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INTRODUCTION

A thoracoabdominal approach to resection of the esophagus is most useful for tumors of the distal esophagus that lie inferior to the aortic arch and tumors 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, Sweet described the technique of anastomosis based on the principles of meticulous technique and attention to detail.3 The thoracoabdominal incision provides excellent access to the abdomen, and 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 rigorous patient selection and complete staging workup 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. Endoscopy also allows for identification of Barrett esophagus and potential gastric involvement.

Further evaluation by computed tomographic (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 is most useful in the detection of distant metastases, typically to liver or lung.6

Endoscopic ultrasound (EUS) is used 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%.7 EUS is clearly superior to CT in T staging and appears more accurate in predicting T4 disease.8,9 A negative EUS for regional nodal disease is particularly useful due to the low false-negative rate.8

Positron emission tomography (PET) imaging has becoming a more valuable tool in the evaluation ...

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