CHAPTER 6 Esophagectomy
Case Study
A 65-year-old male reports a 5-month history of weight loss, difficulty swallowing solid food, and progressive discomfort in the region of the midsternum. He denies cough or other respiratory symptoms. He reports a history of long-standing intermittent heartburn and has used both alcohol and cigarettes in the past. On physical examination, he appears thin. No abdominal masses are palpable. A computed tomography (CT) scan of the chest and abdomen and a barium swallow show a mass in the lower portion of his esophagus. An upper endoscopy confirms the presence of a mass at 35 to 38 cm. Biopsy specimens show adenocarcinoma with Barrett’s epithelium background changes. Endoscopic ultrasound shows tumor extending into the muscularis without obvious lymph node enlargement. A positron emission tomography (PET) scan does not show any evidence of distant metastatic disease.
BACKGROUND
The esophagus extends from the hypopharynx to the stomach. The cervical esophagus begins at the cricopharyngeus muscle and is approximately 5 cm in length. The thoracic esophagus, measured from the level of the first thoracic vertebra, is typically 20 to 25 cm in length. The blood supply to the esophagus is segmental and arises from the inferior thyroid arteries proximally and the left gastric artery distally. The aortic esophageal and bronchial arteries supply the mid-esophagus. The lymphatic drainage of the esophagus is extensive. Mucosal and submucosal lymphatics communicate along the entire length of the muscular esophagus; because of this, tumors of the esophagus have a tendency to spread longitudinally. Moreover, esophageal lymphatics drain to multiple regional beds and drainage may proceed in either a proximal or a distal direction. Lesions of the upper and middle thirds of the esophagus most often drain to the hilar, periesophageal, and supraclavicular nodes, whereas lesions of the distal third drain to the lesser curvature, left gastric, and celiac nodes. Notwithstanding, positive celiac nodes are found in up to 10% of metastatic tumors of the upper esophagus and distal esophageal tumors may drain to the hilar and supraclavicular nodes.
INDICATIONS FOR RESECTION
PREOPERATIVE EVALUATION
Although mortality rates have declined, particularly at high-volume centers, esophageal resection continues to be associated with significant morbidity, particularly in older patients and those with comorbidities. The preoperative evaluation should identify significant comorbidities that may increase perioperative risk. Pulmonary function studies, an electrocardiogram, and an echocardiogram should be performed. Cardiac catheterization and revascularization should be performed when appropriate. Smoking cessation and avoidance of alcohol should be encouraged. Patients who lost significant weight before surgery should receive preoperative nutritional support and reversal of malnutrition should be documented. On occasion, this may require enteral feedings via a feeding tube or intravenous parenteral nutrition. Oral hygiene should be optimized before surgery to lessen the risk of severe infection in the event of a leak from the cervical anastomosis.
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