Subtotal Esophagectomy Transhiatal Approach

Stefan B. Hosch, Emre F. Yekebas, Jakob R. Izbicki

Introduction

The surgical trauma of the transhiatal approach is less pronounced as compared to a transthoracic approach. On the other hand, the lymphatic clearance is less radical, at least for the mid and upper mediastinum. This is the reason why some surgeons are in favor of the transthoracic approach even for distal adenocarcinoma. Subtotal transhiatal esophagectomy is indicated for benign conditions and for distal carcinoma.

Indications and Contraindications

■ Intraepithelial squamous cell neoplasia

■ Poor risk patients

■ Extensive stricture (stenosis) due to erosion (chemical burns) unresponsive to nonsurgical treatment including bougienage

■ Extensive peptic stricture (stenosis)

■ Relapse of megaesophagus after surgical repair of cardiospasm combined with peptic strictures and failure of dilatation

■ Extensive benign esophageal tumors (exceptional cases, usually local excision)

■ Esophageal rupture or iatrogenic perforation with mediastinitis (primary repair not

Indications

Adenocarcinoma of distal esophagus (>T1 stage)

feasible)

Contraindications

■ Florid gastroduodenal ulcer

■ Infiltration of aorta

■ Distant metastasis

Preoperative Investigation/Preparation for the Procedure

Colonoscopy CT scanning (thorax + abdomen): Abdominal ultrasound:

History: Risk factors:

Laboratory tests: Endoscopy:

Clinical evaluation:

Previous gastric or colonic surgery

Alcohol, nicotine, gastroesophageal reflux disease (GERD), Barrett's esophagus

Recurrent laryngeal nerve status, cervical lymphadenopathy

CEA, liver function tests, coagulation test Esophagogastroduodenoscopy with biopsy -to exclude gastric infiltration If colonic interposition is likely Staging

Staging

Esophageal endosonography: Staging, r/o aortic infiltration Bronchoscopy (if tumor is r/o bronchial infiltration localized in mid-third):

Bowel cleansing (If colonic interposition is likely)

Respiratory therapy

Procedure Access

Upper transverse incision with median extension. Alternatively midline laparotomy.

STEP 1 Laparotomy and inspection of the stomach, distal esophagus, liver and regional lymph nodes

Placement of self-retaining retractor system for exposure of the epigastric region (A).

Mobilization of the left lateral liver by transection of the left triangular ligament. To prevent injury of adjacent structures, a pack is placed under the left lobe of the liver (B).

Esophageal Transection

STEP 2

Preparation and mobilization of the stomach with epigastric lymphadenectomy including para-aortic lymphatic tissue

Dissection of the greater curvature is commenced from below, thoroughly sparing the origin of the right gastroepiploic vessels and the arcade between left and right gastroepiploic vessels up to the level of the splenic hilum (A).

Dissection of the greater curvature is continued towards the spleen. The left gastroepiploic artery is transected directly at its origin at the splenic artery. Transection and ligature of the short gastric vessels is performed, thus mobilizing the fundus and the greater curvature completely. For esophageal carcinoma the parietal peritoneum is incised at the upper pancreatic margin and lymphadenectomy is begun along the splenic artery. The flaccid part of the lesser omentum is dissected. The cranial part of the hepatogastric ligament (hepatoesophageal ligament) is dissected from the diaphragm. An accessory left liver artery with strong caliber should be preserved. In this case the left gastric artery has to be diverted distally to the origin of this accessory liver artery (B).

Preparation and mobilization of the stomach with epigastric lymphadenectomy including para-aortic lymphatic tissue

Lymphadenectomy of the hepatoduodenal ligament is performed. Remove all lymphatic tissue around the hepatic artery up to the celiac trunk, of the portal vein and as well as the lymphatic tissue around the common bile duct. Ligature and diversion of the right gastric artery are carried out close to its origin below the pylorus (C-1, C-2).

Transection of the left gastric artery. All lymph nodes along the left gastric artery, the splenic artery, the common hepatic artery, the celiac trunk, and para-aortic lymph nodes are removed (D).

In benign diseases, blunt dissection of the esophagus is performed without lymphadenectomy. The right gastric artery may be ligated below the pylorus.

The blood supply of the gastric tube after preparation is exclusively provided by the right gastroepiploic artery.

Esophagus And Aorta

STEP 3 Mobilization of the abdominal part of the esophagus and incision of the esophageal hiatus

The lymph node dissection is continued along the celiac trunk to the para-aortic region. The lymphatic tissue is transposed to the lesser curvature and is later resected en bloc with the tumor.

For better exposure the diaphragmatic crura are incised with diathermia and the stumps may be ligated. Blunt mobilization of the esophagus is done with the index finger. During this maneuver connective tissue fibers between the esophagus, diaphragmatic crua and abdominal aorta must be removed carefully (A).

The abdominal esophagus is mobilized and pulled caudally with a rubber tube.

STEP 3 (continued)

Mobilization of the abdominal portion of the esophagus and incision of the esophageal hiatus

The hiatus is incised ventrally following transection of the left inferior phrenic vein between ligatures (B).

Insertion of retractors. The retrocardial lymphatic tissue is removed en bloc with the specimen (C).

STEP 4 Transhiatal esophageal dissection in the posterior mediastinum including para-aortic lymphadenectomy: mobilization of the distal esophagus

Dissection of the distal esophagus is performed by detachment of its anterior surface from the pericardium. Infiltrated pericardium can be resected en bloc. Sharp dissection is continued anteriorly up to the tracheal bifurcation and completed by blunt dissection upwards. The trachea and the brachiocephalic trunk are palpable anteriorly. Severe damage of the trachea, the azygos vein, the pulmonary vessels or the aorta, respectively, may occur especially in the case of extensive local tumor growth (A-D).

Transhiatal esophageal dissection in the posterior mediastinum including para-aortic lymphadenectomy: mobilization of the distal esophagus

After complete anterior and posterior mobilization, the esophagus is pulled caudally. The ligament like so-called lateral "esophageal ligaments" consisting of branches of the vagus nerves, pulmonary ligaments and esophageal aortic branches should be trans-sected sharply between clamps (clips may be used alternatively), thus avoiding bleeding, chylothorax or chyloperitoneum (E).

Excision of parietal pleura. In the case of tumor infiltration of the pleura or lung, en-bloc resection of adherent tissue can be performed following enlargement of the diaphragmatic incision if needed (F).

Para Aortic Lymphadenectomy

Transhiatal esophageal dissection in the posterior mediastinum including para-aortic lymphadenectomy: mobilization of the distal esophagus

Further dissection up to the tracheal bifurcation by division of the lateral ligaments. This step includes lymphadenectomy of the posterior mediastinum and posterior to the tracheal bifurcation (G-1, G-2).

For blunt dissection of the esophagus proximal to the tracheal bifurcation, the lateral ligaments should be pulled down and consecutively ligated.

If possible, blunt dissection is completed up to the upper thoracic aperture (H).

STEP 5 Construction of the gastric tube

Starting at the fundus, the lesser curvature is resected using a linear stapler device. It follows the direction to the pylorus. Shortening of the gastric tube can be avoided by stretching the stomach longitudinally (A).

The stapleline is oversewn by seromuscular interrupted sutures. The diameter of the gastric tube should be 2.5-3cm following this procedure (B).

Zollinger Atlas Surgical Operations

STEP 6 Mobilization and dissection of the cervical esophagus; resection of the esophagus

For better exposure the patient's head is turned to the right. A skin incision is performed along the anterior edge of the sternocleidomastoid muscle. Dissection of the platysma and blunt dissection between the straight cervical muscles and the sternocleidomastoid muscle are done followed by lateral retraction of the sternocleidomastoid muscle. Sharp dissection of the omohyoid muscle enables exposure of the lateral edge of the thyroid, the jugular vein and the carotid artery by retracting the strap muscles medially (A, B).

Displacement of the esophagus using a curved instrument. Dissection of the cervical esophagus and upper thoracic esophagus is completed by blunt dissection with the finger or dissector (C, D). The nasogastric tube is removed. Transection of the esophagus is performed with a stapler (C) or with scissors (E), after ligation of the aboral part of the esophagus. A strong thread or a rubber band is fixed at the aboral stump of the esophagus before the esophagus is transposed into the abdominal cavity. This eases later transposition of the gastric tube to the neck.

Gastric Tube

STEP 7 Reconstruction

Gastric tube pull-through. In rare cases mobilization of the duodenum may be necessary (Kocher maneuver) to lengthen the gastric tube. Optional methods of placement (A, B, C):

a) Esophageal bed b) Retrosternal c) Presternal

STEP 8 Cervical anastomosis

A two-layer anastomosis of the gastric tube and the esophageal stump is performed. The first seromuscular sutureline is performed in an interrupted fashion (A). The protruding parts of the esophagus and the gastric tube are resected (B). The second inner sutureline of the posterior wall can be performed as a running suture (C).An enteral three-lumen feeding tube is then inserted over the anastomosis and placed into the first jejunal loop for postoperative enteral nutrition (D).

The anterior wall is completed with interrupted or running sutures. The second suture of the anterior wall can be performed in a U-shaped fashion. This may provide an inversion of the anastomosis into the gastric tube (E, F).

STEP 9 Final situs

A soft drainage is placed dorsal to the anastomosis, followed by closure of the skin. Drainage of the mediastinum is warranted by two soft drains from the abdomen.

Mediastinal Drains

Standard Postoperative Investigations

■ Postoperative surveillance on intensive care unit

■ "Generous" indication for postoperative endoscopy

■ Daily check of the drainage

Postoperative Complications

■ Pleural effusion and pneumonia

■ Anastomotic leakage

■ Necrosis of the interponate

■ Injury to recurrent laryngeal nerve (uni- or bilateral)

■ Mediastinitis

■ Chylus fistula

■ Scarring of the esophageal anastomosis with stenosis (long term)

Tricks of the Senior Surgeon

■ Mobilization of the duodenum on the one hand may facilitate the placement of a feeding tube. On the other hand, it may include the possibility of shortening the length of the tube to get a better blood supply of the anastomotic region.

■ Wide incision of the diaphragm crura provides optimal exposure of the posterior mediastinum to minimize risks of blunt mediastinal dissection.

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