Radical esophagectomy should encompass all lymph node stations having a greater than 10% incidence of metastases. Nevertheless, lymphatic metastasis cannot be diagnosed precisely either by ultrasonography or CT imaging before surgery. Therefore, radical surgery for cancer of the thoracic esophagus requires complete three-field lymph node dissection.
The first step of the operation is an anterolateral thoracotomy through the fourth intercostal space. The thoracic duct, azygos vein, pleura, and periesophageal tissues including lymph nodes and lymphatic channels in the mediastinum are dissected en bloc. The right and left recurrent laryngeal nerves are identified, and the upper mediastinal lymph nodes (including the node group of the recurrent laryngeal nerve chain) are cleared (Fig. 20-8). After this procedure, paratracheal lymph nodes on both sides (Fig. 20-9), subcarinal, right and left hilar lymph nodes, posterior mediastinal lymph nodes adjacent to the descending aorta and left pleura, and diaphragmatic lymph nodes are dissected en bloc (Fig. 20-1). The lymph nodes inside the aortic arch (left tracheobronchial) are dissected separately (Fig. 20-10). To avoid ventilatory impairment, the right or left bronchial artery and the pulmonary branches of the vagus nerve should be preserved (Fig. 20-11).
Lymph node dissection is started with identification of the right recurrent laryngeal nerve in the utmost upper mediastinum. (Illustration adapted from an original sketch provided by author.)
Upper mediastinal dissection. The right and left recurrent nerves are separated, and tissues are cleared around the nerves. (Illustration adapted from an original sketch provided by author.)
Completion of dissection inside the aortic arch. (Illustration adapted from an original sketch provided by author.)
Preservation of the right bronchial artery and pulmonary branches of the vagus nerve. (Illustration adapted from an original sketch provided by author.)
For the abdominal procedure, after an upper midline laparotomy, en-bloc dissection of lymph nodes is carried out along the cardia, lesser curvature, left gastric artery, celiac axis, common hepatic artery, and splenic artery (Fig. 20-12). The left gastric artery is cut at its origin. Along with all these dissected lymph nodes, the proximal stomach is cut between the junction of the right and left gastric arteries to the farthest point in the fundus using a linear stapler (Fig. 20-13). The gastric remnant, based on the right gastroepiploic artery and right gastric artery, is used for esophageal reconstruction. We do not perform pyloroplasty. The extent of abdominal lymph node dissection is very similar to that of D2 lymph node dissection for gastric cancer surgery.
Dissection areas in the abdomen. (Illustration adapted from an original sketch provided by author.)
The cut line of the stomach. The proximal stomach is cut between the junction of the right and left gastric arteries to the farthest point on the fundus. (Illustration adapted from an original sketch provided by author.)
In the neck, a collar incision is made as in thyroidectomy. The middle deep cervical and supraclavicular lymph nodes (102 and 104 in Fig. 20-1), which are located lateral to the common carotid artery, ventral to the anterior scalene muscle and phrenic nerve, and inferior to the superior belly of the omohyoid muscle, are removed. Then the lymph nodes along the cervical recurrent laryngeal nerve are excised (Fig. 20-14). These lymph nodes are between the common carotid artery and trachea (101 in Fig. 20-1), and they should be removed meticulously and carefully so as not to traumatize the recurrent laryngeal nerve.
Dissection along the cervical recurrent laryngeal nerve on the left side. (Illustration adapted from an original sketch provided by author.)
The patient is usually extubated in the operating theater when the PaO2 level (torrs) exceeds three times the FiO2 (%). The patient is transferred to the surgical ICU and is monitored there for a period of approximately 1 week.
The surgeon should be aware of four main complications in the postoperative course of esophagectomy with three-field lymph node dissection (Fig. 20-15). They consist of pulmonary complications, cardiac complications, anastomotic leakage, and recurrent nerve paralysis. Among these, pulmonary complications are by far the most common and of grave concern. Pulmonary compromise may be caused by the wide dissection around the trachea and bronchi, which leads to various degrees of ischemia of the respiratory tract and a decreased cough reflex.
Postoperative complications after three-field dissection. Anastomotic leakage includes radiologic minor leakage (2.8%) and clinical fistula formation (3.2%).
Hypoxemia requires inhalation of a high concentration of oxygen and was seen in 25.4% of the study group (Fig. 20-16). It is caused mainly by pneumonia, atelectasis, and pulmonary edema. Pulmonary edema or potential pulmonary edema sometimes develops in radical esophagectomy patients after removal of the thoracic duct, which causes lymphatic retention in the retroperitoneum, hypoproteinemia, and depletion of intravascular volume. The rate of fluid infusion during the procedure is maintained at approximately 7 to 8 mL/kg/h, taking into account the blood loss and urine output (Fig. 20-17). Consequently, potential pulmonary edema can occur in the resorption period approximately 48 hours postoperatively. It can be controlled successfully by administration of dopamine, albumin, and diuretics (e.g., furosemide). It should be borne in mind that intraoperative restriction of fluid transfusion to keep the lungs “dry” can result in tachycardia with serious hypotension postoperatively.
Pulmonary complications after three-field dissection.
Perioperative management of three-field dissection.
Pulmonary embolism is a less common complication, but one should maintain a high degree of suspicion in patients with no obvious cause of hypoxemia. Its prevention is very important. It is advisable to use pneumatic pressure garments on both legs and to administer heparin (200–250 U/kg per day) throughout the perioperative period until patients are mobile.
Cardiac complications occurred in 22.9% of patients. They mainly consist of tachycardia, arrhythmia, atrial fibrillation, premature ventricular contractions, and so forth. These complications are usually seen in the resumption period as a consequence of cardiac overload because of resorption of fluid from the third space. Cardiac overload can be controlled by administration of diuretics. Tachycardia also may occur because of intravascular hypovolemia. Differentiating overhydration from underperfusion is important to implement proper corrective measures. Low-dose dopamine is often administered for approximately 1 week postoperatively to ensure better circulation and maintain diuresis.
We use a hand-sewn two-layer anastomosis. The inner-layer suture is continuous and consists of a 5-0 monofilament absorbable material. The outer layer is completed with interrupted fine silk sutures. Clinical leakage involving fistula formation occurred in 3.2%. All patients underwent a barium swallow on the ninth postoperative day, and 6.0% of the patients were diagnosed as having anastomotic leakage. Minor leakage usually healed within 1 to 2 weeks of conservative management with total parenteral nutrition.
Recurrent Laryngeal Nerve Palsy
Recurrent laryngeal nerve palsy is one of the causes of pulmonary complications. In our series, 10.1% of patients with three-field lymph node dissection suffered from recurrent laryngeal nerve palsy, and 95% of them had impairment of the left recurrent nerve. This may cause silent aspiration of saliva, which contains bacteria from the oral cavity. Inadequate glottic closure also impairs the cough reflex and expulsion of retained secretions by preventing buildup of adequate intratracheal pressure. Hoarseness owing to unilateral nerve palsy recovers within 3 months, but bilateral nerve palsy occasionally may require tracheostomy to bypass the closed glottic aperture caused by the unopposed action of the cricothyroid muscle.
Mortality within 30 days of surgery is called direct operative death. Mortality of patients who succumbed for any reason during hospitalization even after the 30-day period is called postoperative hospital death, and this includes direct operative death. In our series from January 1998 to December 2011, 687 patients underwent esophagectomy (R0 resection) with three-field lymph node dissection and reconstruction. We had 9 direct operative deaths and 21 postoperative hospital deaths, including the 9 direct operative deaths. The direct operative death rate was 1.3%, and the postoperative hospital death rate was 3.1%. These rates compare favorably with the mortality rates reported in other large series.