blood pressure monitoring. Two large-bore peripheral intravenous catheters. Epidural catheter for postoperative analgesia. Standard endotracheal tube. Foley catheter.

Patient Positioning After induction of general anesthesia, flexible endoscopy is performed by the operating surgeon to verify the exact location of the mass or abnormality and to ensure that there is an adequate normal length of proximal esophagus above for construction of a cervical esophagogastric anastomosis. Following completion of endoscopy, a 16 French nasogastric tube is placed to evacuate air from the stomach. Figure 5–1: The patient should be supine with a folded blanket under the shoulders to provide adequate neck extension. The head is turned to the right and supported on a padded head ring. The skin of the neck, chest, and abdomen is prepared and draped from the angle of the mandible superiorly to the pubis inferiorly, and from both midaxillary lines anteriorly. Both arms are padded and tucked at the patient's side following the placement of arterial and venous access lines. Figure 5–1

Procedure Overview Transhiatal esophagectomy is widely used for the resection of both benign and malignant esophageal disease. In experienced hands, it is a safe and well-tolerated alternative to transthoracic esophagectomy, and it avoids the morbidity of mediastinitis resulting from an intrathoracic anastomotic leak. Using this approach, the thoracic esophagus is resected through a widened diaphragmatic hiatus and a cervical incision. Alimentary continuity is restored with a gastric conduit anastomosed to the remaining cervical esophagus above the level of the clavicles. Abdominal Phase The abdomen is entered through a midline supraumbilical incision (see Figure 5–1). Exploration of the abdomen is performed to confirm that the stomach is an appropriate conduit and is not extensively replaced by tumor nor contracted from prior surgery or caustic ingestion. Mobilization of the stomach. Following exploration, the triangular ligament of the liver is divided using electrocautery. A self-retaining, upper hand, table-mounted retractor is used to facilitate exposure, and the left lobe of the liver is padded and retracted to the right with a liver blade. The greater curvature of the stomach is visualized, and the course of the right gastroepiploic artery is identified. Beginning at the midpoint of the greater curvature of the stomach, the greater omentum is separated from the stomach to the level of the pylorus between right-angled clamps, using 2-0 silk ties for hemostasis. Care is taken to apply the clamps 1–2 cm below the right gastroepiploic artery to avoid injury to this vessel. Attention is then directed to the superior aspect of the greater curvature of the stomach. The left gastroepiploic artery and short gastric vessels are identified and divided between right-angled clamps using 2-0 silk ties for hemostasis. To prevent gastric necrosis, it is important to avoid ligation of these vessels too close to the stomach. Additionally, the surgeon must take care to avoid injury to the spleen during this portion of the dissection. Figure 5–2: Mobilization of the lower esophagus. Following the division of these vessels, attention is turned to the diaphragmatic hiatus. The peritoneum overlying the esophageal hiatus is incised, and the esophagus is encircled with a 1-inch Penrose drain. The gastrohepatic omentum is then incised, taking care to preserve the right gastric artery. The left gastric artery and vein are divided between clamps and doubly ligated, avoiding injury to the celiac axis. The artery is ligated and divided at its origin from the celiac axis, sweeping any adjacent lymph nodes toward the stomach. Throughout this dissection, the surgeon should be mindful of aberrant vascular anatomy, particularly an aberrant left hepatic artery arising from the left gastric artery, which might need to be preserved. To maximize the reach of the stomach superiorly, a generous Kocher maneuver is performed, and the duodenum is mobilized sufficiently so that the pylorus can be grasped and moved to the level of the xiphoid process medially. Two traction sutures are placed, one at the superior and one at the inferior pole of the pylorus. A 2-cm long pyloromyotomy is created, beginning 1.5 cm on the gastric side and extending through the pylorus and onto the duodenum for 0.5–1 cm. This is performed using the cutting current of a needle-tipped electrocautery device and a fine-tipped vascular mosquito clamp to dissect the gastric and duodenal submucosa away from the overlying muscle. The pylorus is marked with two metallic silver clips on the traction sutures for future radiographic localization. Downward traction is placed on the Penrose drain encircling the esophagogastric junction. The diaphragmatic hiatus is progressively dilated manually until the surgeon's hand can be inserted into the posterior mediastinum through the hiatus. A narrow Deaver retractor is placed into the hiatus to allow visualization, division, and ligation of the lateral attachments of the distal half of the esophagus. Gentle blunt dissection is used in combination with electrocautery and a long right-angled clamp to expose the lateral esophageal attachments and mobilize the distal 5–10 cm of the lower esophagus. The low posterior mediastinum is gently packed with a gauze "lap pack" as attention is now turned to the neck. A feeding jejunostomy tube should be placed in all patients. A 14 French rubber jejunostomy tube is inserted approximately 8–10 inches beyond the ligament of Treitz. This is secured in place using two 4-0 polypropylene purse-string sutures and a 4-cm long Weitzel maneuver. The tube is clamped and anchored to the operative drapes until later in the procedure when the jejunostomy is brought out through the left abdominal wall. Figure 5–2 Figure 5–3 Cervical Phase Figure 5–3: Cervical incision and mobilization of the cervical esophagus. Palpation of the cricoid cartilage indicates the level of the cricopharyngeal sphincter, the beginning of the esophagus. A 5–7 cm incision is created along the left anterior border of the sternocleidomastoid (SCM) muscle from the sternal notch to the level of the cricoid cartilage. An incision superior to this point provides no added exposure of the cervical esophagus, which is located inferior to the cricoid cartilage. The platysma muscle is incised. The fascia along the anterior edge of the SCM muscle is incised in the direction of the wound, and the SCM muscle is retracted laterally to expose the omohyoid muscle. The omohyoid muscle and its contiguous fascial sheath are divided, exposing the underlying carotid sheath. The SCM muscle and carotid sheath and its contents are gently retracted laterally, while the larynx, thyroid, and trachea are retracted medially using only a finger. Hand-held retractors should not be used for this purpose to prevent injury to the recurrent laryngeal nerve lying in the tracheoesophageal groove. The middle thyroid vein is divided. The inferior thyroid artery, which is always found at the level of the cricoid cartilage and upper esophageal sphincter, is identified, divided, and ligated. The dissection is carried directly posterior until the prevertebral fascia is identified. Blunt finger dissection into the superior mediastinum separates the cervical and upper thoracic esophagus from the prevertebral fascia. Upward retraction on the cervical esophagus by a finger placed gently along the tracheoesophageal groove elevates the upper thoracic esophagus from the superior mediastinum into the cervical wound, and sharp dissection posterolateral to the tracheoesophageal groove is used to free the anterior surface of the esophagus away from the trachea. The cervical esophagus is encircled with a 1-inch Penrose drain. With upward traction on the Penrose drain, the cervical esophagus is mobilized circumferentially to the level of the carina by the surgeon's index finger, which is kept directly against the esophagus. Mediastinal Dissection Figure 5–4A: Posterior mobilization of the intrathoracic esophagus. Back in the abdomen, working through the diaphragmatic hiatus, the surgeon palpates the esophagus to assess its mobility and establish that transhiatal resection is feasible. The surgeon inserts one hand through the diaphragmatic hiatus posterior to the esophagus. The hand is advanced superiorly, keeping as close to the spine as possible along the prevertebral fascia. At the same time, the cervical esophagus is gently retracted anteriorly and medially using the rubber Penrose drain. A "sponge-on-a-stick" is inserted through the cervical incision behind the esophagus. By advancing the sponge stick inferiorly, the esophagus is dissected free from the prevertebral fascia. Working upward from the diaphragmatic hiatus and downward through the cervical incision, posterior mobilization of the esophagus is completed using a combination of finger dissection and dissection with the sponge stick. The sponge stick is advanced downward until it meets the surgeon's hand inserted through the diaphragmatic hiatus. At this point, a 28 French Argyle Saratoga sump catheter is placed through the cervical incision into the mediastinum along the dissected path to evacuate blood. Figure 5–4B: Anterior mobilization of the intrathoracic esophagus. While the esophagogastric junction is retracted inferiorly with its encircling Penrose drain, the surgeon places his or her hand against the anterior esophagus, palm downward. The hand is advanced into the mediastinum, gently dissecting the esophagus from the posterior pericardium and the carina. The cervical esophagus is retraced superiorly and laterally, and the surgeon places his or her hand against the anterior wall of the esophagus. The hand is advanced inferiorly with two fingers dissecting along the wall of the anterior esophagus to free the esophagus from the posterior membranous trachea. Care must be taken to avoid injury to the trachea during this process. With the anterior and posterior esophageal attachments divided, the cervical esophagus is gently retracted superiorly into the cervical wound as the lateral attachments of the upper esophagus are progressively swept away by blunt dissection. Approximately 5–8 cm of the upper thoracic esophagus is circumferentially mobilized in this fashion. Attention is then turned to the abdominal field. The previously placed lap pad is removed from the posterior mediastinum. The hand is inserted palm downward through the diaphragmatic hiatus and advanced along the anterior esophagus until the circumferentially mobilized upper thoracic esophagus can be identified by palpation. The remaining lateral esophageal attachments and vagal branches are gently avulsed by drawing the hand inferiorly along the esophagus in a "raking" motion. If difficulty is encountered in this dissection, the upper sternum can be divided to provide exposure of the upper thoracic esophagus in the superior mediastinum and division of its lateral attachments under direct visualization. Throughout the mediastinal dissection, intra-arterial blood pressure is monitored with a radial artery catheter to avoid prolonged hypotension due to displacement of the heart. Once the entire thoracic esophagus has been mobilized, the nasogastric tube is withdrawn to a level above the upper esophageal sphincter. The cervical esophagus is elevated out of the wound and divided approximately 8–10 cm distal to the upper sphincter using a GIA surgical stapler. Approximately 5 cm of excessive cervical length should be left to ensure a tension-free reconstruction. The thoracic esophagus and stomach are then delivered downward through the diaphragmatic hiatus, and the sump catheter is advanced down into the posterior mediastinum from the neck incision. A narrow Deaver retractor is inserted into the diaphragmatic hiatus to allow the surgeon to inspect the mediastinum for bleeding and the mediastinal pleura for injury that indicates the need for a chest tube. If the pleura has been violated, a 28 French chest tube is inserted in the appropriate anterior axillary line in approximately the sixth intercostal space, sutured in place, and connected to an underwater seal chest tube suction system. The posterior mediastinum is packed again with a large gauze abdominal lap pad to control minor bleeding, and the cervical wound is covered with a moist pack as the surgeon returns to the abdomen for preparation of the gastric conduit. Figure 5–4A Figure 5–4B Creation of the Gastric Conduit and Abdominal Closure Figure 5–5A: Preparing the gastric conduit. With the mobilized stomach and attached esophagus placed on the patient's anterior chest wall, the site along the greater curvature of the stomach that will reach most superior is identified by gently pulling the fundus toward the cervical incision. Once this point is identified, it is continuously retracted superiorly, as the fat along the lesser curvature is cleared between clamps and ligated at the level of the second "crow's foot." The upper stomach is progressively divided by sequential applications of the GIA stapler, starting at the lesser curvature and working toward the fundus. Traction on the fundus during this maneuver must be maintained to straighten the stomach sufficiently to reach the neck. The proximal stomach is divided approximately 5 cm distal to the esophagogastric junction, and the specimen is passed off of the field. The staple line along the lesser curve of the stomach is oversewn with a running 4-0 polypropylene Lembert stitch. Figure 5–5B: Completed gastric conduit. The completed gastric conduit should reach 4–5 cm above the left clavicle. Figure 5–6: Delivery of the gastric tip into the cervical wound in preparation for the anastomosis. Using a narrow Deaver retractor to expose the diaphragmatic hiatus, the superior tip of the gastric fundus is placed through the hiatus. The surgeon's hand should remain on top of the stomach, gently guiding it upward through the posterior mediastinum, underneath the aortic arch and into the superior mediastinum. When the gastric fundus can be palpated in the superior mediastinum with a finger inserted through the cervical incision, a Babcock clamp is inserted into the superior mediastinum and the gastric tip gently grasped. The jaws of the clamp are not completely closed to minimize trauma to the gastric tip. The gastric tip should not be pulled into the cervical wound, but rather the stomach pushed upward and the tip guided with the hand inserted through the diaphragmatic hiatus into the cervical wound. The surgeon should ensure that the stomach is not twisted by noting that the staple line along the lesser curvature of the stomach is facing toward the patient's right side and by palpating the stomach through the diaphragmatic hiatus and the cervical incision. The gastric tip should remain pink and without evidence of ischemia throughout the remainder of the procedure. The position of the stomach in the neck wound is maintained by packing a small moistened gauze pad into the thoracic inlet alongside the stomach to prevent it from retracting downward into the mediastinum. Attention is redirected to the abdomen, which is inspected for hemostasis. After delivery of the gastric conduit into the cervical incision, the pyloromyotomy will lie 3–4 cm below the level of the diaphragmatic hiatus. The diaphragmatic hiatus is closed loosely using one or two interrupted No. 1 silk sutures until three fingers slide easily alongside the stomach in the hiatus. Additionally, one or two interrupted 3-0 silk sutures are placed between the anterior gastric wall and the adjacent hiatus to discourage migration of a loop of small intestine through the hiatus into the chest. Finally, the left lobe of the liver is returned to its anatomic location, and the triangular ligament is sutured over the hiatus to prevent future herniation of abdominal contents. The jejunostomy tube is brought out of the left upper abdominal wall through a separate stab incision and tacked to the adjacent peritoneum using interrupted 3-0 silk sutures. The jejunostomy tube is secured to the skin using a 2-0 polypropylene suture. The abdomen is then closed using No. 1 looped PDS suture on the muscle fascia, running 2-0 chromic catgut suture on the subcutaneous tissue, and running 3-0 nylon suture on the skin. The abdominal incision is isolated from the field with a sterile towel to prevent wound contamination by oral flora, which can occur once the cervical esophagus is opened for performance of the anastomosis. A sterile drape is placed over the abdominal field. Figure 5–5A Figure 5–5B Figure 5–6 Cervical Esophagogastric Anastomosis Figure 5–7A-D, Figure 5–7E-F: Creation of the cervical esophagogastric anastomosis. After closure of the abdomen, attention is turned to the cervical wound. The tip of the divided cervical esophagus is grasped with an Allis clamp and retracted superiorly and to the right. The anterior wall of the stomach is grasped using a Babcock clamp, and the staple line is rotated more medially. A seromuscular traction suture is placed in the anterior gastric wall to elevate the stomach into the wound, the cervical esophagus is aligned with the stomach, and the site of the anastomosis selected. A 1.5-cm vertical gastrotomy is created in the anterior gastric wall to allow later insertion of a 3-cm Endo-GIA staple cartridge (Figure 5–7A). The cervical esophageal staple line is amputated obliquely, allowing for enough redundancy to accommodate later retraction of the stomach into the thoracic inlet (Figure 5–7B). The staple line is then sent for pathologic examination as the proximal esophageal margin. Two stay sutures are placed, one at the anterior tip of the divided esophagus and the other between the posterior end of the divided esophagus and the superior end of the gastrotomy (Figure 5–7C). These stay sutures align the back wall of the cervical esophagus and the front wall of the stomach for construction of the anastomosis. An Endo-GIA-30 stapler is placed in the stomach as the traction sutures are drawn inferiorly, gently pulling the stomach and esophagus downward as the stapler is advanced inward and closed (Figure 5–7D). Two lateral suspension sutures of 4-0 Vicryl are placed between the cervical esophagus and the stomach on either side of the anastomosis to alleviate tension on the anastomosis. The stapler is fired and removed, thereby creating a 3-cm-long side-to-side stapled esophagogastric anastomosis. The previously placed 16 French nasogastric tube is guided across the anastomosis and into the intrathoracic stomach. The gastrotomy and esophagotomy are closed in two layers of running and interrupted 4-0 monofilament absorbable suture, and each side of the anastomosis is marked with a hemoclip for future radiographic localization (Figure 5–7E, F). The wound is irrigated, and a 0.25-inch Penrose drain is placed adjacent to the anastomosis. The drain is sutured to the skin. The neck incision is closed loosely by reapproximating the SCM muscle fascia to the omohyoid muscle, fascia, and platysma using absorbable interrupted 3-0 Vicryl sutures, and the skin edges are reapproximated with running 4-0 nylon. Figure 5–8: Final anatomic position of the gastric conduit. Sterile dressings are applied, and the thoracostomy tubes are placed on suction. A postoperative chest radiograph should be obtained in the operating room to confirm full expansion of both lungs, absence of hemothorax or pneumothorax requiring an additional chest tube, and appropriate positioning of the tip of the nasogastric tube above the silver clips marking the pylorus. Figure 5–7A–D Figure 5–7E–F Figure 5–8

Postoperative Care Immediate postoperative chest radiograph while the patient is in the operating room to exclude unrecognized pneumothorax or hemothorax. Extubation in the operating room and initiation of epidural anesthesia. Early use of an incentive spirometer within several hours of awakening from anesthesia. Early ambulation beginning on postoperative day (POD) 1. Ice chips by mouth (not to exceed 30 mL/h) for throat comfort until the nasogastric tube is removed on POD 3. Initiation of oral liquids on POD 4, with progressive daily advancement to full liquids, then mechanical soft (pureed) diet, and a soft diet by POD 7. Initiation of jejunostomy tube feedings on POD 3 and tapering as oral intake increases. Monitoring for resolution of ileus. Barium swallow examination on POD 7 to document integrity of the anastomosis, adequate gastric emptying through pylorus and hiatus, and absence of obstruction at the jejunostomy site. If oral intake is poor, nocturnal jejunostomy tube feeding supplementation can be used. If the patient is eating well and has no complications, the jejunostomy tube can be removed 4 weeks postoperatively during follow-up examination.

Potential Complications Intraoperative Pneumothorax. Hemothorax. Uncontrollable mediastinal bleeding (< 1%). Need for thoracostomy tubes due to entry into pleural cavity (75%). Iatrogenic splenectomy (3%). Membranous tracheal laceration (< 1%). Injury to the gastric or duodenal mucosa during pyloromyotomy (< 2%). Early Postoperative Recurrent laryngeal nerve injury (< 1–2%) causing hoarseness and difficulty swallowing. Chylothorax (1%). Cardiac arrhythmia (atrial fibrillation). Sympathetic pleural effusion. Pneumonia and atelectasis (2%). Cervical esophagogastric anastomotic leak (4%). Gastric tip necrosis (1%). Dysphagia. Regurgitation. Postvagotomy "dumping." Anastomotic stricture requiring dilation. Delayed gastric emptying due to incomplete pyloromyotomy, narrowing of the diaphragmatic hiatus, or jejunostomy tube site obstruction. Late Cervical anastomotic stricture. Diaphragmatic hernia. Small bowel obstruction due to torsion at the jejunostomy tube site (< 1%).

Pearls and Tips Marking the pyloromyotomy and cervical esophagogastric anastomosis with hemoclips allows for visualization on postoperative imaging to assess the position of the stomach in the chest and gastric emptying. Use only a fingertip to retract the cervical esophagus, thyroid, and trachea medially during mobilization of the cervical esophagus. To minimize the chance of injury to the recurrent laryngeal nerve, do not place metal retractors against the tracheoesophageal groove. Minimize gastric trauma during mobilization and particularly to the gastric tip so that a healthy stomach can be anastomosed to the esophagus, reducing the risk of postoperative anastomotic leak. When creating the gastric conduit, preserve as much of the stomach as possible to maximize collateral circulation. Repeatedly assess the color and viability of the stomach after mobilization of the stomach, when the gastric tube is delivered into the cervical wound, and after the closure of the diaphragmatic hiatus to be certain that there is no venous congestion or ischemia from mechanical causes. Avoid use of suspension sutures to tack the gastric tip to the prevertebral fascia because of the risk of vertebral osteomyelitis. Use a radial artery catheter to monitor for intraoperative hypotension, particularly during the mediastinal dissection. Hypotension can be caused by cardiac displacement or hemorrhage from injury to mediastinal structures. Aggressive preoperative conditioning with abstinence from cigarette smoking, regular use of an incentive spirometer, and walking are rewarded by a less complicated postoperative course.

References Orringer M. Transhiatal esophagectomy without thoracotomy. Operative Techniques in Thoracic and Cardiovascular Surgery. 2005;10:63–83. Orringer MB, Marshall B, Chang AC, et al. Two thousand transhiatal esophagectomies: changing trends, lessons learned. Ann Surg. 2007;246:363–372.[PubMed: 17717440] [Full Text] Orringer MB, Marshall B, Iannettoni MD. Eliminating the cervical esophagogastric anastomotic leak with a side-to-side stapled anastomosis. J Thorac Cardiovasc Surg. 2000;119: 277–288.[PubMed: 10649203] [Full Text]