The thoracoabdominal approach to resection of the esophagus is most useful with tumors of the distal esophagus that lie inferior to the aortic arch as well as lesions of the gastric cardia. Eggers first reported the use of a left thoracoabdominal incision for a partial resection of the esophagus in 1931.1 Eventual resection of the distal esophagus and replacement with mobilized stomach was described by Adams and Phemister in 1938.2 Finally, Sweet described the technique of anastomosis based on the principles of meticulous technique and attention to detail.3 The thoracoabdominal incision provides excellent access to the abdomen. With extension of the incision through the costal arch, left rectus muscle, and diaphragm, the esophagus can be mobilized and replaced with stomach, colon, or jejunum depending on the situation. In addition, with an upward paravertebral extension of the incision and Sweet's double-rib resection, one can reach almost any lesion of the intrathoracic esophagus.3
Because of the magnitude of a thoracoabdominal esophagectomy or any esophagectomy, it is important to engage in a rigorous selection and staging workup before proceeding with surgical intervention. While patients with widely disseminated disease and extreme comorbid illnesses are easily eliminated from surgical consideration, most patients undergo a systematic evaluation of resectability and a review of risk factors.
The initial evaluation of patients with esophageal carcinoma should include a contrast esophagogram and upper gastrointestinal endoscopy. Esophagoscopy with biopsy of the lesion is essential to obtain a tissue diagnosis, to confirm that there is not a second synchronous esophageal carcinoma, and to obtain a more accurate assessment of the extent of the tumor both grossly and microscopically by mucosal biopsy. Endoscopy also permits detection of Barrett's esophagus and evaluation of potential gastric involvement.
Further evaluation by CT imaging of the thorax and abdomen provides information regarding invasion of adjacent structures (e.g., pericardium and diaphragm), tracheobronchial invasion, and mediastinal lymph node involvement. However, recent reports have noted the accuracy of CT imaging for the presence of locoregional disease to be as low as 50%.4,5 CT imaging of the abdomen with contrast material also assists in the detection of hepatic metastasis.
Endoscopic ultrasound (EUS) is used commonly in the staging of esophageal cancer. It provides valuable data regarding the depth of tumor invasion, potential nodal involvement, and the opportunity for fine-needle aspiration of local lymph nodes. Accuracy in predicting T status with EUS in esophageal cancer is greater than 80%, and accuracy in predicting N status ranges around 70%.6 EUS is clearly superior to CT in T staging, and CT appears more accurate in predicting T4 disease.7
PET imaging is becoming a more valuable tool in the evaluation of distant metastatic disease. PET scans have almost no role in the determination of T status, but with N disease, the results are encouraging, with reports of greater than 90% accuracy.8 (PET imaging may have a further application in monitoring for disease recurrence.)
An evaluation of preoperative risk factors includes an assessment of pulmonary and cardiovascular function. Pulmonary function testing should be obtained if there are any questions as to the patient's respiratory status. Smoking should be stopped well in advance of surgery. A cardiovascular assessment also should be performed with a history and physical examination, as well as an ECG and, if deemed necessary, a stress test or cardiac catheterization.
All esophagectomy procedures, including thoracoabdominal esophagectomy, begin with endoscopy in the OR. Repeat endoscopy provides confirmation of the location of the tumor and evaluation of the esophagus for a second lesion or extension into the stomach. With tumors of the middle and upper thirds of the esophagus, bronchoscopy also should be performed. A double-lumen endotracheal tube is placed, permitting deflation of the left lung during the thoracic dissection, and broad-spectrum antibiotics are given before surgical incision and may need redosing during the procedure.
The patient is positioned in the right lateral decubitus position, which permits access to both the left side of the chest and the upper abdomen. The initial step is an exploration of the abdomen through the medial portion of the incision. This permits inspection of the liver, palpation of the celiac nodes, and further evaluation of the stomach. With no metastatic disease identified, the incision is carried into the chest over the seventh or eighth rib (Fig. 19-1). The higher the interspace, the easier it is to perform the anastomosis. As the diaphragm is divided, it should be clearly marked with stitches to allow reapproximation at the conclusion of the case.
The incision is carried into the chest over the seventh rib. The higher the interspace, the easier it is to perform the anastomosis. As the diaphragm is divided, it should be clearly marked with stitches to allow reapproximation at the close of the procedure.
Thoracic exploration begins with an inspection of the left lung, diaphragm, pericardium, and pleural space. Opening of the mediastinal pleura permits further inspection of the extent of the tumor, evaluation of possible invasion of the aorta or lung, and determination of metastases to the paraesophageal and paraaortic lymph nodes.
Dissection begins in the chest, freeing the esophagus and draining the nodes in continuity. The descending aorta is completely bared by division of the aortoesophageal branches. Aortic involvement precludes resection. The esophagus is encircled after the dissection is carried medially along the posterior aspect of the mediastinum up to the level of the left main stem bronchus, away from the proximal tumor margin. Gentle traction on the esophagus facilitates dissection of the paraesophageal nodes and fat. The thoracic duct is rarely seen with the left thoracoabdominal approach and is not routinely ligated.