Esophageal Surgery

Chapter 70 Esophageal Surgery



Angela M. Mislowsky, MD, Richard F. Heitmiller, MD



INTRODUCTION


Esophagectomy is a complex surgery associated with significant morbidity and mortality. Complications can lead to lengthy hospital stay and can negatively affect postsurgical quality of life by altering or interrupting the ability to swallow. Understanding the complications that are possible with this surgery is vital to their prevention. The two key principles for performing esophagectomy successfully are (1) to prevent complications to begin with, if possible, and (2) to have safeguards in place to manage complications if they do occur. The objective of this chapter is to review both principles.



INDICATIONS



• Esophageal cancer

• Barrett’s mucosa with high-grade epithelial dysplasia

• Advanced functional disorders

• Multiple failed previous antireflux procedures

• Strictures


OPERATIVE STEPS



Step 1 Positioning: supine with head turned to right

Step 2 Incision: supraumbilical incision from xyphoid to umbilicus

Step 3 Divide triangular ligament and retraction of left lateral segment of liver

Step 4 Separate greater omentum from stomach

Step 5 Divide short gastric vessels

Step 6 Incise peritoneum overlying hiatus, encircle esophagogastric junction

Step 7 Divide gastrohepatic omentum

Step 8 Divide left gastric vessels

Step 9 Mobilize distal greater curve of stomach

Step 10 Perform Kocher’s maneuver

Step 11 Perform pyloroplasty or pyloromyotomy


OPERATIVE PROCEDURE


The technique of esophagectomy can be broken down into three parts, as summarized in Box 70-1. The first is the step of gastric mobilization; the second, esophageal dissection along with at least single-field lymphatic dissection for patients with cancer; and the third is the reconstructive esophageal anastomosis. We have advocated routine use of an adjuvant jejunostomy feeding tube.1 When used, this would be the fourth surgical step.



Box 70-1 Esophagectomy Technique: Overview



• Step 1 Gastric mobilization. If jejunum or colon is used instead of stomach, assess conduit options before proceeding with esophageal resection

• Step 2 Esophageal dissection

• Step 3 Reconstructive anastomosis; most commonly, esophagogastric anastomosis

• Step 4 Adjuvant jejunostomy

The several different incisional approaches to performing esophagectomy include transhiatal (midline laparotomy, left cervical incision), Ivor Lewis (right thoracotomy and midline laparotomy), three-incision (cervical, right thoracotomy, midline laparotomy), and left thoracoabdominal methods. Despite their widely variant incisions, all utilize the three-part surgical steps stated previously. Selection of the specific approach is based on location of the esophageal tumor or disease, reconstruction plans, and surgical preference. In experienced hands, there is no difference in morbidity, mortality, and survival as a function of surgical approach.


The majority of surgeons prefer to use the mobilized stomach to replace the resected esophagus. Advantages of the stomach as a replacement conduit include easy mobilization and superb blood supply that minimizes the incidence of conduit ischemia and results in only one anastomosis. Colon or jejunum may also be used as replacement conduits. Doing so results in more operative time, a higher risk of conduit ischemia, and more reconstructive anastomosis. For the purposes of this chapter, the discussion of complications largely focuses on the technique of esophagectomy when the stomach is used for esophageal replacement.



Complications


Complications are listed in the same order as they might arise during the surgery and postoperative management of a patient undergoing esophagectomy. Therefore, complications include operative complications, those that occur early and late during the initial hospital stay, and finally those encountered after discharge. The complications to be discussed are listed in Box 70-2.



Box 70-2 Esophagectomy Complications



Operative



• Bleeding

• Splenic injury

• Airway injury

• Esophageal conduit issues
• Transmural opening

• Ischemia

• Insufficient length

• Chyle leak


Early Inpatient Complications (<72 hr)



• Respiratory complications
• Atelectasis

• Pleural effusion

• Respiratory failure

• Pneumonia

• Hoarseness (recurrent laryngeal nerve injury)

• Conduit ischemia

• Arrhythmia


Late Inpatient Complications (>72 hr)



• Aspiration pneumonia

• Anastomotic leak

• Wound infection

• Chyle leak


Postdischarge Complications



• Anastomotic stricture

• Diaphragmatic hernia


Transhiatal Phase



• Blunt dissection of esophagus away from surrounding pleura and aorta with downward traction maintained on gastroesophageal junction

• Small vessels and lymphatics are clipped and divided

• Dissection progresses cephalad, staying on esophagus

• Proximal small vessels and lymphatics are avulsed when unable to clip


Cervical Phase



• Oblique incision along anterior border of sternocleidomastoid

• Divide platysma and omohyoid

• Retract sternocleidomastoid and carotid sheath laterally and larynx and trachea medially

• Dissect esophagus posterior along prevertebral fascia

• Incise areolar tissue overlying lateral esophageal wall

• Dissect esophagus circumferentially

• Continue circumferential mobilization of esophagus down to carina

• Divide cervical esophagus and deliver into abdomen with umbilical tape tied to esophagus to maintain posterior mediastinal route


Abdominal Phase Part II



• Tubularize gastric conduit

• Bring gastric conduit through posterior mediastinal tunnel and out cervical incision

• Esophagogastric anastomosis

• Place cervical drain

• Feeding jejunostomy

• Close incisions


Surgical Resection of the Esophagus



Operative Bleeding


The esophagus has a diverse and robust blood supply and lies in close proximity to many prominent vascular structures. Therefore, surgical resection of the esophagus always carries a risk of significant bleeding. The reported rate of perioperative hemorrhage complicating esophagectomy ranges from 0.3% to 4%.2–4 The risk and consequences of bleeding vary depending on the technique of esophagectomy. The risk of bleeding related to preparing the stomach for esophageal conduit is shared by all incisional techniques.


Open thoracotomy approaches minimize the risk of unexpected vascular injury because these methods give direct visual exposure of the operative field. In addition, vascular injuries can be promptly identified and repaired, generally through the same exposure. Conversely, these approaches add a thoracotomy incision and open the mediastinal pleura. Diffuse, small mediastinal bleeding vessels, likely to thrombose if contained to the mediastinum, may result in greater blood loss if they can drain into the opened pleural space. Risk of chest wall bleeding from the thoracotomy incision is also introduced.


Transhiatal esophagectomy is associated with very real and significant bleeding during the intrathoracic, “blunt,” or transhiatal phase of esophageal dissection. Bleeding may result from large esophageal arteries originating from the aorta, inferior pulmonary vein, or pulmonary artery, as illustrated in Figure 70-1. Bleeding is usually immediately apparent as brisk blood flow exiting from the lower mediastinum or from the neck. However, if the mediastinal pleura has been opened during transhiatal dissection, then the bleeding event, or at least its severity, can be masked. When this happens, the first sign of trouble is an unexpected volume requirement or unstable hemodynamics. It is essential that the surgeon and anesthesiologist remain in communication during this phase of the operation.


image

Figure 70-1 The proximity of the esophagus to major intrathoracic vascular structures such as the pulmonary artery, superior and inferior pulmonary veins, aorta, and esophageal arteries and the juxtaposition of the airway and esophagus.


The abdominal phase of esophagectomy involves mobilizing the stomach based on the right gastroepiploic arcade and adding a Kocher maneuver. Bleeding may occur from any of the divided vessels including the short gastric, right and left gastric, and paraduodenal vessels. Bleeding is most likely to occur in regions where exposure is most compromised. Most commonly, this means the short gastric vessels and the left gastric vessels. Splenic injury is discussed separately.



• Consequence



The consequence of bleeding varies greatly depending on the vessel injured, what esophagectomy technique is being used, and how rapidly the problem is diagnosed and repaired. Outcomes range from bleeding that increases the estimated blood loss but does not require transfusion or change a patient’s clinical course to exsanguination and death. From least to most severe, consequences include
• Bleeding from any vessel source that is controlled but results in a need for transfusion.

• Bleeding from any vessel source that requires re-exploration for repair with or without transfusion.

• Bleeding that is abnormal but self-limited. This may result in hematoma or hemothorax with resultant fevers, potential for infection, or respiratory compromise.

• Bleeding from the right gastroepiploic vessels whose repair compromises the use of the stomach as a replacement conduit.

• Massive bleeding that jeopardizes the patient’s life, may require additional incisions for exposure and repair, and significantly alters the patient’s planned clinical care.

Grade 2–5 complication


• Repair



For open surgical techniques, bleeding vessels are directly exposed and bleeding is controlled by standard methods. Smaller vessels are ligated or coagulated; larger vessels may require proximal and distal control prior to suture repair. Use of prosthetic material, such as patches or pledgets, is to be avoided whenever possible because of the potential for infection from the esophagus.

Intrathoracic bleeding during transhiatal surgery is one of the most feared complications. Bleeding from esophageal feeding arteries emanating from the aorta can lead to a sizeable blood loss before it can be visualized and controlled. If the vessel can be visualized easily in the lower mediastinum, it should be ligated, clipped, or coagulated promptly. If not, pack the mediastinum with a lap pad. This will greatly reduce the bleeding and make finding and controlling the vessel easier. Narrow hand-held malleable retractors often help greatly to see up into the mediastinum to find the bleeding vessel. Liberal use of suctioning and a surgeon’s headlight are also beneficial. Massive bleeding from the aorta, inferior pulmonary vein, or pulmonary artery is immediately life-threatening. Once bleeding is identified, it is essential that the surgeon have an idea which vessel was injured. Even without seeing into the chest, the surgeon should have an idea what was injured based on where the dissection had been just before injury. Pack the mediastinum. Notify your anesthesia colleague. Get blood into the room. Consider calling for vascular or cardiac surgery assistance. Almost invariably, another incision will be needed to get exposure for repair. A median sternotomy is not the best incision to use to fix the vessels injured during transhiatal dissection. A separate thoracotomy is most appropriate. Choose left or right based on what you think is injured. Rapidly close the abdominal incision or leave it covered, turn the patient, and get exposure. Then identify and control the bleeding using standard methods. If the inferior pulmonary vein is injured, it cannot simply be ligated because this will destroy the lower lobe. In addition, an open pulmonary vein risks serious air embolism. Position the patient’s head down until the injury site is controlled. As mentioned previously, intraoperative consultation with cardiothoracic surgery may be needed.



• Prevention



Prevention is key to prevent bleeding complications. For open cases, an understanding of the anatomy, careful dissection, and prophylactic proximal and distal control of vessels potentially at risk during esophageal dissection or gastric mobilization will minimize bleeding complications. Within the abdomen, use of mechanical retraction devices, nasogastric decompression of the stomach, and coagulating devices adapted from laparoscopic surgery both optimize exposure and help to safely coagulate and divide difficult exposure vessels like the short gastrics.

During transhiatal dissection, the surgeon must stay in the immediate paraesophageal plane, as shown in Figure 70-2. A nasogastric tube within the esophagus and downward countertraction to keep the esophagus straight are both very helpful. Alert your anesthesia colleague that you are starting the chest dissection. Begin the dissection posteriorly because this is often the easiest side of the esophagus to clear. Never persist with transhiatal dissection if the pathology forces you off the juxtaesophageal plane. If this is the case, convert to a thoracotomy approach. It will make for a longer case but will prevent disastrous consequences.


image

Figure 70-2 Safe transhiatal esophageal dissection in the immediate paraesophageal plane and the proximity of the trachea and left main stem bronchus to the esophagus.



Splenic Injury


Injury to the spleen during esophagectomy requiring incidental splenectomy occurs with a reported incidence of 4.1% to 8.4%.5,6 Most commonly, the spleen is injured by traction on short gastric vessels during gastric mobilization that secondarily tear the splenic capsule. Occasionally, the spleen is directly injured by retraction. There are no data to support routine inclusion of the spleen as part of an esophageal resection for cancer. Although there are no data that splenectomy influences cancer recurrence rates,5 adverse consequences of splenectomy are well-described. It is, therefore, a complication that should be avoided.



• Consequence



Splenectomy increases a patient’s susceptibility to overwhelming sepsis secondary to encapsulated organisms.

Grade 4 complication


• Repair



The spleen is salvaged, if possible, using standard methods of packing or suturing. If not, it is resected keeping the dissection close to its hilum.


• Prevention



Achieve optimal exposure of the upper abdomen using assistants or mechanical devices for retraction. Keep the stomach decompressed with a nasogastric tube. Avoid unnecessary traction on the stomach and short gastric vessels because this could result in secondary splenic capsular tearing. Many coagulation or surgical clipping devices originally designed for use in laparoscopy are now in mainstream use with open surgeries. These permit much easier control of the deep short gastric vessels that were considerably more difficult to control by standard ligation techniques.


Airway Injury


The trachea, carina, and main stem bronchi are in close proximity to the esophagus and are at risk for injury during esophageal resection (see Figs. 70-1 and 70-2). The trachea is oriented so that its weakest feature, its soft membranous wall, is immediately adjacent to the esophagus. The defenses of the membranous wall are further compromised when it is thinned and distended over an indwelling endotracheal balloon cuff. The reported rate of airway injury is unclear. Intraoperative injuries are identified and managed immediately. There is no reported series to indicate rate of injuries.


The membranous wall of the trachea is at risk for injury when encircling the esophagus in the neck during transhiatal cases (Fig. 70-3). The trachea and carina are at risk for injury while mobilizing proximal third esophageal tumors in the chest. The main stem bronchus, especially on the left side, is at risk for injury during transhiatal esophageal dissection. If the airway opening is proximal to the endotracheal tube (ETT) cuff, the surgeon will see the open airway; however, there should be no change in the patient’s cardiorespiratory status. If, however, the airway is opened distal to the ETT cuff, air escapes during positive-pressure ventilation leading to an urgently unstable situation.


image

Figure 70-3 The membranous wall of the trachea is at risk for injury during mobilization of the cervical esophagus.



• Consequence



The consequence of the airway opening depends on its orientation with regard to the endotracheal cuff. An airway injury proximal to the balloon cuff merely opens the airway. This can be repaired as described later. Both the initial injury and the closure risk injuring the ipsilateral recurrent laryngeal nerve (RLN). Failure to buttress the repair site with some tissue patch risks later development of an esophagorespiratory fistula.

An airway injury distal to the ETT cuff results in an immediate escape of air and anesthetic gas, especially with positive-pressure ventilation. Patients may become rapidly unstable with limited ability to ventilate them and with associated fire risk if the electrocautery is used. During transhiatal dissection, in addition to difficulty with ventilation, significant pneumomediastinum and even tension pneumothorax may result if there is communication with the pleural space.


Grade 2/4/5 complication



• Repair



Airway injury proximal to the ETT cuff should be closed primarily with interrupted 4-0 Vicryl sutures. The suture line needs to be secondarily covered with a soft tissue patch such as a regional rotational muscle flap, pericardial fat pad, or intercostal muscle pedicle flap. The patient’s airway is then managed as per routine postoperatively.

An airway injury distal to the ETT cuff requires more urgent action. If the hole is accessible, it can be temporarily occluded with one’s finger. The best way to repair these injuries, whenever possible, is to direct the ETT distal to the hole to convert a distal airway hole into a proximal one. If this cannot be done, have the anesthesiologist manually ventilate the patient with more rapid, low-volume breaths, then close the hole between breaths, as described previously. This leaves the airway injury site exposed to positive-pressure ventilation. In the short term, this is acceptable; however, patients should be extubated as early as possible postoperatively.


During transhiatal esophagectomy, if an airway injury is created in the cervical trachea, it should be repaired primarily. An intrathoracic injury requires repositioning the patient for a thoracotomy. A right thoracotomy is preferred. Not only will this provide exposure to the trachea and carina, but the left posterior aspect of the left mainstem bronchus is easily seen as well.

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Jun 21, 2017 | Posted by in GENERAL SURGERY | Comments Off on Esophageal Surgery

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