Esophagectomy: Transhiatal and Reconstruction



Esophagectomy: Transhiatal and Reconstruction


Robert E. Glasgow





DIFFERENTIAL DIAGNOSIS



  • THE is most commonly used in treatment of esophageal cancer. In particular, adenocarcinomas of lower third of the esophagus and Siewert types I and II GE junction adenocarcinoma (FIG 1; Table 1) are optimally suited for this approach.


  • Squamous cell carcinomas (SCCs) of the lower third of the esophagus may also be approached via THE, whereas tumors of the middle and upper third of the esophagus usually require transthoracic esophagectomy (TTE) to allow for direct visualization of the dissection of the involved esophagus.


PATIENT HISTORY AND PHYSICAL FINDINGS



  • All patients should undergo a comprehensive medical history with emphasis not only on clinical history pertinent to the primary indication for consideration of THE but also the pertinent comorbid conditions that would influence treatment planning. Included in this history is a comprehensive past surgical history. Prior fundoplication will make dissection of the esophageal hiatus more difficult. Patients with a prior history of gastric resection, for example, may not be candidates for use of the stomach as a conduit for reconstruction because of inadequate length or blood supply. Finally, if the colon is to be considered for use for reconstruction, the influence of prior colectomy on anatomy and blood supply should be very carefully considered.



  • Whether it be for benign or malignant disease, the principal symptom at the time of presentation for a patient who would undergo THE is dysphagia. Often, these patients have significant nutritional impairment, most notably, weight loss.


  • In patients with adenocarcinoma of the esophagus and GE junction, a history of GE reflux disease should be elicited as well as a careful history of prior endoscopic and radiographic evaluations. In patients with SCC, a prior and current history of tobacco and alcohol use should be elicited.


  • A comprehensive physical examination should be performed with special attention to the cervical and supraclavicular areas for enlarged lymph nodes, chest exam for possible effusions, and abdominal exam for palpable masses and periumbilical lymph nodes (Sister Mary Joseph nodule).






FIG 1 • Imaging and diagnostic evaluation of a patient with a localized T3, N1, M0 Siewert type 2 GE junction adenocarcinoma undergoing consideration for THE. A. Upper endoscopy showing ulcerated mass in the lower third of the esophagus. B. CT showing an enlarged mass at the lower third of the esophagus. C. PET-CT. D. Endoscopic ultrasound showing mucosal-based mass invading into the adventitia of the esophagus. E. Endoscopic ultrasound showing enlarged lymph node fine needle aspiration (FNA) biopsy confirming adenocarcinoma.








Table 1: Siewert Classification for Gastroesophageal Junction Adenocarcinoma













Type I: Adenocarcinoma of the lower esophagus with the center located within 1 cm above and 5 cm above the anatomic EGJ.


Type II: True carcinoma of the cardia with the tumor center within 1 cm above and 2 cm below the EGJ.


Type III: Subcardial carcinoma with the tumor center between 2 and 5 cm below EGJ, which infiltrates the EGJ and lower esophagus from below.


EGJ, esophagogastric junction.


From Rüdiger Siewert J, Feith M, Werner M, et al. Adenocarcinoma of the esophagogastric junction: results of surgical therapy based on anatomical/topographic classification in 1,002 consecutive patients. Ann Surg. 2000;232(3):353-361.



IMAGING AND OTHER DIAGNOSTIC STUDIES


Upper Endoscopy with Biopsy



  • All patients presenting with dysphagia should undergo upper gastrointestinal endoscopy and biopsy with the goal of making a diagnosis and localizing the site of obstruction (FIG 1).



    • Multiple biopsies of suspicious areas (nodules, ulceration, stricture, possible Barrett’s) should be obtained.


    • Endoscopic mucosal resection (EMR) of focal nodules should be performed to provide accurate T staging and to evaluate degree of differentiation and vascular and/or lymphatic invasion.


    • For cancer, the location of the tumor as measured from the incisors and GE junction and extent of tumor length, circumferential involvement, and degree of obstruction should be documented.


Computed Tomography of Chest and Abdomen



  • Once a diagnosis of cancer is made, a computed tomography (CT) of the chest and abdomen with oral and intravenous contrast is done.


  • Tumor location, locoregional involvement or invasion, regional and extraregional lymph node involvement, and metastatic disease should be evaluated and recorded.


  • If metastasis is suspected, biopsy of concerning lesions should be undertaken to confirm stage and direct palliative treatment.


Positron Emission Tomography-Computed Tomography



  • In patients whom a standard CT of the chest and abdomen is unremarkable, a positron emission tomography-computed tomography (PET-CT) should be performed again to confirm primary tumor location and extent, evaluate regional and extraregional nodal involvement, and exclude occult metastases.


Endoscopic Ultrasound



  • In patients without metastatic disease (stage 4), an endoscopic ultrasound is done to document depth of invasion of the tumor (T stage) and evaluate mediastinal and perigastric/celiac lymph node involvement (N stage). Biopsy of suspicious lymph nodes is indicated.


  • All patients should then be assigned a pretreatment TNM stage to guide treatment planning discussions, preferably under the direction of a multidisciplinary treatment planning conference attended by surgical, medical, and radiation oncology.1 The National Comprehensive Cancer Network (NCCN) defines optimal treatment planning algorithms.2


  • In considering options for reconstruction, the two most common conduits are the stomach and colon. Although variations in stomach blood supply are very rare, variations in colonic blood supply are common enough to justify preoperative evaluation of arterial anatomy and collateral circulation by visceral angiography in planning choice of conduit.



    • For purposes of using the stomach as a conduit for esophageal reconstruction, an intact right gastric and, more importantly, right gastroepiploic artery is imperative (FIG 2).


    • For purposes of the colon as a conduit for esophageal reconstruction following a THE, an adequate collateral blood supply via an intact marginal artery is required (FIG 3). Obviously, a colonoscopy to exclude and/or treat colonic pathology must be done prior to use of the colon.


SURGICAL MANAGEMENT



  • As THE is a technically complex operation with a high degree of associated morbidity and mortality, this operation should be done by surgical teams experienced in the perioperative management of these patients.3, 4, 5 This includes experienced operating room personnel and anesthesiologists.


Preoperative Planning



  • Patients should undergo preoperative evaluation by the surgical and anesthesia team for purposes of mitigating perioperative risks in the area of cardiac, pulmonary, and renal comorbidities.


  • A discussion should be done with the patient as to how pain will be measured and managed following surgery. Regional anesthetics such as an epidural catheter are very
    helpful in alleviating pain, thereby allowing the patient to be more engaged in early mobilization and physical therapy.


  • Perioperative antibiotics should be administered within 60 minutes of skin incision and redosed in a timely manner during the operation. Cefazolin, dosed to weight specifications and redosed every 4 hours, is recommended. Cefoxitin can also be used and redosed every 3 hours. For patients with a beta-lactam allergy, clindamycin or vancomycin and aminoglycoside or aztreonam or fluoroquinolone are used. All prophylactic antibiotics are not necessary beyond surgery completion.6


  • Perioperative monitoring with an arterial line is helpful especially during blunt mediastinal esophagus dissection where transient hypotension is common because of decreased venous return and compression on the heart. Rarely is a central line indicated.


  • Appropriate deep venous thrombosis prophylaxis is required. Intermittent sequential compression devices should be placed prior to induction of anesthesia and continued after surgery. Chemical prophylaxis should be instituted postoperatively once clinically indicated.


  • Urinary catheters are placed following induction of anesthesia and discontinued within 24 hours of surgery.






FIG 2 • Stomach blood supply for purposes of using the stomach as a conduit for reconstruction following THE. Arrows show lines of division including the short gastric arteries, left gastroepiploic artery, left gastric artery, and ligation of the right gastric artery at the incisura angularis at the point of origin of the gastric conduit staple line.


Positioning



  • Patients undergoing THE are positioned supine on the operating room table (FIG 4).


  • Both arms are tucked and pressure points padded to prevent injury during the course of the operation.


  • A towel or medium gel roll is placed behind the shoulders to allow for mild extension of the neck. This is of particular importance in obese, short-necked patients.


  • The head is rotated 30 degrees to the right to open exposure to the left neck.


Placement of Surgical Incisions



  • A midline laparotomy from the xiphoid process to the umbilicus is made (FIG 4).


  • After verifying the patient to be a candidate for resection and verifying that THE can proceed, a 5-cm incision is made overlying the anterior border of the left sternocleidomastoid muscle with the inferior extent at the head of the clavicle. Contraindications to THE include difficult mediastinal blunt dissection of the esophagus because of tumor or treatment effect, excessive mediastinal bleeding with blunt dissection, and inadequate conduit length for reconstruction.







FIG 3 • Colon blood supply for purposes of using the colon as a conduit for reconstruction following THE.






FIG 4 • Supine position with location of surgical incisions for THE.

Jul 24, 2016 | Posted by in GENERAL SURGERY | Comments Off on Esophagectomy: Transhiatal and Reconstruction

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