22: Left Transthoracic Esophagectomy (Ellis)

The worldwide estimate for new cases of esophageal cancer was 482,300 in 2008.¹ In 2012 over 17,500 new cases of esophageal cancer were diagnosed in the United States alone, with over 15,000 deaths. Despite advances in chemotherapeutic agents and radiation therapy, surgery remains the core component of treatment of this disease. Especially in early-stage disease, surgery is still offered as definitive therapy. The incidence of esophageal adenocarcinoma has been increasing steadily in the United States.^2,3 Adenocarcinoma of the esophagus develops predominantly in a segment of intestinal metaplasia, and thus the increased incidence of esophageal adenocarcinoma translates into an increasingly prevalent disease in the distal third of the esophagus.⁴ Given the anatomic configuration of the esophagus within the thoracic cavity, no one surgical incision provides uniform access to the entire esophagus. The surgical approach therefore must be tailored to the individual patient, permitting adequate exposure to the diseased region of the esophagus with the least amount of invasiveness.

Although resection of the distal esophagus via a left transthoracic incision was first described in the 1930s, the increasing prevalence of distal esophageal cancer has renewed interest in this surgical approach.

Likewise, for Barrett esophagus and high-grade dysplasia, the left transthoracic approach can be optimal allowing a safe complete resection through a single incision with much shorter operating times (about 2 hours).⁵

The advantage of left transthoracic esophagectomy is readily apparent in that it affords a surgical resection with a single incision. In addition to the obvious advantage of decreasing the patient's discomfort, the left transthoracic esophagectomy also can be performed in much less time than the Ivor Lewis or McKeown esophagectomy, with operative time averaging 2 to 3 hours.⁶ The left transthoracic approach does have a number of disadvantages that should be noted. First, although the division of the diaphragm provides excellent visualization of the left upper quadrant of the abdomen via the left chest, the remainder of the abdomen cannot be accessed using this approach. As a result of the limited abdominal exposure, adequate dissection of the pylorus cannot be achieved to perform pyloromyotomy. Many surgeons profess that gastric drainage is an essential component of esophageal reconstruction with gastric conduit placement after esophagectomy and identify the inability to perform a drainage procedure as a significant limitation of the left transthoracic approach. Evidence for the vital role of gastric drainage, however, is lacking. A meta-analysis of randomized controlled trials revealed that although pyloric drainage decreased the incidence of early gastric drainage dysfunction, the incidence of gastric drainage dysfunction in patients not receiving pyloric drainage was only 10%.⁷ Results from this study that suggest a trend toward increased bile reflux in patients treated with pyloric drainage have led some surgeons to question, in general, the value of pyloric drainage in esophageal reconstruction.

A further limitation of the left transthoracic approach is the lack of adequate exposure to perform a feeding jejunostomy. Early enteral nutrition has been demonstrated in some studies to be associated with improved outcome after esophagectomy in comparison with parenteral nutrition.⁸ Although jejunostomy is not easily accomplished via the left chest approach, enteral nutrition still may be possible using a nasojejunal feeding tube. To prevent inadvertent anastomotic injury from a blind tube insertion, the nasojejunal tube may be placed at the time of surgery using direct visualization to guide the tube through the anastomosis and endoscopic guidance to position the tube within the jejunum. The position of the nasal feeding tube within the jejunum may be secured using an endoscopic clip to fix the tube to the bowel wall. Alternatively, enteral access may be achieved laparoscopically using a jejunostomy tube or a percutaneous jejunal feeding tube placed under radiologic guidance.

A more subtle limitation of the left transthoracic approach is the technical challenge of performing the esophageal anastomosis within the left chest. Considering the relationship of the distal esophagus to the heart and great vessels within the left thorax, right-handed surgeons may experience some increased technical difficulty when performing the hand-sewn anastomosis from this exposure. The initial technical challenge of performing an esophagogastric anastomosis within the left chest arises from the unfamiliar angle of approach to the operative field for most right-hand dominant surgeons. This can be overcome with experience in this approach. The exposure and approach are identical with the left chest approach for Heller myotomy and Belsey repair. Finally, if a resection requires more extensive dissection, and a left neck anastomosis is thought to be the best approach, the mobilization can be completed under the aortic arch and the conduit prepared for a separate new approach by repositioning the patient.

In fact, in Asia, most surgeons perform total esophagectomies for squamous cell cancer through a sole left thoracotomy approach. Recently, there has been adoption of the standard Ivor Lewis approach in China, as a way of accomplishing a more extensive lymph node dissection. Still, many Asian surgeons perform the resection through the classical Ellis approach.

The limited exposure of the abdomen and thorax resulting from the left thoracotomy approach increases the importance of thorough preoperative staging to rule out metastatic disease. CT scanning, PET scanning, and endoscopic ultrasound (EUS) are essential components of preoperative staging. Any evidence of metastatic disease identified by CT, PET, or EUS is further investigated using EUS-guided fine-needle aspiration if accessible. At our institution, we continue to pursue an aggressive approach to surgical staging of all patients with esophageal cancer using laparoscopic and thoracoscopic staging for any patient evidencing a suggestion of advanced disease on CT, PET, or EUS. With the advent of more successful EUS-FNA of thoracic lymph nodes, the number of node-negative patients subjected to surgical staging has dropped to about 25%. In patients requiring laparoscopic staging because of suspicion of advanced disease, a jejunal feeding tube may be placed laparoscopically at the time of staging to facilitate perioperative alimentation.

In addition to oncologic staging and standard preoperative testing, preoperative cardiac stress testing and pulmonary function testing should be obtained to confirm the patient's ability to tolerate single-lung ventilation. The patient is placed on a full liquid diet 48 hours before surgery, advancing to a clear liquid diet 24 hours before surgery. Some surgeons still use an antibiotic bowel preparation with oral neomycin and erythromycin base the day before surgery.

After placing a dual-lumen endotracheal tube in the correct position, as confirmed by bronchoscopy, an 18F nasogastric tube is placed. The patient is placed in the right lateral decubitus position with the arm positioned such that it is flexed 45 to 90 degrees at the shoulder and elbow. The bed is then flexed at the patient's hips to widen the intercostal spaces. The surgeon stands to the patient's left side with the assistant to the patient's right side (Fig. 22-1).

The patient's skin is prepared and draped widely to the right of the midline in the event that a laparotomy or thoracoabdominal incision is required. The eighth rib is identified by counting the ribs from caudad to cephalad by palpation. The skin is incised over the seventh intercostal space from 4 cm lateral to the costal margin to the posterior axillary line. The latissimus dorsi muscle is divided, but care is taken to preserve the serratus anterior muscle by freeing the inferior attachment of the muscle and thus allowing the muscle to be retracted superiorly. The ribs are again counted to confirm the position of the eighth rib. The seventh intercostal space is entered along the superior edge of the eighth rib. For patients who receive preoperative chemotherapy and radiation, the seventh intercostal muscle bundle is harvested during entry into the thorax to buttress the esophageal anastomosis.

The rib is cut posteriorly just at the junction of the paraspinous muscles, and a small portion of the rib is resected. A rib spreader is used to permit exposure of the left chest. A systematic exploration of the left hemithorax is performed, and mediastinal lymph nodes are sampled for staging. The inferior pulmonary ligament is divided to permit cephalad retraction of the left lung, and the inferior pulmonary ligament lymph nodes (level 9) are removed for pathologic staging. The lung may be palpated for evidence of metastasis.

The mediastinal pleura overlying the esophagus is incised anteromedially in a plane along the pericardiopleural reflection and posterolaterally along the medial aspect of the aorta (Fig. 22-2A). Dissection is continued for several centimeters superiorly and inferiorly to permit sufficient mobilization of the esophagus to identify and palpate the tumor. The nasogastric tube is used as a guide to identify the plane of dissection, and the esophagus is mobilized circumferentially using blunt finger dissection and then encircled with a Penrose drain (Fig. 22-2B). Esophageal mobilization is continued proximally to a point 5 cm above the superior edge of the tumor and distally until the surgeon's fingers can pass easily into the abdomen.

After the esophagus is fully mobilized, the diaphragm is incised in a semilunar fashion approximately 2 to 4 cm from the costal margin. Given the direction of travel of the phrenic nerve fibers, radial incisions should be avoided on the diaphragm to prevent postoperative diaphragmatic paresis. As the diaphragm is being divided, marking sutures are placed on both sides of the divided diaphragm approximately every 5 cm along the incision line to assist with proper orientation of the diaphragm during closure. Care must be taken not to injure the underlying spleen or left colon.

After dividing the diaphragm, the surgeon next explores the abdomen, paying particular attention to the celiac axis and liver. The peritoneum overlying the gastroesophageal junction is incised, and the gastroesophageal junction is freed by blunt finger dissection. The gastroesophageal junction then is encircled with a second Penrose drain (Fig. 22-3). A Harrington retractor is used to retract the left lateral lobe of the liver medially to provide exposure of the hiatus. Gentle retraction with a laparotomy pad or “sponge stick” over the spleen completes the exposure.

The peritoneal reflection is incised to the left of the hiatus close to the gastric serosa. The peritoneum overlying the short gastric vessels is divided, and the vessels themselves are divided using a Harmonic Scalpel (Ethicon-Endosurgery, Inc.), taking care to divide the short gastric vessels well away from the gastroepiploic artery to maximally preserve the right gastroepiploic artery. If involved with tumor, the spleen may easily be included with the specimen. The stomach is further mobilized by dividing the posterior attachments. Care should be taken to identify, ligate, and divide the “unnamed” posterior gastric vessels, which arise as direct branches of the splenic artery and vein. These vessels are commonly encountered in the lesser sac, and inadvertent injury may result in significant hemorrhage.

The mobilized stomach is grasped and retracted superiorly and to the right by the first assistant, standing to the right side of the patient. With the stomach retracted in this manner, the surgeon achieves excellent exposure of the lesser sac, and the left gastric artery and vein can be identified (Fig. 22-4). Palpation with the surgeon's right hand will permit identification of the celiac trunk branching from the aorta. Any celiac lymph nodes encountered are dissected free and are included with the specimen. Next, the left gastric artery and vein are sharply dissected, separately ligated over a clamp with 2-0 silk suture ligature, and divided. Alternatively, we now use an endoscopic linear vascular stapler with a white (vascular) load to divide the left gastric artery.

With the stomach now fully mobilized, attention is directed to fashioning the gastric conduit. The nasogastric tube is pushed toward the lesser curvature in preparation for dividing the stomach. The gastric conduit is created using multiple firings of an endoscopic linear stapler with a large green load along a line parallel to the greater curvature of the stomach to create a gastric tube approximately 3 to 4 cm wide, eventually transecting the stomach from the specimen. The length of the conduit is determined by the location of the tumor and the proximal extent of the planned esophagectomy because a minimum of 5 cm of stomach distal to the tumor should be included with the conduit (Fig. 22-5). The staple line is reinforced using 3-0 silk interrupted Lembert sutures.

The esophagus and proximal stomach specimens then are delivered into the chest through the diaphragm. Next, the gastric conduit is passed through the hiatus into the chest and is positioned without twisting or tension along the aorta in preparation for anastomosis.

The esophagogastrostomy is performed as a two-layer anastomosis. The posterior wall anastomosis is performed before the esophagus is divided and the specimen is removed, because by retracting the intact specimen superiorly, the posterior esophagus is exposed to facilitate suturing (Fig. 22-6). The posterior wall outer-layer anastomosis is performed using interrupted 3-0 silk horizontal mattress sutures (Fig. 22-7A). After the posterior row of sutures is placed, the posterior esophagus is opened using an angled knife blade. The anterior half of the esophagus is not yet divided, again to permit traction on the specimen to expose the anastomotic site. Any large arterial vessels that are bleeding are point cauterized, but care is taken to minimize electrocautery along the anastomotic line.

The gastrotomy is performed next, also using sharp incision through the gastric serosa and then mucosa. The inner layer of the anastomosis is performed using 4-0 interrupted absorbable sutures taking full-thickness bites of the esophagus and large seromuscular and small mucosal bites on the stomach (Fig. 22-7B). When the posterior half of the inner row of sutures is completed, the sutures are placed on clamps and retracted laterally, and the remainder of the esophagus is transected along a bevel to create a slightly longer esophageal length anteriorly than posteriorly (Fig. 22-7C). Before completing the anastomosis, the nasogastric tube is advanced under direct vision through the anastomosis and into the stomach (Fig. 22-7D). The anterior inner full-thickness anastomosis is then completed such that the knots are within the lumen at the completion of the inner layer. Finally, the anterior outer layer of interrupted 3-0 silk horizontal mattress suture is placed to complete the anastomosis.

At this point, the anastomosis may be further buttressed by using an intercostal muscle bundle harvested during initial thoracotomy. The intercostal bundle is secured over the anastomosis with interrupted 3-0 absorbable sutures. Alternatively, the stomach may be used to reinforce the anastomosis (Fig. 22-7E). By taking a second row of Lembert sutures over the anterior suture line, the stomach serves to bury the entire anterior suture line, creating a so-called “ink well.” Some surgeons prefer a stapled anastomosis for this approach as well, in which case a circular load is probably easier than a linear load. After this, any redundant stomach is returned to the abdomen to avoid future technical issues related to torsion or sacculation of the gastric conduit.

After ensuring adequate hemostasis, attention is directed to closing the diaphragmatic defect. The previously placed sutures within the diaphragm are used as markers for orientation, and the diaphragm is reapproximated using interrupted figure-of-eight absorbable monofilament sutures. To prevent herniation into the abdomen and subsequent traction on the anastomosis, the gastric tube may be secured to the mediastinal pleura and/or diaphragm with a number of interrupted 3-0 silk sutures. The chest is drained with a single 36F chest tube placed inferiorly and posteriorly to provide dependent drainage. After thorough reexpansion of the lung, the chest is closed using #1 absorbable PDS suture for the paracostal sutures, as well as #1 absorbable running suture to reapproximate the muscle layers. The subcutaneous tissues are closed using a 2-0 absorbable suture in a running fashion, and the skin is reapproximated with a running 3-0 subcuticular suture.

Before the patient emerges from anesthesia, the nasogastric tube is secured in position using a bridle technique by passing an umbilical tape around the choana or suturing the tube to the septum with a large nylon suture. The patient is extubated in the OR after gaining consciousness.

Postoperative care is similar to that for any other patient after esophagectomy. The chest tubes are connected to −20 cm H₂O of suction. A thin barium esophagram is performed on postoperative day 7. For patients who have received preoperative chemotherapy and radiation, the esophagram is conducted on postoperative day 10 to allow greater time for anastomotic healing. After confirming a well-healed anastomosis, free of leak, the nasogastric tube is removed and an oral liquid diet is initiated. As a secondary method of checking for anastomotic leak, the initial liquid diet offered may consist of brightly colored liquids (e.g., grape or cranberry juice); thus any leakage of these liquids may be easily identified by the drainage from the chest tube. If the patient tolerates a liquid diet with no evidence of fever or leukocytosis, the chest tube is removed, and the patient's diet is advanced to a soft diet of six small meals a day.

The left transthoracic approach provides adequate exposure of the distal esophagus and left upper quadrant to permit effective esophageal resection and reconstruction for distal esophageal tumors. Uniquely, the left transthoracic approach enables esophagectomy by means of a single incision, thereby improving postoperative recovery and decreasing operative time. With the increasing incidence of esophageal adenocarcinoma and the resulting increase in distal esophageal tumors and particularly early-stage cancers, the left transthoracic esophagectomy is an important adjunct to the surgical armamentarium of thoracic surgeons practicing in the current era.

A 55-year-old white male malpractice attorney had a history of reflux. After treating his symptoms with Rolaids for years and recently resorting to over-the-counter H₂ blockers, he presented for esophagoscopy. At the time of his endoscopy, he was found to have Barrett mucosa. Four quadrant biopsies were done 2 cm above and below the gastroesophageal junction. Pathology demonstrated a T1a noninvasive adenocarcinoma at the gastroesophageal junction. Although Barrett mucosa was found 2 cm above and below the lesion, there was no dysplasia. Work-up showed that the patient had excellent pulmonary function, good cardiac performance, and no other specific medical illnesses. After discussion with the patient and his family, the thoracic surgeon decided that a left transthoracic esophagectomy would allow the best swallowing in the postoperative period, although the patient still may experience some symptoms of reflux. The patient concurred, and a left transthoracic esophagectomy with anastomosis at the level of the inferior pulmonary vein was done using a two-layer hand-sewn anastomosis. The patient had a normal swallow study on postoperative day 7 and was discharged from the hospital on postoperative day 10 able to eat six small meals per day. He presented back to the thoracic clinic on postoperative day 30 for routine follow-up. At that time, he complained of dysphagia to solid foods, which had gotten progressively worse. A repeat esophagogastroduodenoscopy (EGD) demonstrated an anastomotic stricture, which was dilated up to a 40F bougie without difficulty. The patient again was able to resume eating six small meals a day, and at follow-up EGD 1 month later he had no evidence of residual stricture, although there was some visible esophagitis present. pH testing of the gastric juices showed a normal pH, and biopsy showed mild esophagitis. The patient resumed his H₂ blocker once daily and subsequent EGD 6 months later showed complete resolution and no evidence of Barrett mucosa.

Since the initial description of this technique, we have unfortunately lost one of the greatest esophageal surgeons, my mentor Dr. F. Henry (Bunky) Ellis Jr. Dr. Ellis was a strong proponent of this technique and reinvigorated its use in the United States. His emphasis on technical expertise at the time of resection and reanastomosis are legendary. I generally use this technique in patients with short-segment Barrett esophagus and in patients with T1 tumors of the esophagogastric junction. This approach allows one to save the majority of the esophagus with resultant good swallowing and gastric pouch function and is relatively quick (under 2.5 hours!). The main drawbacks are increased reflux and, if a narrow tube is not used, compression of the left lower lobe. Jejunostomy and pyloroplasty are not generally done when using this technique.