22: Left Transthoracic Esophagectomy (Ellis)

Introduction

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

Particularities with This Approach

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 ...