Chapter 27: Surgical Procedures to Resect and Replace The Esophagus

INTRODUCTION

Billroth and Czerny described the first esophageal resections in the 1870s, and these consisted of resections of the cervical esophagus without reconstruction. Later, resection of gastroesophageal (GE) junction tumors was performed by laparotomy with gastroesophageal anastomosis to reestablish intestinal continuity. Because there were concerns over respiratory compromise, surgeons were hesitant to enter the chest to perform esophageal resection. In 1915, Torek described the first transthoracic esophageal resection.¹ He used a left thoracotomy to resect the esophagus but did not attempt reconstruction. Instead, a cervical esophagostomy and abdominal gastrostomy were performed. A 3-ft-long external rubber tube was used to connect the ostomies, and it allowed the patient to eat for 17 more years (Fig. 27-1). Turner performed the first transhiatal esophagectomy in 1933.² Oshawa reported the first transthoracic resection of the esophagus with esophagogastric anastomosis in 1933.³ Knowledge of this procedure did not become widespread in the Western community until Adams and Phemister described the procedure in 1938.⁴

Ivor Lewis is credited with popularizing transthoracic resection of the esophagus. Initially, he performed the procedure in two stages: first, mobilizing the stomach via laparotomy, and several days later resecting the intrathoracic esophagus and reconstructing with the stomach. The Ivor Lewis approach (which is an upper midline laparotomy for mobilization of the gastric conduit followed by right thoracotomy for resection and reconstruction) and the transhiatal approach are currently the two most commonly used techniques of esophageal resection. In 1962, McKeown described a tri-incisional approach. He used a right thoracotomy to mobilize the esophagus. The patient was then repositioned in the supine position, the gastric conduit was mobilized by laparotomy, and the anastomosis was performed in the neck.⁵ Minimally invasive options for surgical resection have also become increasingly popular.^6,7 Thoracoscopic and laparoscopic techniques, robotic surgery, as well as combined minimally invasive with open approaches have created a wider variety of experiences and are discussed in other chapters.

NEOADJUVANT TREATMENT

Historically, surgery has been the primary mode of treatment for localized esophageal cancer. Nonetheless, the long-term results of surgery alone for esophageal cancer are disappointing, with a 5-year survival of approximately 20%.^8–10 Given the poor results with surgery alone, preoperative chemotherapy with or without radiation has been proposed as a means of improving long-term survival. Twelve randomized trials have been performed using preoperative chemoradiation, while nine additional randomized ...