Mark B. Orringer
Presentation
A 65-year-old man presents with a 3-month history of progressive low retrosternal dysphagia and a 15-lb weight loss. He has experienced heartburn and effortless regurgitation of gastric contents, worse when supine and after eating, for more than 15 years and treated with over the counter antacids. In the past 5 years, however, the heartburn has gradually subsided along with his need for antacid use. He has had no abdominal pain, hematemesis, or melena. Aside from mild chronic dehydration, his physical examination is entirely unremarkable.
Differential Diagnosis
The primary concern in an adult with new-onset dysphagia is esophageal carcinoma, and this symptom should never be attributed to a benign cause (e.g., gastroesophageal reflux disease [GERD]) without ruling out a gastrointestinal malignancy. In North America, adenocarcinoma of the esophagus has surpassed squamous cell carcinoma as the most common histologic type. The scenario of chronic reflux disease sets the stage for Barrett’s metaplasia and the progression to dysplasia followed by adenocarcinoma. Barrett’s mucosa is associated with a 30- to 40-fold increased risk for the development of esophageal carcinoma. The presence of high-grade dysplasia in a biopsy of Barrett’s mucosa signals imminent malignant transformation and is the trigger for resectional therapy in appropriately selected patients. Not uncommonly, as in the presentation above, patients with Barrett’s adenocarcinomas give a history of years of symptomatic GERD followed by a quiescent period as the squamous mucosa is replaced by metaplastic columnar mucosa, which is not acid sensitive, and then the development of dysphagia as obstruction from the carcinoma occurs. When taking a history in such a patient, finger point localization of the dysphagia (“sticking”) to the low retrosternal area increases the likelihood of a distal esophageal mechanical obstruction. Other causes of dysphagia in the adult that need to be considered include a chronic reflux stricture due to recurrent esophagitis, neuromotor esophageal dysfunction (achalasia, diffuse spasm), reflux induced esophageal dysmotility, and an esophageal diverticulum.
Workup
There are few physical findings of esophageal carcinoma: signs of dehydration and recent weight loss from esophageal obstruction, an enlarged left supraclavicular (Virchow’s) lymph node, and nodular hepatomegaly due to massive hepatic metastases. Laboratory studies showing anemia of chronic GI bleeding, hypoalbuminemia from impaired nutrition, and elevated liver enzymes due to hepatic metastases are uncommon in higher socioeconomic levels with access to medical care. In the adult who complains of new-onset dysphagia, two diagnostic studies are warranted: (1) a barium swallow examination (not a video fluoroscopic “swallow study” or an “upper GI series,” which do not routinely image the thoracic esophagus), and (2) esophagoscopy and biopsy with brushings for cytology, which establish a diagnosis of carcinoma in 95% of cases. The barium swallow examination typically reveals an “applecore” constriction of the distal esophagus proximal to a sliding hiatus hernia (Figure 1). Once the diagnosis of esophageal carcinoma has been established, the next order of business is “staging of the tumor,” which dictates treatment. If a hard Virchow’s node is palpated, a fine needle aspiration biopsy yielding metastatic carcinoma establishes a diagnosis of stage IV disease, which essentially eliminates the surgeon’s role in the case and initiates referrals for chemotherapy and radiation therapy.
FIGURE 1 • Barium swallow study showing a typical “applecore” constriction of adenocarcinoma proximal to a sliding hiatal hernia This was an adenocarcinoma arising within Barrett’s mucosa.
Diagnosis and Treatment
A complete, modern staging evaluation of esophageal carcinoma involves a CT scan of the chest and abdomen (to define the local extent of the tumor and obvious metastatic disease to mediastinal or upper abdominal lymph nodes or distant organs), a PET scan (to document that the tumor is localized and that there is no occult distant metastatic disease), and esophageal endoscopic ultrasonography (EUS) (to define the depth of intramural tumor invasion and the involvement of paraesophageal and upper abdominal lymph nodes) (Table 1).
TABLE 1. TNM Staging of Esophageal Cancer
From the AJCC. Cancer Staging Manual. 7th ed. New York, NY: Springer-Verlag, 2010.
For patients with stage IA disease or those who are older than 75 years (and do not tolerate neoadjuvant treatment well), an esophagectomy is recommended. For those 75 years of age and younger with stage IB through III tumors, neoadjuvant chemoradiation therapy—typically with cisplatin and 5-FU and 45 to 50 Gy of radiation—is advised. Patients with stage IV esophageal carcinoma (distant metastatic disease) are not candidates for esophagectomy.
Patient selection, careful preoperative evaluation, and preparation for surgery are key to a successful outcome after esophagectomy. Baseline pulmonary function tests (spirometry and diffusion capacity) are indicated in those with a history of cigarette smoking. Nuclear medicine assessment of myocardial perfusion and ventricular function is indicated in those with a cardiac history. Clinical judgment—taking into account the results of the above tests and one’s assessment of the patient’s ability to withstand the physiologic insult of an esophagectomy—dictates patient selection for surgery. The importance of adequate patient preparation for the operation cannot be overemphasized: Patients must completely abstain from cigarette smoking and use an incentive inspirometer issued at their first consultation visit for a minimum of 3 weeks before the planned operation and walk 2 to 3 miles each day to condition themselves for early postoperative ambulation. Adequate preoperative hydration is key, particularly in those with radiation esophagitis, and may require insertion of a small caliber nasogastric feeding tube for administration of liquid diet supplements and water if swallowing is severely impaired. A gastrostomy tube is to be avoided since it complicates preparation of the stomach as an esophageal substitute and increases the rate of postoperative wound infections due to the proximity of the upper midline abdominal incision to the gastrostomy tube site. Patients are instructed to take sufficient fluids so that their urine is dilute; dehydration can lead to perioperative thromboembolic complications that require anticoagulation and delay the operation.
Surgical Approach
There are a number of surgical approaches to esophagectomy: traditional open transthoracic, transhiatal, and minimally invasive video-assisted. The goals of esophagectomy are (1) achieving a complete (R0) resection and (2) restoring the ability to swallow comfortably. A transhiatal esophagectomy (THE) and cervical esophagogastric anastomosis (CEGA) offers advantages over the traditional thoracoabdominal Ivor-Lewis esophagectomy, including (1) avoidance of a thoracotomy (therefore fewer pulmonary complications) and (2) an intrathoracic esophagogastric anastomosis (therefore no mediastinitis from an anastomotic leak). There is little evidence that a mediastinal lymph node dissection at the time of a transthoracic esophagectomy confers a meaningful oncologic survival benefit over the lymph node dissection achieved with the transhiatal approach. Minimally invasive esophagectomy offers the advantages of a potentially more complete mediastinal lymph node dissection and less postoperative pain. However, the ability to fully mobilize the stomach and “straighten” it so that is readily reaches to the neck is compromised resulting in a higher incidence of cervical esophagogastric anastomotic leaks. The morbidity of esophagectomy is more a function of altered GI physiology and not the size or number of the incisions. THE and a CEGA is the author’s preferred approach to resectable esophageal cancer.
Absolute contraindications to THE include (1) biopsyproven distant metastatic (stage IV) disease; (2) tracheobronchial invasion by the tumor proven at bronchoscopy; (3) aortic invasion (documented on CT scan, MRI, EUS, or endovascular ultrasound); and most important, (4) the surgeon’s assessment at the time of palpation of the esophagus through the diaphragmatic hiatus that there is too much esophageal fixation in the mediastinum to proceed safely with a THE. A history of prior esophageal operations or radiation therapy more than 6 to 12 months before may signal the presence of periesophageal fibrosis that precludes a safe THE.
THE is not a random wrenching of the esophagus out of the mediastinum. The operation is performed in an orderly fashion and has four well-defined phases:
1. abdominal—(Figure 2) through a supraumbilical midline incision, exploration to exclude distant metastases and establish that the stomach is a satisfactory esophageal replacement; gastric mobilization, dividing and ligating the short gastric and left gastroepiploic vessels along the high greater curvature, the left gastric on the high lesser curvature, and preserving the right gastric and the right gastroepiploic vessels upon which the mobilized stomach is based; a Kocher maneuver; a pyloromyotomy; insertion of a feeding jejunostomy tube; opening the peritoneum overlying the hiatus and mobilizing the distal 5 to 10 cm of esophagus by blunt and sharp dissection;
FIGURE 2 • THE is performed through a supraumbilical midline abdominal incision and a 5- to 7-cm long oblique left cervical incision that parallels the anterior border of the left sternocleidomastoid muscle (inset). Gastric mobilization involves division and ligation of the high short gastric and left gastroepiploic vessels along the greater curvature and the left gastric artery and vein along the lesser curvature. The right gastric and the right gastroepiploic vessels are preserved. A pyloromyotomy, Kocher maneuver, and insertion of the feeding jejunostomy tube complete the abdominal phase of the operation. (From Orringer MB. Transhiatal esophagectomy without thoracotomy. Oper Tech Thorac Cardiovasc Surg. 2005;10:63, with permission.)
2. cervical—(Figure 3A,B) through a 5- to 7-cm oblique low left neck incision along the anterior border of the sternocleidomastoid muscle, the carotid sheath is retracted laterally and the thyroid and trachea medially; the inferior thyroid artery is divided and ligated; the dissection stays posterior to the tracheoesophageal groove and the cervical esophagus is encircled with a Penrose drain;
FIGURE 3 • A: The cricoid cartilage is palpated and marks the level of the cricopharyngeal sphincter. The most superior extent of the 5- to 7-cm incision extends no more than 2 to 3 cm superior to the cricoid cartilage. (From Orringer MB. Transhiatal esophagectomy without thoracotomy. Oper Tech Thorac Cardiovasc Surg. 2005;10:63, with permission). B: Only the surgeon’s finger, no metal retractor, is placed against the recurrent laryngeal nerve in the tracheoesophageal groove. The cricoid cartilage is the anatomic landmark for localizing the inferior thyroid artery that occurs at the same plane but deeper in the wound. The sternocleidomastoid muscle and carotid sheath and its contents are retracted laterally, and the dissection proceeds posteriorly to the prevertebral fascia. After blunt finger dissection into the superior mediastinum, the cervical esophagus is encircled with a one-inch rubber drain carefully avoiding injury to the recurrent laryngeal nerve in the tracheoesophageal groove. (From Orringer MB. Transhiatal esophagectomy without thoracotomy. Oper Tech Thorac Cardiovasc Surg. 2005;10:63, with permission.)
3. mediastinal dissection—(Figure 4) posterior mobilization of esophagus from the prevertebral fascia using the hand inserted through the hiatus from “below” and a “sponge-on-a-stick” from above; (Figure 5) anterior mobilization of the esophagus away from the pericardium and tracheobronchial tree; (Figure 6A,B) mobilization and division of lateral esophageal attachments; (Figure 7) division of cervical esophagus with surgical stapler; delivering the stomach and attached esophagus out of the abdomen; inspecting low mediastinum through the hiatus for bleeding and pleural entry requiring a chest tube; packing the low mediastinum with a large abdominal gauze pack and the upper mediastinum with two narrow “thoracic” packs; (Figure 8A,B) preparing the gastric conduit by dividing the stomach with the linear surgical staple 4 to 6 cm distal to the esophagogastric junction; oversewing the gastric staple suture line; (Figure 9) transposing the “tubularized” stomach through the hiatus with one hand until the fundus can be palpated anterior to the spine with a finger inserted through the cervical incision; delivering 4 to 5 cm of gastric tip into cervical wound; bringing jejunostomy tube through the abdominal wall; abdominal closure;
FIGURE 4 • The cervical esophagus is retracted anteriorly and to the right as a half sponge on a stick is inserted through cervical incision posterior to the esophagus and advanced downward through the superior mediastinum along the prevertebral fascia until it meets the hand inserted through the diaphragmatic hiatus. Blood pressure is monitored during the mediastinal dissection with a radial artery catheter to prevent prolonged hypotension. (From Orringer MB. Transhiatal esophagectomy without thoracotomy. Oper Tech Thorac Cardiovasc Surg. 2005;10:63, with permission.)
FIGURE 5 • The anterior esophageal dissection mobilizes the esophagus away from the pericardium and the posterior membranous trachea. (From Orringer MB. Transhiatal esophagectomy without thoracotomy. Oper Tech Thorac Cardiovasc Surg. 2005;10:63, with permission.)
FIGURE 6 • A: The hand inserted through the diaphragmatic hiatus along the anterior surface of the esophagus is advanced to the level of the circumferentially mobilized cervical esophagus. (From Orringer MB. Transhiatal esophagectomy without thoracotomy. Oper Tech Thorac Cardiovasc Surg. 2005;10:63, with permission). B: The esophagus is “trapped” against the prevertebral fascia between the index and the middle fingers, and a downward raking motion of the hand avulses the small remaining upper periesophageal attachments. Small vagal branches are avulsed. Larger vagal branches below the pulmonary hila may be delivered downward closer to the diaphragmatic hiatus, visualized, clamped, and either divided with electrocautery or ligated (inset). (From Orringer MB. Transhiatal esophagectomy without thoracotomy. Oper Tech Thorac Cardiovasc Surg. 2005;10:63, with permission).
FIGURE 7 • Once the entire intrathoracic esophagus has been mobilized, 3 to 4 inches are delivered into the cervical wound and the esophagus divided obliquely with a GIA surgical stapler applied from front to back with the anterior tip slightly longer than the posterior corner. (From Orringer MB. Transhiatal esophagectomy without thoracotomy. Oper Tech Thorac Cardiovasc Surg. 2005;10:63, with permission).
FIGURE 8 • A: Once the esophagus and stomach have been delivered out of the abdominal incision, the high lesser curvature of the stomach is cleared of fat and vessels at the level of the second “crow’s foot” and the GIA stapler applied progressively toward the gastric fundus 4 to 6 cm distal to the esophagogastric junction, preserving as much gastric capacity and not “tubularizing” the stomach any more than necessary. (From Orringer MB. Transhiatal esophagectomy without thoracotomy. Oper Tech Thorac Cardiovasc Surg. 2005;10:63, with permission). B: After completing division of the upper stomach, the gastric staple suture line comes to rest toward the patient’s right side. The gastric fundus readily reaches above the level of the clavicles. The staple suture line along the lesser curvature is oversewn with two running 4-0 monofilament absorbable sutures. (From Orringer MB. Transhiatal esophagectomy without thoracotomy. Oper Tech Thorac Cardiovasc Surg. 2005;10:63, with permission.)
FIGURE 9 • The gastric fundus is gently manipulated through the diaphragmatic hiatus and advanced upward into the posterior mediastinum manually until the gastric tip can be palpated with the right index finger inserted through the cervical wound. The tip is then grasped with a Babcock clamp that is not ratcheted closed to avoid gastric trauma. The stomach is advanced upward more by pushing it through the mediastinum from “below” rather than pulling it upward from the neck incision. A 4 to 5 cm length of stomach is delivered above the level of the clavicles with the gastric staple line toward to the patient’s right side (inset). (From Orringer MB. Transhiatal esophagectomy without thoracotomy. Oper Tech Thorac Cardiovasc Surg. 2005;10:63, with permission).
4. CEGA—(Figure 10A-F) side-to-side stapled anastomosis using Endo-GIA surgical stapler; placement of nasogastric tube into intrathoracic stomach; cervical wound drainage (1/4 in Penrose) and closure.
FIGURE 10 • A: The anterior surface of the gastric fundus is elevated out of the cervical wound with a 3-0 cardiovascular traction suture that is secured to an adjacent drape. A 1.5- to 2-cm vertical gastrotomy (dotted line) is performed on the anterior gastric wall. (From Orringer MB. Transhiatal esophagectomy without thoracotomy. Oper Tech Thorac Cardiovasc Surg. 2005;10:63, with permission). B: The stapled tip of the divided cervical esophagus is amputated distal to an occluding DeBakey forceps that serves as a guide for the transection. The amputated tip of the esophagus us submitted to pathology as the “proximal esophageal margin” (From Orringer MB. Transhiatal esophagectomy without thoracotomy. Oper Tech Thorac Cardiovasc Surg. 2005;10:63, with permission). C: A stay suture is placed through the anterior tip of the divided esophagus and another through the upper end of the gastrotomy and the posterior tip of the divided esophagus. These sutures align the posterior wall of the esophagus with the anterior wall of the stomach. (From Orringer MB. Transhiatal esophagectomy without thoracotomy. Oper Tech Thorac Cardiovasc Surg. 2005;10:63, with permission). D:An Autosuture Endo-GIA 30-3.5 staple cartridge (United States Surgical Corporation, Norwalk, CT) is inserted with the anvil in the stomach and the staple-bearing portion in the esophagus. (From Orringer MB. Transhiatal esophagectomy without thoracotomy. Oper Tech Thorac Cardiovasc Surg. 2005;10:63, with permission). E: After firing the knife assembly and advancing the blade, a 3-cm long side-to-side esophagogastric anastomosis has been constructed. The stapler is removed and a nasogastric tube inserted by the anesthesiologist and guided into the stomach by the surgeon. (From Orringer MB. Transhiatal esophagectomy without thoracotomy. Oper Tech Thorac Cardiovasc Surg. 2005;10:63, with permission). F: The esophagotomy and gastrotomy are closed in two layers, an inner layer of running 4-0 monofilament absorbable suture and an outer layer of interrupted 4-0 monofilament absorbable suture. (From Orringer MB. Transhiatal esophagectomy without thoracotomy. Oper Tech Thorac Cardiovasc Surg. 2005;10:63, with permission).
Special Considerations
Unsuspected stage IV disease discovered during the operation (e.g., an omental implant of tumor, a small liver metastasis) contraindicates proceeding with an esophagectomy; the potential morbidity and mortality of an esophagectomy to palliate dysphagia in patients with such poor long-term survival is not justified. The most important contraindication to THE is the surgeon’s assessment of the esophagus through the hiatus that there is so much tumor fixation or dense periesophageal fibrosis that the procedure is unsafe; to avoid an intraoperative “disaster” from persisting with a difficult transhiatal dissection, one should not hesitate to convert to a transthoracic approach if it is indicated. A full right posterolateral thoracotomy through the 5th intercostal space provides the best access to the mid and upper thoracic esophagus; a left posterolateral thoracotomy is used to mobilize distal esophageal tumors.
Postoperative Management
Prior to extubation, a portable postoperative chest radiograph is obtained in the operating room to exclude an unrecognized hemoor pneumothorax for which a chest tube is inserted. The routine use of epidural anesthesia facilitates extubation in the operating room. Use of the incentive inspirometer resumes within several hours of awakening from anesthesia, and ambulation begins the following morning. Ice chips for throat discomfort (not to exceed 30 mL/h) are permitted the evening of surgery. The nasogastric tube is typically removed on the 3rd post-op day. Diet is progressively advanced as tolerated, carefully assessing for ileus several times a day: clear liquids (day 4), full liquids (day 5), pureed diet (day 6), and soft diet (day 7). A barium swallow on day 7 documents integrity of the anastomosis, adequacy of gastric emptying, and absence of obstruction at the jejunostomy tube site. Nocturnal jejunostomy tube feedings are administered if oral intake is inadequate. With an uncomplicated post-op course, discharge typically occurs on the 7th postoperative day. If it is no longer being used, the jejunostomy tube is removed 3 to 4 weeks after surgery. Should a cervical esophagogastric anastomotic leak occur, the cervical wound is opened in its entirety at the bedside and packing of the wound with saline moistened gauze begun. Nutrition is maintained with tube feedings. 36, 40, and 46 French Maloney esophageal dilators are passed at the bedside within 1 week of opening the neck incision to insure that swallowed esophageal contents pass preferentially down the esophagus and that an anastomotic stricture does not form; it is not uncommon for anastomotic leaks to close within 1 week of the esophageal dilatation. If the patient with an anastomotic leak remains febrile, has persistent purulent drainage from the neck wound, and there is an odor of putrid tissue, concern about gastric tip necrosis warrants a return to the OR for inspection of the wound with good lighting and retraction and fiberoptic esophagoscopy. Gastric tip necrosis generally requires takedown of the intrathoracic stomach through the hiatus, amputation of the devitalized stomach with a surgical stapler, and construction of an end cervical esophagostomy. Restoration of alimentary continuity is not undertaken for 6 to 12 months to see if the esophageal cancer recurs early. (Less than half of patients with esophageal cancer and gastric tip necrosis ever undergo reestablishment of alimentary continuity with a colon interposition.)
TABLE 2. Key Technical Steps and Potential Pitfalls to Transhiatal Esophagectomy and CEGA
TAKE HOME POINTS
· The properly mobilized stomach virtually always reaches to the neck for construction of a tension-free CEGA.
· Gentle, atraumatic gastric mobilization—keeping the stomach “pink in the belly and pink in the neck”—is key to avoiding a cervical esophagogastric anastomotic leak.
· Fingertip retraction of the thyroid and trachea medially, avoiding placement of metal retractors against the tracheoesophageal groove, minimizes the chance of recurrent laryngeal nerve injury.
· Clinical judgment and experience determine when tumor fixation or periesophageal fibrosis preclude a safe THE; converting to a transthoracic approach is not a sign of weakness!
· A gastric drainage procedure (pyloromyotomy) is routine to avoid potential outlet obstruction (pylorospasm), which may follow the vagotomy and occurs with an esophagectomy.
· The cervical esophagus must not be divided too proximally in order to avoid tension on the subsequent anastomosis.
· The stomach should be divided 4 to 6 cm distal to the esophagogastric junction, preserving as much gastric volume and submucosal blood supply as possible, not “tubularizing” the stomach.
· To minimize trauma to it, the mobilized stomach is positioned in the mediastinum manually, not pulled by sutures or suction devices, and proper orientation (gastric staple line to the patient’s right, right gastroepiploic pedicle to the patient’s left) must be assured to avoid gastric torsion.
· The hiatus is closed loosely, the stomach sutured to the edge of the hiatus, and the left hepatic lobe secured back in place to avert late migration of intestine through the hiatus into the chest.
· A side-to-side stapled CEGA minimizes the incidence of cervical esophagogastric anastomotic leak.
SUGGESTED READINGS
Davis J, Zhao L, Chang A, Orringer, MB. Refractory cervical esophagogastric anastomotic strictures: management and outcomes. J Thorac Cardiovasc Surg. 2011;141:444–448.
Iannettoni MD. White RI, Orringer MB. Catastrophic complications of the cervical esophagogastric anastomosis. J Thorac Cardiovasc Surg. 1995;110:1493–1501.
Orringer MB. Transhiatal esophagectomy without thoracotomy. Oper Tech Thorac Cardiovasc Surg. 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.
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.