With the specimen delivered into the abdomen, a linear cutter 75-mm stapler is used to divide the stomach to ensure an adequate distal margin from the tumor and to fashion a narrow tube-shaped conduit. The outline for the conduit begins along the greater curvature of the stomach, high on the fundus, and is drawn toward the lesser curvature just above the crow's foot (Fig. 17-16). The staple line along the gastric conduit can be reinforced with invaginating “Lembert” seromuscular sutures. Maintaining a narrow conduit is important physiologically to ensure adequate emptying of the neoesophagus. The hiatus is dilated manually to permit four fingers to be placed through it.
A linear cutting stapler is used to create the gastric conduit. The conduit is fashioned by creating a semicircular line along the greater curvature of the stomach beginning high on the fundus and ending at a point along the lesser curvature just above the crow's foot.
A sterile arthroscopic camera bag is attached to the proximal end of a 30-mL Foley catheter secured to the distal end of the silk tie (Fig. 17-17). The gastric conduit is placed inside the bag and the bag is unfolded. A small aliquot of saline is added inside the bag and suction is applied to the distal end of the Foley drain to maintain traction on the conduit. The Foley catheter, camera bag, and gastric conduit are gently pushed into the mediastinum and out the left cervical incision taking care to prevent twisting of the conduit (Fig. 17-18). The conduit should be gently pushed or fed up the mediastinum rather than pulled up to prevent injury to the walls of the conduit or the vascular pedicle. When oriented properly, the gastric staple line lies on the right side of the neck incision from the patient's perspective, and the pylorus rests at the hiatus (Fig. 17-19). The esophagogastric anastomosis can be performed in one of two ways: hand sewn or stapled. For a hand-sewn anastomosis, the proximal esophageal staple line is cut off and a gastrotomy is made 3 cm below the tip of the conduit. A single layer of interrupted 3-0 silk sutures is used to create the anastomosis (Fig. 17-20). For a stapled anastomosis, a functional end-to-end anatomic side-to-side anastomosis is created using a linear cutting stapler and a thoracoabdominal-30 (TA-30) stapler to close the enterotomies (Fig. 17-21).
The silk tie is attached to the port of a 30-mL Foley balloon catheter, and the catheter is pulled up until it is partway through the neck incision.
The other end of the Foley catheter is attached to an arthroscopic camera bag. The neoesophagus is placed into the folded bag, being careful to ensure proper axial orientation (i.e., the neoesophagus is oriented with the staple line on the patient's right side). A Yankauer suction device is attached to collapse the bag around the neoesophagus.
The gastric conduit is pulled through the posterior mediastinum into the cervical wound.
An end-to-side anastomosis is created with a single layer of interrupted 3-0 silk suture. The anastomosis is created on the posterior aspect of the gastric conduit to ensure more favorable drainage.
Stapled cervical esophagogastric anastomosis. A. small enterotomies are made in the distal esophagus and posterior wall of the gastric conduit. B. Using a linear GIA stapler, the posterior wall of the esophagus and gastric conduit are joined. C. The remaining enterotomy is closed with a TA stapler.
We routinely drain the gastric conduit with a nasogastric tube until resolution of the postoperative ileus to prevent conduit distention and potential ischemia or aspiration. The nasogastric tube can be passed transnasally across the anastomosis, or alternatively a nasogastric tube can be passed through the conduit and out the neck incision. This latter placement technique avoids the morbidity and nasopharyngeal discomfort of a traditionally placed nasogastric tube. A sterile (Levine) tube is brought onto the sterile field and passed through a gastrostomy placed near the tip of the conduit prior to completion of the anastomosis. A purse-string suture is placed around the gastrostomy to prevent leakage. The tube is brought out at the apex of the neck incision and secured to the skin.
A 10-mm Jackson-Pratt closed suction drain is passed posteriorly and to the left of the anastomosis at the level of the thoracic inlet and brought out through a small lateral stab incision. This tube prevents seroma and provides an outlet for drainage in the event of an early leak in the anastomosis. A jejunal feeding tube is inserted routinely for postoperative feeding and to provide access for enteral nutrition if problems with oral feeding occur postoperatively.
Morbidity following esophagectomy is common, most frequently from cardiopulmonary and anastomotic complications (Table 17-3). Thorough knowledge of the common sources of morbidity and mortality following esophagectomy can facilitate prevention, early detection, and rapid treatment of complications, which is essential for satisfactory outcome.
Table 17-3Major Complications of Three-Hole Esophagectomy (N = 250) ||Download (.pdf) Table 17-3Major Complications of Three-Hole Esophagectomy (N = 250)
|COMPLICATION ||FREQUENCY (%) ||N |
|Recurrent laryngeal nerve injury ||14 ||35 |
|Chylothorax || 9 ||22 |
|Anastomotic leak || 8 ||19 |
|Pneumonia || 5 ||13 |
|Postoperative bleeding || 2 || 5 |
|Tracheoesophageal fistula || 1 || 2 |
|Adult respiratory distress syndrome || 1 || 2 |
|Empyema || 1 || 2 |
|Sepsis || 0.4 || 1 |
|Mediastinitis || 0.4 || 1 |
Many esophagectomy patients are ultimately, often malnourished individuals and frequently have a history of smoking and alcohol use. Often, they have comorbid conditions that compromise their cardiovascular and pulmonary status, prolong recovery, and complicate the postoperative management. Pulmonary complications including pneumonia, aspiration, and respiratory failure requiring prolonged intubation are common after esophagectomy and occur at a rate of 20% to 30% at high-volume centers.10 A preoperative epidural catheter for pain control is critical to improve postoperative pulmonary toilet. Conversely, the incidence of cardiovascular complications is relatively low, occurring in 5% to 10% of patients in most large series. Atrial fibrillation is most common but myocardial infarction, arrhythmias, congestive heart failure, deep venous thrombosis, and pulmonary embolism can occur as well.10
Anastomotic leak remains the Achilles heal of esophageal surgery. Most leaks manifest within 10 days of surgery. General factors that influence the development of anastomotic leak include tension on the anastomosis, quality of the arterial and venous blood supplies, location of the anastomosis, manner in which it was performed, and surgeon experience. Anastomotic leaks that are not quickly identified and treated remain a major source of operative mortality. We prefer a cervical as opposed to intrathoracic anastomosis, as in our experience it is easier to treat a leak in the neck than one in the chest. Early initiation of antimicrobial therapy, opening of the neck wound, and making the patient NPO is usually all that is necessary to resolve the leak and prevent severe sepsis. Soilage into the mediastinum is uncommon. Conversely, intrathoracic leaks may necessitate reoperation to adequately drain the source of the mediastinal sepsis. Recently, some have advocated the use of endoluminal stents to seal leaks.
There are many potential sources for hemorrhage after esophagectomy, including unrecognized or poorly controlled injury to the spleen, azygos vein, intercostal vessels, omentum, right gastric artery, and lung parenchyma. Traction injuries of the heart and pericardium can lead to cardiac tamponade. Injury to the phrenic veins during mobilization of the left lateral segment of the liver extending to the vena cava also can give rise to internal bleeding. Patients with unsuspected cirrhosis can have bleeding of the esophageal varices intraoperatively. Prevention of intraoperative bleeding requires close attention to technique and vigilant examination of all potential bleeding sites before closure. Postoperative hemorrhage requires urgent reexploration and occurs with an incidence of 3% to 5%. Diagnosis of postoperative bleeding is usually delayed by 12 to 24 hours. Unexpected tachycardia and decreased urine output are early signs of a developing problem. Since esophagectomy patients have sizable fields of dissection, where the blood can hide, they generally require large-volume blood replacement. After patients are resuscitated with blood products to correct coagulopathies, they are reexplored. This source of bleeding usually can be prevented with meticulous surgical technique.
The thoracic duct follows a similar course to the esophagus, comes in close proximity to the aorta and vertebral bodies, and is at risk of being injured during esophagectomy. Chylothorax occurs with an incidence of 1% to 5%. Diagnosis is made on demonstration of a pleural effusion consisting of a milky white fluid with high triglyceride and lymphocyte counts. It should be suspected with the development of a new right pleural effusion on chest radiographs following early removal of the chest drains or if the chest tube output remains elevated beyond postoperative day 4. The fluid may be clear and have a low triglyceride level if the patient has been NPO for a few days and may not turn milky until enteral feeds have been initiated. Although chylothorax can be managed conservatively in some patients with parenteral nutrition and restriction of enteral intake, the course is frequently prolonged and may lead to significant protein loss. We favor an aggressive reoperative approach with mass suture ligation of the thoracic duct via right thoracotomy if high chest tube outputs persist beyond the seventh postoperative day. To avoid this complication, we routinely ligate the thoracic duct at time of esophagectomy.
Pleural Effusion and Pneumothoraces
Other possible complications of esophagectomy include pleural effusion and pneumothorax. These conditions can be managed conservatively with percutaneous drainage or thoracostomy after other causes have been eliminated, including hemorrhage, chylothorax, conduit leak, metastatic disease, and airway injury. Dissection through the left pleura may result in fluid or air originating in the right hemithorax communicating with the left pleural space.
Recurrent Laryngeal Nerve Injury
A serious complication of esophagectomy is recurrent laryngeal nerve palsy. This injury affects the vocal cords and phonation but more importantly impacts the ability of the patient to detect and protect their airways against life-threatening aspirations. It occurs with an incidence of 10% to 20% in patients receiving a cervical anastomosis.7 Care must be taken in patients receiving oral nutrition with a recurrent nerve palsy to avoid aspiration. We frequently pursue early medialization of the vocal cord if a recurrent nerve palsy is identified.
Rarely, a tracheobronchial injury arises intraoperatively. If undetected at surgery, it can result in a postoperative tracheogastric fistula with persistent pulmonary soiling and recurrent pneumonias. We routinely perform bronchoscopy after the thoracic dissection to look for airway injuries. The risk of injury to the membranous wall of the trachea is minimized when the dissection is carried out under direct vision during the thoracic dissection, which is not possible during a transhiatal approach. If an airway injury does occur, it can be repaired primarily and buttressed with pericardium, omentum, and/or transposed muscle.
Up to 10% of patients undergoing esophagectomy experience delayed gastric emptying in the postoperative period. We routinely perform a pyloromyotomy for all patients undergoing a three-hole esophagectomy to avoid this disabling complication. If a gastric drainage procedure is not added, delayed gastric emptying can often be managed with endoscopic balloon dilatation but the surgeon must be vigilant toward the early detection of retained gastric juices and oral intake to avoid life-threatening aspiration.
It is important for the surgeon to educate the patient and family to recognize some of the late complications that can occur following esophagectomy that may warrant intervention. These include anastomotic stricture, paraesophageal hernia, intestinal motility problems (e.g., dumping syndrome), bile reflux, and post-thoracotomy pain syndrome.
Esophageal Anastomotic Stricture
Tension and inadequate blood supply can lead to esophageal stricture weeks to months after surgery. Patients who develop an anastomotic leak are at high risk for later development of a stricture. Dysphagia is the first sign of an esophageal stricture, and patients should be evaluated with an upper endoscopy and/or barium swallow. We have a low threshold for early endoscopy and dilatation. Anastomotic stricture is a frequent problem for a cervical anastomosis although serial dilatation is very effective and typically resolves the problem without the need for reoperation.