Surgery is the mainstay of treatment for esophageal cancer. Numerous surgical approaches to esophageal resection and replacement have evolved since esophageal resection was introduced in the late 1800s. All these operations gain access to the esophagus through the abdomen, with additional exposure through the thorax and/or neck. The selection of approach is based on numerous factors: type and location of the lesion, submucosal extent, invasion of or adherence to surrounding structures, stage of disease, need for lymphadenectomy, history of previous surgeries, type of conduit chosen for esophageal replacement (i.e., stomach, colon, or jejunum), and neoadjuvant treatment (i.e., chemotherapy, radiotherapy, or both). Surgeon preference and experience often dictate the selection of approach. Popular methods of esophageal resection in the United States for lesions that lie below the thoracic inlet are based on methods developed by Ivor Lewis and McKeown, among others.1–3 They differ by the approach, number of incisions, and location of the anastomosis (intrathoracic or cervical) (Table 15-1). With rare exception, we prefer a three-incision transthoracic approach to esophagectomy. The three-hole esophagectomy developed at Brigham and Women's Hospital was designed specifically to limit morbidity by assimilating the best elements of each of the predecessor surgeries in a safe, expeditious procedure.4–7
Table 15-1. Popular Methods of Esophageal Resection and Replacement in the United States |Favorite Table|Download (.pdf)
Table 15-1. Popular Methods of Esophageal Resection and Replacement in the United States
Good exposure for GEJ tumors
High risk of postoperative reflux
Proximal margin limited by aorta
Upper midline laparotomy
Blind midthoracic dissection
Benign tumor, high-grade dysplasia, malignant
Direct-vision thoracic dissection
Limited proximal margin
Increased risk of postoperative bile reflux
Middle and lower thirds
Good proximal margin
Direct-vision thoracic dissection
Exposure to right RLN during dissection
Increased incidence of postoperative reflux
Muscle-sparing right thoracotomy
Simultaneous abdominal and left cervical
Unlimited proximal margin
Direct-vision esophageal dissection
Cervical anastomosis avoids morbidity of an intrathoracic leak and anastomosis located out of potential radiation field
Reduced risk of postoperative reflux
RLN avoided from left approach
Serratus muscle-sparing thoracotomy
Expeditious two-stage procedure
Upper and middle thirds if neoadjuvant therapy is given
Reduced postoperative pain
More rapid recovery
Longer operation, prolonged anesthesia
More expensive than open procedure
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