The treatment paradigm for the management of esophageal cancer has shifted dramatically over the past decade. Endoscopic therapies including mucosal resection and mucosal ablation have supplanted esophagectomy for the management of early-stage disease including patients with high-grade dysplasia, intramucosal (T1a) carcinoma, and highly selected patients with T1bN0 disease. For those patients with more locally advanced disease (i.e. ≥T2 or node-positive disease), a multimodal approach with neoadjuvant chemoradiotherapy has become the standard of care.1 Esophagectomy remains crucial to long-term survival.
Esophagectomy has historically been a complex operation associated with significant morbidity and mortality. Surgeon experience has proven to be a key factor for favorable outcomes.2 As there are numerous approaches to esophageal resection and replacement, both open and minimally invasive, an esophageal surgeon must develop and refine a technique of resection that can be performed safely and expeditiously to minimize morbidity while aggressively pursuing standard oncologic principles including adequate resection margins and complete lymphadenectomy with the goal of long-term survival.
The selection of operative approach is based on numerous factors: type and location of the lesion, extent of invasion, stage of disease, need for lymphadenectomy, history of previous surgeries, and type of conduit for esophageal replacement (i.e., stomach, colon, or jejunum). Surgeon preference and experience plays an important role in the selection of the operation. Popular methods of esophageal resection in the United States are based on methods developed by Ivor Lewis and McKeown, among others3–5 (Table 17-1). The three-hole esophagectomy has evolved over time in an effort to limit morbidity by assimilating the best elements of each of the predecessor surgeries in a safe and expeditious procedure.6–9 This chapter delineates the conduct of the McKeown esophagectomy and establishes principles that can be applied to any approach for esophagectomy, whether open or minimally invasive.
Table 17-1POPULAR METHODS OF ESOPHAGEAL RESECTION AND REPLACEMENT IN THE UNITED STATES ||Download (.pdf) Table 17-1POPULAR METHODS OF ESOPHAGEAL RESECTION AND REPLACEMENT IN THE UNITED STATES
|TECHNIQUE ||INCISION(S) ||ADVANTAGES ||DISADVANTAGES ||LESIONS |
|LTE ||Left thoracoabdominal |
Good exposure for GEJ tumors
|Single incision |
High risk of postoperative reflux
|Proximal margin limited by aorta ||GEJ |
|Transhiatala ||Upper midline laparotomy |
|No thoracotomy ||Limited lower mediastinal lymphadenectomy |
Blind midthoracic dissection
|Benign disease, high-grade dysplasia, GEJ and lower esophageal tumors |
|Ivor Lewisb ||Right thoracotomy |
|Direct-vision thoracic dissection |
Limited proximal margin
Increased risk of postoperative bile reflux
|Middle and lower thirds |
|Modified McKeownc ||Right thoracotomy |
|Good proximal margin |
Direct-vision thoracic dissection
Exposure to right RLN during dissection
Increased incidence of postoperative reflux
|Middle third |
|Brigham THEd ||Muscle-sparing right thoracotomy |
Simultaneous abdominal and left cervical
|Unlimited proximal margin|
Direct-vision esophageal dissection
Cervical anastomosis avoids morbidity of an intrathoracic leak and anastomosis ...