21: Left Thoracoabdominal Approach

Introduction

A 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, Sweet³ described the technique of anastomosis on the basis of the principles of meticulous technique and attention to detail. 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

Preoperative Assessment

Because of the magnitude of a thoracoabdominal esophagectomy or any esophagectomy, it is important to engage in a rigorous selection and staging work-up before proceeding with surgical intervention. Although 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 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 local 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 adjacent 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 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 in regard to metastatic disease, the results are encouraging, ...