Patient Selection

Operative Steps

Preference Card

Tips and Pitfalls

Results

Patient Selection

Transhiatal esophagectomy (THE) may be used to treat patients with either benign or malignant esophageal disease because the reconstructive result—cervical esophagogastric anastomosis—yields an excellent functional result with a minimum of gastroesophageal reflux. In practice, the majority of patients who require esophagectomy have malignant disease. No single esophagectomy approach is ideally suited for all patients. That is certainly true for the THE technique. With proper patient selection, this approach is safe and very well tolerated.

There are two patient selection criteria which should be met before selecting the THE approach. The first is that the portion of esophagus which needs to be blindly, or bluntly mobilized be extrinsically normal. This portion of esophagus is generally a length of about 5-10 cms extending from the distal trachea into the subcarinal region. This region can not be visualized from either the neck or the abdomen and must be mobilized digitally. This is the inferior aspect of the upper mediastinal esophageal space which is quite tight and which is bordered by the airway anteriorly, the aorta and azygos vein laterally, and the vertebral body posteriorly. Grey-Turner described a “bloodless” plane in the immediate paraesophageal space. Liebermann-Meffert has documented an anatomic explanation for that earlier clinical observation by Grey-Turner. The larger arterial blood supply to the esophagus branches into small capillary arcades approximately 1 cm off the esophageal wall. Dissection within this 'space' disrupts only these smaller vessels which rapidly spasm and thrombose. Dissection outside of this 'space' risks tearing larger vessels which would result in larger blood loss and may require observation and ligation. The first criteria, that the esophagus be externally normal in the region of blunt dissection, means that any pathology which would otherwise prevent you from staying in or accessing this immediate paraesophageal space, is a contraindication for using the THE approach. Previous thoracotomy, especially if the mediastinal pleura was opened, transesophageal inflammatory inflammation as occurs with some ingestion injuries, mid to upper esophageal transmural cancers, all are examples of pathology which prevent access to the safe paraesophageal plane. As mentioned above, the most common indication for esophagectomy is cancer. The fact that adenocarcinoma is the most common esophageal cancer, and that these cancers involve the lower esophagus near the esophagogastric junction, is one of the main factors responsible for the increasing use of the THE approach. Evaluation of the esophageal—mediastinal plane is best done by taking a detailed medical history, chest computed tomography, and endoscopic ultrasound. The second criteria for patient selection is the availability of “long-segment” esophageal replacement. The THE technique uses a cervical anastomosis and therefore any esophageal replacement conduit must reach to the neck. Generally, this means that there needs to be available stomach or colon.

Patients who are particularly thin, even if they meet the criteria above, may not be ideal candidates for THE as blunt dissection in these patients may cause profound hemodynamic compromise. This problem is strictly mechanical, as there simply is not enough room for the surgeon's hand and the heart in thin patients with a narrow A-P diameter of the chest. The most extreme example would be patients with pectus excavatum. Patients who have had previous neck surgery or irradiation, may not be candidates for this technique as the cervical esophagus is not accessible for mobilization and anastomosis. Of note, patients who have undergone prior median sternotomy, as for open heart surgery, remain candidates for THE provided that the above two criteria are met. I have also found that prior PEG tube placement has not prevented gastric mobilization and use.

THE with cervical esophageal anastomosis has been shown to result in transient increased tendency for postoperative aspiration. Any patient in which there is any sugestion of preoperative aspiration tendency should have this evaluated by video pharyngoesophagogram. Ipsilateral recurrent laryngeal nerve injury is reported to occur in 5-10% of patients following THE. Therefore, preoperative vocal cord evaluation is indicated in any patient in which there is suspected cord dysfunction preoperatively.

Patients with esophageal cancer are staged in a standard fashion. Appropriate evaluation of nutritional status is important before considering any patient for esophagectomy.

Operative Steps

Patient positioning. Patients are positioned supine with the left arm tucked by the side and the right arm extended out on an arm board (Figure 1). A roll created from operative linen placed transversely across the shoulders helps to extend the neck and improves cervical exposure. A single lumen endotracheal tube is used and a nasogastric tube is placed before draping. Central venous access is not routine for THE. If it is needed, a right neck or chest approach is used. Arterial blood pressure monitoring is essential. Foley catheter drainage is routine. Upper hand retractor holders are attached to the operative table. Patients are widely prepped and draped to expose the left neck, chest (including wide enough for intraoperative tube thoracostomy if needed), and abdomen. The operative field is one continuous field.

Gastric mobilization.
An upper midline laparotomy incision is used. The incision should extended cephalad over the xiphoid to the lower sternal region. The abdomen is explored. An upper hand retractor is used with two blades. On the left, a bladder blade lifts the inferior sternum cephalad and upwards off the table. On the right, a malleable blade retracts the mobilized left hepatic lobe tip to the right to facilitate exposure of the esophageal hiatus and E-G junction. A standard balfour abdominal retractor completes the exposure. Gastric mobilization is performed preserving only the right gastroepiploic arcade (Figure 2). A 1 inch latex drain, which is used early to encircle and suspend the stomach from the upper hand retractors, is helpful with this portion of the procedure. The left gastric vessels may be exposed and ligated posteriorly through the lesser sac, or anteriorly through the divided gastrohepatic ligament. I prefer the anterior approach. I individually ligate and divide each vessel with silk ligatures. Others choose to staple or use the harmonic scalpel to divide the short gastric vessels. Once the stomach is completely mobilized, a Kocher maneuver is added to straighten the duodenum. This will help easy passage of the stomach to the neck. A pyloric drainage procedure is routinely added. I prefer a pyloromyotomy, which I fashion using the electrocautery set on low power, and which is secondarily covered by an omental patch (Figure 3).

Esophageal mobilization.
The majority of the esophageal mobilization is performed from below, through the esophageal hiatus (Figure 4). It helps, therefore, to widen the hiatus. I prefer to suture ligate the crossing phrenic vein, and then open the hiatus anteriorly. Be careful not to open the adjacent pericardium.

Others prefer to open the hiatus by dividing the left crus. This works too, but has a greater tendency to open the left pleural space. After the hiatus is surgically widened, alert your anesthesia colleague that you are beginning thoracic mobilization so they can more closely watch the blood pressure. The lower portion of the esophagus can be mobilized under direct vision controlling blood vessels and attachments by cautery, or vascular clips. Then begin blunt mobilization into the upper mediastinal space staying right on the esophageal wall. I find that a previously placed nasogastric tube helps me stay on the esophagus. The upper portion of the esophageal mobilization is not completed until the cervical incision is created and the distal cervical esophagus is encircled. This allows for bimanual mobilization (Figure 5). I prefer a left cervical approach using a modified left collar incision. The anterior border of the sternocleidomastoid muscle is retracted laterally, and the prevertebral space is accessed medial to the carotid sheath contents. The distal cervical esophagus is grasped with a babcock clamp which includes the nasogastric tube. The esophagus is then encircled by dissection on the wall of the grasped esophagus. This seems to require less cervical retraction which is the primary cause of recurrent laryngeal nerve injury. The intrathoracic esophageal mobilization is completed.

Creation of the gastric tube.
Proper fashioning of the gastric tube will ensure optimal vascularity, passage into the neck through the superior esophageal mediastinal space, and postoperative emptying. The majority of studies suggest that a gastric tube, based on the greater curvature of the stomach of approximately 4-5 cm in diameter, is ideal to achieve these objectives. The fundus of the stomach becomes the tip of the gastric tube which is fashioned by serial firings of a GIA stapler (Figure 6). I use three 7.5 cm GIA cartridges. Although there are longer linear staplers, using multiple applications of shorter staplers, as described above, optimizes tube length. The staple line is oversewn to prevent later gastro-respiratory fistula formation.

Cervical esophago-gastric anastomosis.
The intrathoracic esophagus and gastric cardia are then delivered from the chest. I pull the esophagus proximally out through the neck unless the lower tumor is too bulky. Others routinely divide the distal cervical esophagus and deliver the tumor though the abdomen. The stomach tube is then passed into the neck. This maneuver is accomplished mostly by pushing up from below, not tugging on the stomach tip from above. I attach a 32F chest tube to the stomach tube tip which prevents twisting and helps set up the anastomosis (Figure 7). It is not to be used to haul the stomach into the neck. Attempting to do so will tear the stomach.

Once in the neck the chest tube is used to hold the stomach tube tip in position at skin level to optimize anastomotic exposure (Figure 8). I use a two-layered, inverting, hand sewn anastomosis (Figure 9). I prefer 4-0 silk sutures for both layers, but absorbable sutures work as well. The outer, posterior row of sutures approximates the esophageal muscle to the seromuscular stomach. The inner posterior row connects the esophageal and gastric mucosa. Once the back row is completed, the excess distal esophagus is excised. The inner mucosal layer continues with each stitch inverting the next so that the knots are intraluminal. Then the second layer—which pulls the esophageal muscle over the first layer—is completed.

Before completing the anastomosis, the nasogastric tube is directed across it under direct vision and secured into place. When the anastomosis is finished, the chest tube traction sutures are cut and the stitch sites are inverted with Lembert or purse-string sutures. A gentle tug on the stomach tube from the abdomen delivers the anastomosis to the midline, prevertebral space.

Closure.
The cervical incision is closed in layers after irrigation. Prior to abdominal closure, an adjuvant jejunostomy tube is placed. The intubated loop of jejunum is marked with metal hemoclips to permit percutaneous replacement of the feeding tube flouroscopically if needed. The abdomen is irrigated and closed in layers.

Preference Card

• Upper hand retractor
• 16 or 18F nasogastric tube
• Laparotomy instruments
• Long, chest clamps are very helpful to clamp and ligate the proximal short gastric vessels
• Long penrose drain
• Gelpi retractors
• GIA 75 stapler with three total cartridges
• 32F chest drain
• 12F red rubber catheter as the jejunostomy tube

Tips and Pitfalls

TIPS

• Taking the time to get the patient positioned, prepped and draped properly will pay dividends throughout the operation.
• Use one, large continuous operative field that extends down onto both sides of the chest in case tube thoracostomy or emergency thoracotomy is needed.
• Place a nasogastric tube prior to beginning surgery. Gastric decompression facilitates stomach mobilization. Having the tube in the esophagus gives digital feed back that you are in the paraesophageal plane.
• A Kocher maneuver will help ensure that the stomach tube passes easily to the neck.
• Widen the hiatus prior to transhiatal dissection.
• If there is bleeding during transhiatal dissection, be aware of where the bleeding is from based on where you were dissecting. Most bleeding will stop by packing and patience. Keep your anesthesia colleague informed.
• If there is any difficulty maneuvering the stomach tube into the neck, because of a tight thoracic inlet or stomach length, do not struggle. Stop and consider adding a partial upper sternotomy. Even division of the manubrium only will widen the outlet and permit anastomosis 1-3 cm lower.
• If at any time during the operation, there is hemodynamic instability as evidenced by hypotension, unexpected fluid requirement, or hematocrit drop, insert bilateral chest tubes.
• Use an adjuvant jejunostomy tube.

PITFALLS

• Ligation of the short gastric vessels too close to the stomach risks focal gastric wall necrosis and leak, or bleeding if the tie comes off.
• Inadequate gastric mobilization or Kocher maneuver will make it hard for the stomach to reach to the neck.
• Transhiatal dissection outside of the paraesophageal plane risks bleeding, airway damage, or a thoracic duct tear.
• If the stomach tube is made too wide or too narrow, it risks ischemia and poor function
• The stomach is pushed to the neck, guided by its tip. Attempts simply to haul the stomach into the neck will tear it.

Results

The most common complications after esophagectomy, by any means, are respiratory and anastomotic. Both are serious complications which can result in death, disability, and lengthy hospital stays.

In a large collective review, Katariya et al (#6), reported a 50% incidence of pulmonary complications after transhiatal esophagectomy. Pneumonia has been reported in approximately 5-20% of patients, and in the majority of series, it is the most common cause of hospital mortality. Gillinov and Heitmiller (#3) have previously reported strategies to prevent post-THE respiratory complications. By instituting methods to reduce the prevalence of postoperative aspiration, the rate of major pulmonary complications was reduced to 10%, and the pneumonia rate was reduced to 3%. In that same series, older age and a past history of obstructive pulmonary disease were risk factors associated with post-operative respiratory complications.

Cervical anastomotic leak rates of 0.8-24% are reported. Dewar et al (#4) identified low serum albumin, running suture technique, high intraoperative blood loss, and postoperative delayed gastric emptying as reisk factors for anastomotic leak. Orringer (#5) has documented that anastomotic leak rated rise dramatically if a substernal gastric pull-up route is used.

Cervical anastomotic stricture rates of 9-50% are reported. The rate depends in part on how the diagnosis is defined. In my experience, approximately a quarter of THE patients will require postoperative anastomotic dilatation for cervical dysphagia. Management of these strictures by bougiennage is successful in the majority of cases. Factors which have been associated with stricture formation include leakage, intraoperative blood loss, gastric tube ischemia, cardiac disease, and anastomotic technique.

Miscellaneous complications include abdominal wound infection or seroma in approximately 5%, and cardiac arrythmias (predominantly atrial fibrillation) in 10% of patients.

The mortality rate for THE is approximately 2-3%. Mortality rates vary, however, depending on patient selection (i.e. age, co-morbidities), indication for surgery, and operator experience.