18: Ivor Lewis Esophagectomy

Introduction

For surgeons familiar with the unique and extraordinary challenges presented by surgery of esophageal malignancy, the words of Ivor Lewis appear as valid today as they were when first written over 50 years ago: “There is little doubt that the successful outcome of radical curative surgery for esophageal carcinoma remains one of the great challenges of surgical practice.”¹ A satisfactory result necessitates optimization of the patient's physical state and tumor staging, a high degree of surgical skill and experience, and teamwork involving close coordination of the surgical, anesthetic, physiotherapeutic, and nursing modalities of treatment.

General Principles and Patient Selection

The procedure first described in 1946 by Ivor Lewis now represents the middle road between “minimal” transhiatal esophagectomy without radical lymph node dissection, as described by Orringer et al.,² and extensive radical resection combined with three-field lymphadenectomy, as described by Akiyama et al.³ The operation combines an extended resection of the esophagus with either standard or extensive thoracic and abdominal lymph node dissection under direct vision through a combined abdominal and thoracic approach. For this reason, the Ivor Lewis esophagectomy is a preferred approach in many centers for patients with resectable tumor of the middle to lower third of the esophagus and gastroesophageal junction.

The procedure has several drawbacks that, in our view, confine its use to a select group of patients. The operation may limit the proximal extent of the esophageal resection, which can be a major concern in the case of skip lesions or tumors that spread through the submucosa. By terminating the dissection at the apex of the chest, one may not appreciate the presence of positive lymph nodes in the neck or reap the potential benefits of a third-field lymphadenectomy. Indeed from our own experience in a series of 174 patients with three-field lymphadenectomy,⁴ we observed that 23% of patients with adenocarcinoma (distal third or gastroesophageal junction) and 25% with squamous cell carcinoma presented with positive cervical lymph nodes. Unforeseen changes in the TNM classification because of such lymph node involvement were observed in 12% of patients. Five-year survival in patients with middle-third esophageal squamous cell carcinoma was 27.7%, and 4- and 5-year survival in patients with distal-third adenocarcinoma was 35.7% and 11.9%, respectively. Finally, the intrathoracic anastomosis, as compared with the cervical anastomosis, is thought to be associated with a higher risk of life-threatening sepsis in the event of leak. For these reasons, we reserve the Ivor Lewis technique for patients with resectable tumors in whom a neck anastomosis is contraindicated. This category includes patients with a past history of cervical malignancy that has been treated by either radical radiotherapy or major surgery and patients with other contraindications to surgery in the cervical region.

Preoperative Assessment

The preoperative evaluation should establish the histologic diagnosis and extent of local and distant disease, as well as the patient's physiologic ...