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Esophagus Resection


Medical editor Johan Wiig MD
Surgeon
Oslo University Hospital

General

During a resection of the esophagus, the portion aboral part of the esophagus with the tumour is resected and the stomach is pulled up into the thorax, if necessary all the way up into the collum, and is anastomosed with the remaining esophagus.

Access can be:

  • transthoracic by creating an opening between the ribs. This provides the best access in the thorax and the easiest lymph node dissection. 
  • transhiatal by operating in the thorax via an opening in the diaphragm and finally anastomosing to the throat. This technique may caus less cardiopulmonary complications.

Cervical esophagus:

  • from the cricoid cartilage to thorax opening (about 15–25 cm from the teeth).
  • regional lymph nodes: cervical, peri-esophageal, internal jugular, scalene, and supraclavicular

Thoracic esophagus:

  • upper: from the opening of the thorax to the tracheal bifurcation (approx. 25–35 cm from the teeth)
  • lower: the distal half between the tracheal bifurcation and cardia (approx. 35–45 cm from the teeth) regional lymph nodes: upper and lower peri-esophageal, subcarinal, mediastinal, and perigastric

The impact of an extensive lymph node dissection is uncertain. In Japan, in the last few decades, it has been emphasized that a lymph node dissection must be performed in the thorax, abdomen, and neck. This has achieved a 40-50% 5 year survival. Western studies have not been able to obtain similar results, therefore lymph node dissections have not been performed to a similar extent. 

Indications

  • Transthoracic access: tumor in all parts
  • Transhiatal access: tumor in upper or lower part of esophagus

Contraindications

  • Metastases to the lungs, liver, or other metastases
  • Infiltration in the lungs, trachea, pericardia, aorta
  • Spreading to supraclavicular lymph nodes
  • Heart/lung disease to a relative severe degree

At the time of diagnosis, over half of the patients will meet one or more criteria for inoperability, therefore only palliative treatment is offered.

Goal

  • Cure

Equipment

  • Self-retaining retractor for ribs
  • Retractors for access to thorax via diaphragm
  • Double tube for separate intubation of main bronchia
  • Forceps 
  • Laparotomy tray
  • Bookwalters self-retaining retractor
  • Staple instruments: cross-stapling  / closing-dividing , possibly circular stapler
  • Clips

Preparation

  • Preoperative bowel evacuation is not performed as this does not improve the frequency of anastomosis leakage or infection. 
  • High-dosage low molecular weight heparin is administered as a thrombosis prophylactic. The first dose is given the evening before the operation to hinder the risk of bleeding from the epidural catheter.
  • Antibiotic prophylaxis is administered.
  • Epidural catheter is installed for postoperative pain treatment.
  • For transthoracic access the patient should be placed in an oblique position with the right side up on the operation table. For transhiatal access, the patient lies in the supine position.
  • The patient is placed under general anesthesia. For transthoracic access, separate intubation of the main bronchis is preferred to be able to collapse the right lung.

Implementation

The operation usually starts by mobilizing the stomach via a mid-line incision in the abdomen.

The lymph nodes around the coeliac arteries are palpated and a frozen section is taken for suspicion of metastasis.

The stomach is divided from the greater omentum while preserving the vessels along the greater curve. The short gastric vessels are divided. The vessels along the lesser curve are cut. The pylorus and duodenum are mobilized. The stomach is divided from the angulus to the top pf the fundus with a stapling instrument, preparing a tube of the gastric remnant. This can also be made in to a type of tube. Splitting of the pylorus fibers is done to facilitate emptying of the stomach (pyloroplasty).

The opening in the diaphragm (hiatus) is widened for the stomach to enter the thorax.

Transhiatal technique

  • The opening for the esophagus in the diaphragm is widened.  
  • The esophagus is dissected up in the thorax via the opening in the diaphragm as far up towards the neck as possible. 
  • Small blood and lymph vessels are divided between clips.
  • An incision is made on the left side of the neck.
  • The cervical esophagus is dissected carefully through an incision on the left of the collum, to prevent damage to the recurrent laryngeal nerves, and divided.
  • A tube is inserted through the thorax aperture into the abdomen. The gastric remnant is sutured to this and carefully pulled and pushed into the collum. An anastomosis is manually performed.
  • A tube is pulled via the nose down into the rest of the stomach.
  • A vacuum drain is installed to the mediastinum.
  • The incisions are closed.

Transthoracic technique

  • An incision is made in the fifth right intercostal room.
  • The lung is collapsed to facilitate better access.
  • The pleura is divided over the esophagus. The esophagus with mediastinal tissue and lymph nodes are sharply dissected.
  • The azygos vein is divided and sutured.
  • The esophagus is cut in a suitable place oral to the tumor and the stomach is pulled up and anastomosed.
  • A tube is pulled through the nose to the stomach.
  • Two separate vacuum drains are placed in the upper and lower part of the thoracic cavity.
  • The incisions are closed.
  • If the tumor is located high in the thorax, it may be appropriate to dissect through the neck to achieve dissection margin above the tumor.

Handling the removed specimen

It is advantageous to bring the specimen unfixed to the pathology department. The specimen should always be cut up, but allow the tumor area to remain undisturbed to be stretched onto a cork disc for fixing. An unopened esophagus in the tumor area contributes to achieve adequate sections for the microscopic assessment of the "circumferential" resection margin. 

The operation specimen description should include information about the localization (upper, middle, lower 1/3 of esophagus) and the size of the specimen (maximum diameter).

 


Follow-up

  • Relatively often, patients stay on a respirator for a few days after the operation.
  • The thorax drain is removed when health status is good enough and no more than 200 ml/day collects.
  • The nastogastric tube is removed when the bowel resumes activity, or a couple of days.
  • X-ray contrast examination is performed after 6-7 days to check the anastomosis. After this, the patient may eat.
  • The patient is discharged after 10-14 days.

Complications from surgery

  • Pneumonia with or without heart failure occurs relatively often. 
  • Anastomosis failure occurs more frequently than after other intestinal  surgery. Anastomosis failure can cause mediastinitis with a high mortality. The condition requires surgical installation of thoracic drain or is treated with a covered stent.
  • Stenosis in the anastomosis may be caused by fibrosis or tumor recurrence. This should be treated with endoscopic blocking or a stent.
  • For large remains of the stomach, some patients may have a delay in stomach emptying.
  • Some patients have a tendency to have the "dumping syndrome" or rapid empty of stomach content.
  • Damage to the vagus nerve (vagotomy) can cause intractable diarrhea in a very few patients.

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