Chapter 5. Transhiatal Esophagectomy

• Resectable esophageal carcinoma.
• Barrett esophagus with high-grade dysplasia.
• Carcinoma of the cardia or proximal stomach.
• Achalasia.
• Advanced disease (mega-esophagus).
• Failed esophagomyotomy.
• Benign (undilatable) stricture.
• Recurrent hiatal hernia or reflux esophagitis following multiple hiatal hernia repairs.

Absolute

• Biopsy-proven distant metastatic (stage IV) esophageal cancer.
• Tracheobronchial invasion by upper or mid-third tumors visualized on bronchoscopy.
• Aortic invasion demonstrated on MRI, CT scan, or endoscopic ultrasound (EUS).

Relative

• Cardiopulmonary comorbidities.
• Previous esophageal surgery causing excessive mediastinal adhesions.
• Previous radiation therapy (more than 6–12 months prior) causing mediastinal and esophageal radiation fibrosis.

• In our series of patients, overall mortality is 1%, and more than 70% of patients experience no postoperative complications.

Expected Benefits

• Resection of the intrathoracic esophagus and accessible associated adenopathy for definitive therapy or local management of disease, while restoring normal swallowing and digestive function as much as possible.

Potential Risks

• Cervical esophagogastric anastomotic leak (5–10%).
• Cervical dysphagia or esophageal stricture requiring early postoperative dilation (50–60%).
• Postvagotomy dumping symptoms (25–50%).
• Recurrent laryngeal nerve injury (< 5%).
• Chylothorax (< 2%).
• Mediastinal hemorrhage (< 1%).
• Membranous tracheal injury (< 1%).
• Gastric tip necrosis (< 1%).
• Surgical site infections and systemic complications common to any major operation (eg, pneumonia, venous thromboembolism, and cardiovascular events).

• A table-mounted "upper hand" retractor facilitates exposure of the operative field.
• Endoscope for preoperative visualization of the esophageal abnormality and to ensure an adequate normal proximal margin.
• 14-inch right-angle clamps.
• Extra-long 16-inch electrocauterizing device.
• Gastrointestinal anastomosis (GIA) stapler

Preoperative Planning

• Thorough preoperative staging evaluation is essential before performing transhiatal esophagectomy for malignancy.
  • Esophagoscopy and biopsy, to establish the location of the tumor and histology.
  • CT scanning, to demonstrate the local extent of the tumor and presence of distant metastatic disease.
  • EUS, to define the depth of tumor invasion within the esophageal wall and surrounding tissues. EUS can also identify dissemination of tumor into regional lymph nodes and can be combined with fine-needle aspiration for confirmation of malignancy.
  • Positron emission tomography has recently become a standard part of the staging evaluation and determines occult distant metastatic disease.
• For patients with a history of gastric disease or previous gastric surgery, or patients with esophagogastric junction tumors that may necessitate resection of a major portion of the stomach, a barium enema should be performed to assess the colon as an alternate conduit if the stomach is not suitable.
• Maximizing the patient's preoperative cardiopulmonary status is paramount to successful recovery.
• Patients should abstain from cigarette smoking and alcohol use for a minimum of 3 weeks before the operation.
• Patients should use an incentive spirometer on a regular basis (10 deep breaths three times daily), and walk at least 1–3 miles per day.
• For patients with severe dysphagia, weight loss, or dehydration, liquid supplementation by either oral ...