16: Transhiatal Esophagectomy

Transhiatal esophagectomy was popularized by Orringer in the late 1970s as a less invasive approach to esophagectomy.^1,2 This approach avoids thoracotomy and has been endorsed primarily by nonthoracic general surgeons who perform esophagectomy. For trained thoracic surgeons, the main drawbacks of this approach are the inability to perform an extensive lymph node dissection and the risk of injury to the great vessels and main airways with tumors of grade T3 or greater.^3,4 We describe herein our current technique for transhiatal esophagectomy, which includes minor modifications to the original Orringer technique.

Comparisons of transhiatal versus transthoracic esophagectomy published in the last decade have included retrospective studies,^5,6 prospective studies,⁷ randomized controlled studies,⁸ and meta-analyses.⁹ The published evidence suggests that transhiatal esophagectomy is associated with a reduced risk of pulmonary complications and in-hospital mortality as well as a shortened length of hospital stay, but an increased risk of anastomotic leakage and postoperative vocal cord paralysis. Although there is no clear difference in overall long-term survival, there is an apparent trend toward improved 5-year survival with transthoracic esophagectomy in patients with a limited number of involved lymph nodes.¹⁰ Published data comparing transhiatal esophagectomy with totally minimally invasive esophagectomy is rather limited.^11,12

Transhiatal esophagectomy is performed via an upper midline laparotomy incision and a left neck incision. Unlike the left transthoracic approach, the transhiatal approach offers excellent exposure of the abdominal cavity.^13-15 A generous Kocher maneuver can be performed, allowing the pylorus to extend almost to the hiatus. This helps to provide the length needed to pull the stomach into the neck. A pyloromyotomy or pyloroplasty can be performed easily, helping to decrease symptomatic gastric stasis postoperatively. There is ample exposure to allow a feeding jejunostomy to be created, aiding in postoperative nutrition.

The lack of a thoracotomy incision in transhiatal esophagectomy has potential advantages. The incisional pain associated with thoracotomy is avoided. The need for one-lung anesthesia is obviated. A chest tube is usually not required. These factors may be of particular importance in patients with severe chronic obstructive pulmonary disease, poor pulmonary function, or both. On the other hand, the lack of exposure of the mediastinum limits the surgeon's ability to fully assess that portion of the surgical field and to perform radical resection.⁴ Moreover, the surgeon's hand dissects bluntly behind the heart for a significant length of time during the procedure, making this approach more risky intraoperatively in patients with compromised cardiac function.¹⁶

The left neck incision used in transhiatal esophagectomy affords excellent exposure of the cervical esophagus. The esophageal resection can be extended fairly high in the neck, encompassing even high esophageal lesions adequately. The length of gastric conduit required to reach the neck results in higher leak and stricture rates compared with intrathoracic anastomoses. In the event of a cervical esophagogastric anastomotic leak, however, satisfactory drainage is easily obtained by reopening the neck wound, making the clinical consequences less severe than those of an intrathoracic anastomotic leak. Although methods have been described for performing a stapled cervical esophagogastric anastomosis, the lack of an ideally suited stapling device makes these techniques somewhat awkward. The anastomosis is usually hand sewn and may take no more time to complete than a stapled anastomosis.

The left recurrent laryngeal nerve is at risk in transhiatal esophagectomy, and left vocal cord palsy is a well-recognized complication. In addition to increasing the risk of aspiration owing to incoordination of swallowing, vocal cord palsy may reduce the effectiveness of coughing and compromise tracheobronchial toilet. Peristalsis in the proximal esophageal remnant may help to decrease clinically significant gastroesophageal reflux postoperatively. The relatively short length of remaining cervical esophagus after transhiatal esophagectomy may represent less of a barrier to inevitable postoperative gastroesophageal reflux than the longer esophageal remnant found with intrathoracic anastomoses.

The upper midline abdominal incision used in transhiatal esophagectomy affords excellent exposure of the entire abdomen. Unlike the left transthoracic approach, this exposure permits the surgeon to search thoroughly for abdominal metastatic disease before undertaking any resection. Metastases typically may be found in the omentum, mesentery, or liver and may be biopsied readily. In the absence of distant metastatic disease, the exposure afforded by the upper midline incision used in transhiatal esophagectomy allows for complete resection of the left gastric and celiac axis lymph nodes en bloc with the esophagogastrectomy specimen.

The lack of a thoracotomy incision results in virtually no exposure of thoracic or mediastinal structures. To a large extent, dissection of the esophagus is performed blindly and bluntly. Segmental arteries are avulsed close to the esophageal wall, and an adequate radial resection margin is not easily achievable.¹⁷ There is no reliable way to remove lymph node—bearing periesophageal fat en bloc with the specimen.¹⁸ Furthermore, with the transhiatal approach, there is no effective way to examine the lung for metastases. These factors underscore the need to ascertain early-stage disease preoperatively before committing to the transhiatal approach.

The patient's ability to withstand the procedure and its possible complications should be carefully evaluated preoperatively. Pulmonary and cardiac function should be assessed. Significant carotid artery stenosis and coronary artery disease should be ruled out. As a result of the high incidence of deep vein thrombosis in patients with esophageal cancer, preoperative lower-extremity venous duplex scanning should be considered.

Transhiatal esophagectomy affords little or no exposure of the upper and middle thirds of the thoracic esophagus for the surgeon. To avoid intraoperative airway injury or vascular injury, any possibility of adherence or direct invasion of the tumor into adjacent structures such as the trachea, aorta, or azygos vein should be excluded before undertaking this approach. For tumors arising above the distal third of the thoracic esophagus in particular, a high-quality CT scan with intravenous and oral contrast material is important. More detailed evaluation for tumor invasion into surrounding structures can be achieved with endoscopic ultrasound (EUS). Currently available clinical (preoperative) staging methods may often fail to identify nodal metastases.¹⁹ Unlike approaches that involve a thoracotomy incision, the technique of transhiatal esophagectomy does not permit en bloc mediastinal lymphadenectomy. The transhiatal approach does not afford exposure of any but the most inferiorly located mediastinal nodes.²⁰ Every effort should be made to exclude metastatic tumor involving lymph nodes above the esophageal hiatus, which would result in an unrecognized incomplete resection. The use of CT and PET scans may be helpful.

Patient Preparation

An epidural catheter may be placed before induction of anesthesia to facilitate postoperative pain management. Pneumatic intermittent calf compression boots are applied. With the patient in the supine position under general single-lumen tube endotracheal anesthesia, a Foley catheter and a radial arterial line are placed. Central venous access may be obtained via the right side of the neck.

To confirm the location of the tumor and/or extent of Barrett epithelium, as well as to rule out gastric/duodenal pathology, upper endoscopy may be performed using minimal air insufflation. After removing the endoscope, an 18F Salem sump nasogastric tube is placed, and the stomach is decompressed. A transverse roll is placed beneath the shoulders, and the head is placed on a gel donut and turned to the right. The entire abdomen and left neck are prepared and draped in continuity (Fig. 16-1). An intravenous antibiotic is administered before making the skin incision, and additional doses are given periodically as appropriate throughout the procedure for wound prophylaxis.

Preparation of the Stomach

An upper midline laparotomy incision is made. The peritoneal cavity and abdominal viscera are examined for evidence of metastatic disease or other pathology. The xiphoid process is excised with electrocautery. A Buchwalter retractor is placed. A bladder blade is used to retract the lower sternum cephalad, and Richardson blades are used to retract the rectus muscles laterally (Fig. 16-2). The left triangular hepatic ligament is divided with electrocautery (Fig. 16-3). The mobilized left hepatic lobe is retracted rightward with a wide Deaver blade covered with a laparotomy sponge (Fig. 16-4).

The nasogastric tube is positioned along the greater curvature of the stomach with its tip near the pylorus and is used as a handhold on the stomach. The abdominal esophagus is dissected from its crural attachments with electrocautery, encircled, and elevated on a Penrose drain. Alternatively, for lesions that are possibly directly invading the area of the esophagogastric junction (EGJ), a cuff of diaphragm can be resected with cautery under direct vision. The greater curvature of the stomach is mobilized using a harmonic scalpel, taking great care to avoid injury to the gastroepiploic arcade (Fig. 16-5).

The gastric fundus is mobilized using a harmonic scalpel to divide the short gastric vessels. Divided branches may be reinforced with ligatures or clips. The posterior gastric vessel, a penultimate branch usually well visualized off the splenic artery, is carefully divided and ligated. The left gastric vessels are dissected, reflecting the left gastric lymph nodes toward the stomach. The left gastric vessels are divided using a roticulating vascular stapler (Fig. 16-6).

A generous Kocher maneuver is performed. The serosa overlying the anterior wall of the pylorus is incised with electrocautery, avoiding the great pyloric vein of Mayo. A complete pyloromyotomy is performed using straight Mayo scissors or a #15 blade. Alternatively, a formal Heineke-Mikulicz pyloroplasty may be performed (see Chapter 17).

Mobilization of the Abdominal, Thoracic, and Cervical Esophagus

Attention is turned to the diaphragmatic hiatus, where the peritoneal reflection and phrenoesophageal ligament are taken with electrocautery dissection, completely mobilizing the esophagus in the hiatus. Transhiatal exposure is achieved by manual retraction using the hooked handles of two narrow Deaver retractors (Fig. 16-7).

Mobilization of the intrathoracic esophagus proceeds cephalad while maintaining downward traction on the stomach. Blunt manual dissection is performed along the anterior and posterior aspects of the thoracic esophagus in a relatively avascular plane. Lateral attachments containing segmental vascular branches are divided close to the esophagus using electrocautery under direct vision whenever possible (Fig. 16-8). Divided lymphatics are meticulously ligated with surgical clips. Care is taken to avoid injury to the inferior pulmonary veins.

As mobilization of the esophagus proceeds cephalad, direct visualization becomes impossible. Blunt “blind” manual dissection is undertaken anteriorly and posteriorly using the palpable nasogastric tube within the esophageal lumen as a guide. Care is taken to avoid injury to the membranous wall of the trachea anteriorly and to the aorta and azygos vein posteriorly (Fig. 16-9). Lateral attachments containing segmental vessels are hooked on the surgeon's finger and gently avulsed close to the esophagus using a downward motion using hemaclips and cautery when possible.

While mobilizing the superior thoracic esophagus, the surgeon's entire hand will be passed through the stretched diaphragmatic hiatus, working into a retrocardiac position. The surgeon must closely monitor the arterial line tracing during this portion of the procedure. If hypotension develops, it may be necessary for the surgeon to remove his or her hand from the chest intermittently to permit the blood pressure to recover. Major vascular injury must be recognized promptly; although repair may be possible through the dilated hiatus, emergency anterolateral thoracotomy is sometimes required.²¹ The thoracic esophagus is mobilized in this fashion to the level of the thoracic inlet.

After the entire thoracic esophagus has been completely mobilized, attention is turned to the left neck, where an incision is made along the anterior border of the sternocleidomastoid muscle and deepened through the platysma. This step can often be facilitated by a second surgeon starting on the neck just as the surgeon is starting the periesophageal dissection from below; this can shorten the overall time and make good use of the two surgeons working from opposite ends through the completion of the anastomosis. The omohyoid muscle is divided with electrocautery. The contents of the carotid sheath are reflected posteriorly with the sternocleidomastoid muscle. The middle thyroid vein is divided between surgical ties. Dissection is continued through an areolar plane to the vertebral bodies, reflecting the thyroid, trachea, and esophagus anteromedially. Blunt digital dissection is carried out along the vertebral bodies in a caudal direction until the thoracic inlet is entered. The surgeon's fingers from above and below should be able to touch without difficulty while again observing the blood pressure monitor. The esophagus is encircled in the thoracic inlet using blunt digital dissection. A Penrose drain is passed around the distal cervical esophagus and is used to elevate it into the incision (Fig. 16-10).

The esophagus is separated from the membranous wall of the cervical trachea with careful blunt dissection aided by electrocautery. Special care is taken to avoid injury to the recurrent laryngeal nerves.

Resection of the Specimen and Delivery of the Stomach to the Neck

The tip of the nasogastric tube is pulled back to the top of the cervical esophagus, which is divided well above the thoracic inlet using a GIA stapler. The fenestrated end of a large chest tube is sutured to the distal end of the divided cervical esophagus (Fig. 16-11). With downward traction on the mobilized stomach, the mobilized esophagus and the attached chest tube are pulled inferiorly through the posterior mediastinum until the fenestrated end of the chest tube appears through the diaphragmatic hiatus in the abdomen. The greater curvature of the stomach is fashioned into a long tube using sequential firings of the GIA stapler, taking care to obtain an adequate margin around the lesser curvature of the stomach. The detached esophagogastrectomy specimen is delivered from the operative field.

The long gastric staple line is oversewn with imbricating seromuscular suture. The newly fashioned gastric tube is placed in a sterile plastic endoscopic camera sleeve. The endoscopic camera sleeve is sutured to the fenestrated (abdominal) end of the chest tube that was passed through the posterior mediastinum (Fig. 16-12). Sheathed in the sterile plastic camera sleeve, the gastric tube is delivered cephalad via the diaphragmatic hiatus into the posterior mediastinum in the surgeon's hand. Simultaneous traction on the cervical end of the posterior mediastinal chest tube is used to pull the sterile plastic camera sleeve upward, delivering the gastric tube atraumatically through the thoracic inlet into the cervical incision.

Creation of the Anastomosis and Feeding Jejunostomy

A suitable point on the stomach, away from the long gastric staple line, is selected for the anastomosis. A hand-sewn two-layer anastomosis is fashioned. A row of interrupted seromuscular sutures is placed between the stomach and the cervical esophageal remnant, fashioning the outer layer of the posterior wall of the anastomosis (Fig. 16-13). Care is taken to avoid leaving an excessive length of cervical esophagus. Every effort is made to ensure that the anastomosis remains both tension free and above the level of the thoracic inlet. The esophageal staple line is grasped in a Kocher clamp and excised using a scalpel blade. The stomach is entered with electrocautery and suctioned. The inner layer of the posterior wall of the anastomosis is fashioned with interrupted absorbable suture.

The nasogastric tube is advanced beyond the anastomosis into the stomach and positioned with its tip at the level of the diaphragmatic hiatus. It is then placed on suction and secured to the skin of the nasal septum with a heavy nonabsorbable monofilament suture. The inner layer of the anterior wall of the anastomosis is completed with running or interrupted absorbable suture. The outer layer of the anterior wall of the anastomosis is completed with a row of interrupted seromuscular sutures. Alternatively, a modified “Orringer” posterior wall stapled anastomosis using an EndoGIA stapler can be performed, then closing the anterior wall in two layers.

A feeding jejunostomy is created. The tip of an 18F red rubber catheter is trimmed and passed through two concentric seromuscular purse-string sutures of absorbable material placed in the antimesenteric wall of the jejunum 40 cm beyond the ligament of Treitz. The red rubber catheter is imbricated into the antimesenteric wall of the jejunum proximally using a row of interrupted seromuscular absorbable sutures. The feeding tube is brought out through the abdominal wall lateral to the rectus muscle sheath at the level of the umbilicus. The serosal surface of the jejunum is sutured to the parietal peritoneum at the jejunostomy tube site using absorbable sutures at several points to prevent volvulus. The feeding tube is secured to the skin with a heavy silk suture.

A short 1-inch Penrose drain is secured with a silk suture to the skin at the inferior end of the neck incision and passed behind the esophagogastric anastomosis. Care is taken to avoid passage of the Penrose drain below the thoracic inlet. The neck incision is closed in two layers using a running 3-0 absorbable suture to reconstitute the platysma muscle and a running 4-0 subcuticular suture to reapproximate the skin. The abdomen is closed in two layers using #1 absorbable running suture to reconstitute the linea alba and staples to reapproximate the skin.

The patient typically is extubated in the operating room at the end of the procedure. An upright chest radiograph is obtained in the recovery room to verify the position of the nasogastric tube and central line and to rule out pleural effusion or pneumothorax. After discharge from the recovery room, the patient is monitored in an intermediate care telemetry unit. To avoid aspiration, the head end of the bed is elevated (reverse Trendelenburg), maintaining an angle of at least 30 degrees at all times. Fastidious maintenance of patency of the nasogastric tube is critical to ensure that the stomach is kept empty. Aggressive thromboprophylaxis is maintained with pneumatic intermittent calf compression boots and subcutaneous heparin. Daily upright chest radiographs are helpful to rule out distention of the gastric conduit, pleural effusion, pulmonary infiltrates, and ileus. Patient-controlled analgesia, chest physical therapy, and incentive spirometry are used to prevent atelectasis. Early ambulation is encouraged.

The Penrose drain is removed from the neck on the first postoperative day, after bile leak and hemorrhage have been excluded. No oral intake of any kind is permitted initially. Tube feedings may be started via the jejunostomy when appropriate and are increased gradually to the goal rate. A bowel regimen is helpful for avoiding constipation. Plasma electrolyte levels are monitored daily, and potassium and magnesium level determinations are repleted aggressively.

Throat discomfort related to the nasogastric tube may be alleviated with topical anesthetic spray. After 6 days without any oral intake, ice chips are permitted sparingly. Seven days postoperatively, a fluoroscopic swallow study is performed with the nasogastric tube in place. Small amounts of contrast material are frequently aspirated during this examination. Because of its propensity to cause chemical pneumonitis when aspirated, water-soluble contrast medium should be avoided completely and barium used instead. There are no known adverse consequences of barium extravasation in the chest. In the absence of a leak, the nasogastric tube is removed, and the patient is allowed to continue taking ice chips orally.

If there are no signs or symptoms of leak or infection, the patient's diet is advanced to clear fluids on the first morning after a normal barium swallow. Full fluids are permitted the next day. When appropriate, a mechanical soft diet is permitted. Carbonated beverages should be avoided. Oral medications may be administered in elixir form, but pills should be avoided for 6 weeks. When tolerating soft solids orally, the patient is discharged from the hospital.

Patients frequently will experience early satiety as a consequence of the diminished capacity of the stomach. Rather than eating three large meals each day, continuous “grazing” is more likely to achieve oral caloric intake goals. Jejunal tube feeds should be used only nocturnally to encourage oral intake during the day. When caloric intake goals are met orally, the jejunostomy tube is removed. To reduce gastroesophageal reflux, patients should be advised not to wear restrictive clothing around the waist. Patients should strictly refrain from oral intake for 2 to 3 hours before retiring to bed. The head must be elevated at all times either by placing 6-inch blocks under the head of the bed or by sleeping on a 30-degree foam wedge.

Early Complications

During the course of esophageal mobilization in the neck, the recurrent laryngeal nerves (especially on the left side) may be injured, resulting in vocal cord paresis or paralysis. This reduces the effectiveness of coughing and impairs the patient's ability to expectorate tracheobronchial secretions. Furthermore, vocal cord weakness increases the patient's vulnerability to aspiration. The result is an increased risk of postoperative pneumonia. Patients with postoperative vocal cord dysfunction must receive especially close attention to tracheobronchial toilet and nasogastric tube patency. In some cases, medialization of the impaired vocal cord may be warranted.

During the course of blunt dissection of the thoracic esophagus, the mediastinal pleura may be breached on either side. This sometimes can lead to delayed accumulation of unilateral or even bilateral pleural effusion. If a divided lymphatic vessel is not ligated properly, a chylothorax may result. To avoid respiratory embarrassment, postoperative pleural effusions should be drained immediately and completely with a pigtail catheter or chest tube. In the event of a chylous leak, tube feeds should be stopped immediately and parenteral nutrition instituted. Early surgical intervention is warranted for large lymph leaks that persist despite a withdrawal of enteral nutrition.

Respiratory problems are among the most common postoperative complications associated with esophagectomy, even when performed via the transhiatal approach. Aspiration of gastric contents is frequently the cause. Aspiration is often due to occlusion of the nasogastric tube with resulting gastric distention, excessive oral intake, or failure to maintain head elevation at all times. Many patients undergoing esophagectomy have a history of excessive alcohol consumption and are prone to delirium and other symptoms. Careful attention should be paid to a history of excess alcohol consumption, and appropriate prophylaxis with short-acting benzodiazepines should be instituted. Care should be taken to avoid inadvertent removal of the nasogastric tube by delirious patients.

Anastomotic Leak

An early anastomotic leak is attributable to technical error and should be readily appreciated when saliva and/or bile is seen draining from the Penrose drain in the neck on the first or second postoperative day. Leaks are more commonly due to a failure of anastomotic healing and usually occur on the sixth or seventh postoperative day, long after the Penrose drain has been removed. Signs of a delayed cervical anastomotic leak include erythema, fluctuance, and crepitus in the neck, as well as drainage of saliva and/or bile from the cervical incision. Early reopening and drainage of the inferior aspect of the cervical wound are imperative to prevent tracking of infection into the mediastinum. This usually can be accomplished satisfactorily at the bedside. The neck should be explored at the bedside with a gloved finger introduced via the reopened wound to ensure that any collection in the neck has been drained adequately. A large Penrose drain should be reintroduced via the lower end of the neck wound with its tip positioned behind the anastomosis. The drain may be sutured to the skin at the lower end of the neck wound. Its external end should be trimmed to a length of 2 to 3 cm and secured with a large safety pin to prevent it from becoming lost inside the wound. In the absence of fever and leukocytosis, a barium contrast swallow study is performed. If there is no extravasation of contrast material into the mediastinum, oral fluid intake is permitted, and the patient's diet is gradually advanced to soft solids. The patient should be instructed to push gently on the neck wound dressing when swallowing to decrease the leakage of food and drink. The anastomotic leak typically resolves in 2 to 3 weeks.

The development of mediastinal emphysema, pleural effusion, fever, hypoxia, hypotension, oliguria, acidosis, or a decline in mental status should lead the clinician to suspect mediastinitis. Although anastomotic leaks usually are drained effectively by reopening the neck wound, leaked secretions occasionally may track below the thoracic inlet into the mediastinum and/or pleural cavity. In this event, early and aggressive resuscitation of the patient along with institution of intravenous antibiotics is mandatory. Intubation and mechanical ventilation may be required. When the patient's condition has been stabilized, CT imaging is essential to rule out intrathoracic collections requiring drainage. Early and complete chest tube drainage or CT-guided percutaneous drainage of all collections is essential.

Occasionally, despite early intervention for a cervical anastomotic leak, the patient may remain septic. Under such circumstances, ischemia or gangrene of the proximal aspect of the gastric tip should be suspected. The characteristic odor of gangrenous tissue may be detectable from the cervical wound or the mouth. Very gentle flexible endoscopy may be performed—using minimal air insufflation—to assess mucosal viability. Full-thickness ischemia of the proximal gastric tip can be identified by more aggressive exploration of the neck incision in the operating room. When necrosis of the gastric tip has resulted in a leak that tracks below the thoracic inlet, the anastomosis should be taken down. The proximal esophageal end should be sutured to the skin in the neck as an end-esophagostomy. The stomach should be brought back down into the abdomen, and the gangrenous portion should be resected. The proximal end of the gastric remnant then can be secured to the parietal peritoneum in the left upper quadrant as an end-gastrostomy. Four to six months later, when the patient is doing well at home on jejunostomy feedings, continuity of the upper gastrointestinal tract can be restored electively. The gastric remnant is often long enough to permit an extra-anatomic (typically substernal) gastric pull-up with primary reanastomosis in the neck.

Stricture

Healing of the cervical esophagogastric anastomosis may be complicated by stricture, resulting in dysphagia to solids. The incidence of anastomotic stricture is increased if an anastomotic leak occurs postoperatively.²² Anastomotic strictures usually respond to repeated dilatation. Dilatation may be instituted as early as 4 weeks postoperatively, even if there is ongoing residual anastomotic drainage from the cervical wound. Initially, Savary bougies are used in the operating room under brief general anesthesia. Patients are encouraged to resume eating a mechanical soft diet immediately after undergoing dilatation to inhibit immediate recurrence of the anastomotic stricture. Dilatations are performed every 2 to 3 weeks until the dysphagia subsides. In the rare instance that requires numerous dilatations for complete resolution of the stricture, patients may be taught to dilate themselves at home every 4 to 7 days in an upright seated position using a Maloney bougie.²³

At our institution, we perform most esophagectomies with an open thoracotomy approach (i.e., left transthoracic [see Chapter 21], Ivor Lewis [see Chapter 17], or McKeown/three-hole [see Chapter 16] technique). In certain circumstances we do use the transhiatal technique as described earlier. These include primarily high-risk patients with poor pulmonary function who have early-stage localized tumors as well as patients with long-segment Barrett dysplasia.

A 77-year-old White man with long-segment Barrett esophagus presented with high-grade dysplasia near the esophagogastric junction. The patient had a history of coronary artery disease and mild chronic obstructive pulmonary disease. He underwent a transhiatal esophagectomy after an extensive workup showed no revascularizable lesions in the coronary arteries and no evidence of carcinoma on multiple biopsies. His postoperative course was unremarkable, and he underwent a barium swallow on postoperative day 7 that was read as normal. One day later, after eating a mint lozenge, he noticed a swelling over his left neck incision. On examination, he had fluctuant swelling over the anastomotic site with minimal redness and no fever or leukocytosis. His incision was opened and explored at the bedside. No obvious leak was noted, and no gangrene was found. The wound was irrigated and packed with wet-to-dry gauze dressings for 2 weeks. He was discharged home on postoperative day 10 in good condition tolerating a soft mechanical diet. He presented 6 weeks later with dysphagia and on esophagogastroduodenoscopy was found to have an anastomotic stricture. He required balloon and later Savary bougie dilations every 1 to 2 months for almost a year, after which his stricture resolved.

Although rarely used by most thoracic esophageal surgeons for esophageal cancer, transhiatal esophagectomy still has many proponents. In addition to general surgeons who prefer this technique as it can be done without a thoracotomy, in certain situations this operation can be helpful. For example, this operation can be performed in patients who are found to have Barrett esophagus with moderate-to-severe dysplasia or patients with a T1a or T1b distal esophageal cancer, since the risk of lymph node metastasis is below 10%. In addition, patients who have severe pulmonary dysfunction may benefit from this approach, which avoids thoracotomy. Despite the potential advantages inherent with this approach, careful attention to technical details is paramount.