 Surgical options for esophageal carcinoma Background: The epidemiology of esophageal carcinoma has changed dramatically during the last two decades. Whereas this used to be distinguished as a disease seen among heavy smokers and drinkers, it is now resulting more commonly from the aftermath of chronic gastroesophageal reflux disease (GERD). Specifically, the histologic changes in the esophageal lining resulting from chronic GERD injury referred to as Barrett's esophagus appear to be behind this emerging epidemiologic trend. Microscopically, this trend in the United States has resulted in a shift from a disease with predominate squamous cell histology to that characterized largely as adenocarcinomas. Additionally, the location of these tumors has changed from the majority of tumors occurring in the mid- to lower esophagus to the preponderance of carcinomas being found at the junction between the esophagus and stomach opening (gastroesophageal junction).
At this time, surgical resection of esophageal cancer remains the mainstay of treatment for patients who are without obvious metastatic disease or locally advanced disease. There is now expanding interest in combining chemotherapy and radiation therapy in the treatment plan for esophageal carcinoma prior to surgical resection. This combination therapy is aimed at controlling undetectable micrometastatic disease outside of the surgical field and reduction size of the primary tumor prior to surgical resection. These concepts are discussed at greater length and scope in this newsletter issue by David Friedland, M.D., Division of Hematology/Medical Oncology. There are multiple issues that must be considered by the thoracic surgeon prior to proceeding with resecting the esophagus and reconstructing the upper GI tract. The extent of the esophageal resection and the accompanying lymph node dissection; the esophageal replacement choices and positioning of this conduit within the chest; and the incisional approaches needed to accomplish esophagectomy must all be considered and decisions individualized to the needs of the patient. No single operative approach to esophagectomy is appropriate for all patients. Certainly, the operative approach chosen appears to be less important than the pathologic stage of the cancer at the time of resection in determining the patient's overall prognosis (Figure 3). Of course, the thoracic surgeon should strive to accomplish a complete resection of all disease at the time of the operation to reduce the likelihood of local recurrence. Along these lines, a 5-centimeter proximal margin of resection above the esophageal
carcinoma is ideally sought. The entire distal esophagus is typically removed along with
the upper aspect of the stomach (Figure 4). The lymph glands and mesentery of the proximal
stomach are also removed to diagnose any metastatic involvement by the cancer in this
region. With this resective goal in mind, a subtotal esophagectomy is performed in most
patients. Incisional approaches to esophagectomy: The incisional approach chosen to accomplish esophagectomy depends upon the location of the tumor, the functional status of the patient and the experience of the surgeon with any one particular technique. Cancers located in the mid-thoracic esophagus are best approached with a combined right thoracotomy and abdominal incision (laparotomy) approach the Ivor Lewis technique. A cervical incision may be chosen to extend the length of esophageal resection and accomplish the proximal esophageal anastomosis to the esophageal substitute in the neck. When this latter cervical incision is performed, the approach is known as the three-incision esophagectomy. Cancers in the lower esophagus or at the gastroesophageal junction may be approached
with the Ivor Lewis technique, three-incisional approach, left-sided thoracoabdominal
incision or the transhiatal esophagectomy technique
Our group performs nearly 40 esophagectomies a year at Allegheny General Hospital. Reviewing this large yearly experience, we find that all of the incisional approaches described above were used with some frequency; however, the transhiatal esophagectomy technique is the one preferred in most circumstances. As the majority of esophageal cancers are now found in the lower esophagus or gastroesophageal junction, the transhiatal approach is appropriate. The additional trauma of thoracotomy is avoided, and the operative time is usually shorter than the other incisional approaches described. The transhiatal esophagectomy technique is characterized by the performance of an abdominal incision to accomplish dissection about the stomach and lower esophagus. The dissection of the low intra-thoracic portion of the esophagus is performed through this upper-abdominal incision by opening the diaphragmatic hiatal opening of the esophagus. Direct visualization of the esophagus to the level of the tracheal carina is possible. A cervical incision is performed to accomplish dissection of the cervical esophagus and the upper intra-thoracic portion of the esophagus beyond the thoracic inlet of the neck. A very short segment of the esophagus between the distal membranous trachea and the tracheal carina requires digital dissection without direct visibility. The esophageal substitute is transposed through the bed of the resected esophagus and anastomosed to the proximal esophagus through the cervical incision. The transhiatal esophagectomy approach has very acceptable morbidity, low mortality and excellent long-term functional results. Video-assisted esophagectomy approaches have also been explored with the expansion of laparoscopic and thoracoscopic techniques. This approach has been primarily explored for the management of very small carcinomas without lymph node enlargement. We and others have described this technique in small series of esophagectomies. The procedure is completed with small abdominal and cervical incisions and with the assistance of laparoscopy and thoracoscopy. At this time, we see little additional benefit with regard to operative morbidity, surgical time or postoperative results (including hospitalization and postoperative pain) compared to the transhiatal approach to esophagectomy. Peri-esophageal tissue dissection: The extent of the peri-esophageal lymph node dissection and the removal of tissues around the esophagus required during the surgical resection remains a controversial issue. The attitude of surgeons varies greatly as to the benefit of wide removal of adjacent tissues during esophagectomy. The extent of this peri-esophageal dissection intertained varies from removing the esophagus and all peri-esophageal lymph nodes to the "en bloc" esophagectomy, which includes the removal of the surrounding pleura and all adjacent fibroareolar tissues, the posterior pericardium (heart sac), central aspects of the diaphragmatic crura surrounding the esophagus, and the azygous vein and thoracic duct. Japanese thoracic surgeons have advocated and promoted the "three-field" extended lymphadenectomy during the course of esophagectomy, which involves the radical dissection of all lymphatic drainage of the esophagus from the neck, chest and abdomen. The results with this more radical operative approach are still too preliminary to generally recommend and, at the present time, most thoracic surgeons continue to limit the peri-esophageal dissection of the lymphatic structures to those about the abdominal and thoracic esophagus. Esophageal replacement options: Our first choice for esophageal replacement following esophagectomy is the stomach; however, if the stomach is unavailable, colonic interposition is usually considered as a second-line alternative. When the stomach is adequate for this esophageal replacement, it is mobilized from its anatomic connections in the left upper abdomen and stretched upwardly through the diaphragmatic opening to reach the proximal normal esophagus. The blood supply of the gastric transposition graft is based upon the right gastroepiplic artery and the right gastric artery. The other two main contributions to gastric blood flow (left gastric artery and the short gastric arteries) are necessarily ligated to accomplish the gastric mobilization and adequate resection of the lymphatic drainage of the stomach. For the most part, the stomach is a resilient substitute for the esophagus, and the technical aspects of its mobilization for anastomosis to the esophagus are straightforward. The gastric transposition provides a good functional result following esophagectomy and requires only a single anastomosis to restore alimentary tract continuity. The use of a colon interposition requires longer surgical time to accomplish the reconstruction of the upper gastrointestinal tract, as several segments of bowel require dissection, transposition and re-attachment to complete the procedure. The blood supply to the colon is also more delicate and tenuous than that of the stomach, which leads to a more demanding dissection. Patients requiring a significant portion of their stomach to be resected to obtain clear margin from the esophageal tumor; patients with previous surgery upon their stomach (i.e. antrectomy for ulcer disease); or those with potential compromise of their stomach blood supply are potential candidates for colonic interposition as an esophageal substitute. The proximal small intestine (jejunum) can also be used as an interposition graft as an esophageal replacement. The graft's blood supply is based upon its mesenteric vascular pedicle, or it may be prepared as a "free graft" when short segments of the esophagus must be replaced. Positioning of the esophageal substitute: Trans-thoracic positioning of the esophageal replacement can be in a subcutaneous or substernal position. It can also be transposed through one of the hemithoraces; however, the most common positioning of the esophageal replacement following esophagectomy is within the posterior mediastinal bed of the resected esophagus. The position of the anastomosis between the proximal esophagus and the esophageal substitute is also an important component of the procedure. The abdominal and right thoracic approach popularized by Ivor Lewis results in an anastomosis between the esophagus and transposed stomach within the chest. This had been the traditional approach for distal and mid-third esophageal lesions. When the anastomosis is maintained in the chest, the stomach can be subjected to the positive pressure of the abdomen, which can lead to chronic irritation from acid reflux. When a long-term cure is achieved after esophagectomy, the risk of chronic esophageal stricturing related to this reflux injury can be significant. This problem of late peptic stricturing of the intra-thoracic anastomosis and the risk of significant morbidity/ mortality surrounding the development of an intra-esophageal anastomotic leak has led many surgeons to employ a cervical site of anastomosis between the proximal esophagus and the esophageal substitute. We are among those surgeons who prefer an extra-thoracic or cervical anastomosis to restore alimentary continuity following esophagectomy. For the most part, we favor the use of the transhiatal approach to esophagectomy popularized by Orringer. When a radical intra-thoracic dissection is indicated, we use the "three-incision" approach to esophagectomy. A right thoracotomy is combined with the abdominal dissection and a cervical incision for proximal esophageal anastomosis to the esophageal substitute. Intra-operative adjuvant radio-brachytherapy: This technique involves the weaving of radioactive iodine seeds embedded into an absorbable suture into a surgical mesh, which is also absorbable in nature. The size of the mesh implant is determined by the extent of the tumor bed. We have been pleased with the local control achieved with this adjunctive therapy, and there has been no radiation implant-related morbidity noted. Postoperative course: The patient is usually supported in the surgical intensive care unit for one to two days following esophagectomy. The length of intensive care stay is generally dependent upon the underlying physiologic condition of the patient and the extent of the surgery performed. The postoperative hospital stay ranges from seven to 12 days. Oral feeding is resumed four to five days after surgery once the patient's intestinal activity returns. We begin with clear liquid feedings and advance the diet quickly to a mechanical soft diet. We recommend avoidance of milk products during the recovery period from surgery, as these products may lead to troublesome cramps and diarrhea during the early postoperative period. This diet is maintained for four to six weeks following surgery. A temporary feeding tube (jejunostomy) placed at the time of surgery is used a few days after surgery and maintained for several weeks following surgery to provide supplemental nutrition aiding in the healing process. This feeding tube is usually removed in the outpatient clinic a few weeks after discharge from the hospital. The feeding tube may be maintained for longer periods if the patient's oral alimentation is inadequate. Patients are routinely followed at regular intervals in the thoracic surgical clinic. The support of dietary services and the consulting pulmonary, gastroenterologic and oncology physicians are also immediately available through the multidisciplinary approach to care we strive for at the Allegheny Center for Lung and Thoracic Disease. As mentioned earlier, the prognosis following surgery for carcinoma of the esophagus is primarily dependent upon the pathologic stage of the disease at the time of tumor resection. The primary determinants of stage are the depth of penetration of the tumor, the presence or absence of lymph node involvement, and possible finding of metastatic disease within the chest or abdomen. Additional therapy is rarely indicated when early-stage disease is identified; however, consideration for postoperative therapy (radiotherapy and/or chemotherapy) may be made when more advanced disease is encountered. References 1. McGregor B, Savlov ED. Management approaches to intrathoracic
esophageal carcinoma. Postgraduate General Surgery (5:283-287) 1993;2:98-102. 2. Kane JM, Shears LL, Riberio U, Clark MR, Peterson M, Posner MC. Is esophagectomy following up-front chemoradiotherapy safe and necessary? Archives of Surgery 1997; 132:481-486. 3. Barrett NR. Chronic peptic ulcer of the esophagus and oesophagitis. British Journal of Surgery 1950;38:175-179. 4. Tytgat GNJ, Hameeteman W. The neoplastic potential of columnar-lined (Barrett's) esophagus. World Journal of Surgery 1992;16:308-312. 5. Orringer MB. Technical aids in performing transhiatal esophagectomy without thoracotomy. Annals of Thoracic Surgery 1984;38:128-132. 6. Skinner DB. En bloc resection for neoplasms of the esophagus and cardia. Journal of Thoracic and Cardiovascular Surgery 1983;85:59-71. 7. DeMeester TR, Johansson KE, Franze I, et al. Indications, surgical technique and long-term functional results of colon interposition or bypass. Annals of Surgery 1998;208:460-474. 8. Turnbull ADM, Ginsberg RJ. Options in the surgical treatment of esophageal carcinoma. Chest Surgery Clinics of North America 1994;4:315-329. HOME
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