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INDICATIONS

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Transthoracic esophagectomy is indicated for the management of surgically resectable cancers of the esophagus and gastroesophageal junction. An abdominal incision is utilized to mobilize the distal esophagus and gastroesophageal junction, including the tumor and surrounding lymph nodes. The gastric conduit is mobilized and the blood supply is based on the right gastroepiploic artery. The thoracic esophagus is then approached through a right posterolateral thoracotomy through which the specimen is resected and reconstruction is performed. Surgical resection is indicated for early staged, nonmetastatic tumors that are not amenable to endoscopic resection (T1). Surgery is also performed for nonmetastatic, intermediate staged tumors (T2–T4, N1), but usually follows a course of chemoradiation and restaging. Transthoracic esophagectomy may also be indicated for the management of benign disease such as refractory strictures, caustic injuries, or a dilated “burned esophagus” with dysphagia following treatment for achalasia.

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There is some controversy regarding the optimal surgical approach for esophageal resections. Transhiatal and minimally invasive approaches have become popular due to the potential for decreased complications and data indicated equivalent outcomes. The decision to perform a transthoracic approach is made based on patient factors, surgeon preference, and experience. Potential benefits of the thoracic approach include a more thorough lymph node dissection and lower leak rates.

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PREOPERATIVE PREPARATION

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The preoperative workup for patients with esophageal and GE junction cancers should include a thorough history and physical examination, esophagogastroduodenoscopy for diagnosis, and PET-CT imaging and endoscopic ultrasound for staging. Bronchoscopy should be considered for patients with squamous cell carcinomas, lesions involving the proximal third of the thoracic esophagus, and respiratory symptoms such as cough or hemoptysis. The patient’s medical condition should be considered carefully before undertaking an esophageal resection as these procedures are extensive and patients with medical comorbidities may not tolerate them well. Thorough cardiovascular and respiratory evaluations are particularly important and objective testing such as cardiac stress tests, echocardiography, and pulmonary function tests should be obtained liberally if there are concerns. Patients should be administered a mechanical bowel preparation on the evening prior to surgery in the rare event that esophageal reconstruction with a colon interposition is necessary. Appropriate prophylactic antibiotics are administered intravenously prior to incision. Sequential compression devices and subcutaneous heparin are used for deep vein thrombosis prophylaxis.

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ANESTHESIA

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The procedure is performed under general anesthesia. A double-lumen endobronchial tube is utilized to allow for single lung ventilation during the thoracic part of the procedure. A single lumen tube may be placed for the initial abdominal part of the procedure and then exchanged for a double-lumen tube by the anesthesia team before repositioning and performance of the thoracotomy. A nasogastric tube should be placed early during the procedure to decompress the stomach and facilitate palpation of the esophagus. This should not be secured until completion of the reconstruction as it will be repositioned several times during the procedure. A thoracic epidural may ...

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