Transhiatal esophagectomy may be performed for malignant or benign indications. Esophageal resection should be considered in all fit patients with resectable tumors. The operative risk of the patient is assessed, including nutritional status, pulmonary function, cardiac reserve, hepatic and renal functions, and other comorbidities. Optimal results can be obtained by carefully assessing operative risk and operating on a fit patient.
Transhiatal esophagectomy is most frequently performed for carcinoma of esophagus. It is recommended for early esophageal cancers of the middle (below the level of carina) and lower third of esophagus (type I and II tumors of esophagogastric junction). However, transhiatal esophageal resection may be feasible in upper esophageal carcinomas in some cases.
Transhiatal esophageal resection is also performed for advanced esophageal cancers in patients who are not fit to undergo a thoracotomy.
Among patients with carcinoma, adenocarcinoma and squamous cell carcinoma are the more common cancers resected transhiatally. The less-common esophageal malignancies include adenosquamous carcinoma, lymphoma, poorly differentiated carcinomas, neuroendocrine tumors, stromal malignancies, and carcinosarcoma.
Transhiatal esophagectomy is the preferred approach for patients with benign esophageal disorders such as stricture of the esophagus and Barrett esophagus with high-grade dysplasia. Other benign conditions for which transhiatal esophageal resection may be performed include the following:
Neuromotor dysfunction (achalasia, esophageal spasm/dysmotility)
Recurrent gastroesophageal reflux/recurrent hiatal hernia (multiple failed fundoplications)
Acute caustic injury
Contraindications to transhiatal esophagectomy include the following:
Carcinoma of the upper and middle third of the esophagus (hypopharyngeal, postcricoid, cervicothoracic malignancies) with invasion of tracheobronchial tree, heart, or great vessels (among others) on CT scanning, endosonography, or bronchoscopy
Stage IV cancers with liver metastasis, malignant ascites, or pleural effusion
Esophagus that is adherent to adjacent mediastinal structures, which usually is seen after previous surgery or radiation therapy causing mediastinal fibrosis, discovered intraoperatiely with palpation (If the surgeon feels that it is unsafe to proceed with transhiatal esophagectomy, there should be no hesitation for conversion to thoracotomy.)
Unfitness for surgery due to cardiac or pulmonary comorbidities
Patients with poor nutritional status who have difficulty swallowing may require esophageal dilatation or feeding jejunostomy to improve nutritional status before surgery.
For advanced T3 or T4 tumors of the lower end of esophagus and esophagogastric junction, preoperative laparoscopy and peritoneal cytology are useful to detect radiologically occult metastatic disease.
The consensus is that surgery is the first choice for potentially resectable tumors. Lymph node status is the most important prognostic factor. In T1b tumors (submucosal infiltration), the likelihood of lymph node invasion is approximately 10%-15%. Overall lymph node involvement is 30%-80% in different series, and about 40% of recurrences occur in lymph nodes.
Many surgeons believe that the radical en bloc esophagectomy improved the cure rate, even in cases of lymph node involvement. Performing meticulous extended lymphadenectomy to achieve the so-called R0 situation (ie, no residual microscopic or macroscopic tumor) should be the surgeon’s goal in potentially resectable tumors. At least 15 lymph nodes should be removed for adequate nodal staging in patients who have not received neoadjuvant chemotherapy.
R0 resection (removal of microscopic and macroscopic tumor) is an important prognostic indicator. Leaving behind microscopic (R1) or macroscopic (R2) remnants precludes any chance of curative treatment. It is accepted that, for T1 or T2 supracarinal tumors, complete resection is feasible. For tumors located below the carina, complete R0 resection is feasible for T1, T2, and T3 tumors.
A recent meta-analysis showed a survival advantage provided by neoadjuvant therapy for esophageal cancer. Neoadjuvant chemoradiation is advised for stage II, III, and IVa esophageal carcinomas with good performance status. With frequent use of neoadjuvant chemotherapy, advanced postsurgical pathologic TNM stages significantly decrease over time (P < 0.0001).
Esophageal resection should be considered in all fit patients with resectable tumors. The operative risk of the patient is assessed, including nutritional status, pulmonary function, cardiac reserve, hepatic and renal functions, and other comorbidities. Optimal results can be obtained by carefully assessing operative risk and operating on a fit patient.
Nutritional status should be improved preoperatively by supplemental tube feedings at home.
Patients with esophageal cancer are frequently smokers or alcoholics. They should be evaluated for chronic obstructive or restrictive pulmonary diseases, liver dysfunction with hypoproteinemia, coagulopathy, portal hypertension, or cirrhosis.
Breathing exercises and regular preoperative use of an incentive inspirometer is helpful in training the patient for early postoperative ambulation. The patient should be advised to abstain from smoking. Epidural anesthesia is very useful for comfortable postoperative breathing and early extubation and ambulation.
Routine blood examinations, coagulation profile, liver function tests, renal function tests, chest radiography, and electrocardiography are performed in all patients. Upper gastrointestinal endoscopy with biopsy and barium esophagography is used to confirm and assess disease. Standard staging for esophageal carcinoma is performed.
In cases of malignancy, the locoregional extent of disease and distant metastasis is assessed using CT scanning of the neck, chest, and upper abdomen. Endoscopic ultrasonography is useful in locoregional assessment of the disease, especially for documenting tumor infiltration to adjacent mediastinal structures, mainly the tracheobronchial tree and thoracic aorta. Bronchoscopy with biopsy is also useful in the evaluation of infiltration of the tracheobronchial tree. Positron-emission tomography (PET)–CT scanning and staging laparoscopy are performed in select cases. Preoperative chemotherapy is advised for T3 disease and if lymph node metastasis is suspected.
Videoesophagography may be useful in the assessment of aspiration tendency, and vocal cords should be evaluated via indirect laryngoscopy.
Major complications of transhiatal esophagectomy include atelectasis, pneumonia, pleural effusion, intrathoracic or abdominal hemorrhage, tracheal laceration, esophagogastric anastomotic or pyloromyotomy site leak, recurrent laryngeal nerve paralysis, chylothorax, and wound infection with dehiscence.
Atelectasis, which occurs in 3% of cases, may require prolonged positive-pressure ventilation and can progress to pneumonia in some cases. Both of these complications prolong the patient’s stay in intensive care and overall hospitalization period.
Postoperative hemorrhage may be mediastinal or intraperitoneal. Source of bleeding include a tear in the azygos vein, large prevertebral collateral veins, or spleen. Laparotomy may be required, and mediastinal bleeding can be controlled through the esophageal hiatus in most cases. Thoracotomy may be to control mediastinal hemorrhage. Intraoperative deaths due to uncontrolled hemorrhage have been reported during transhiatal mobilization of the esophagus.
The esophageal hiatus should be widened adequately and the esophagus dissected free under vision in the posterior mediastinum. For esophageal carcinoma, easily accessible subcarinal, paraesophageal, gastrohepatic ligament, and celiac axis lymph nodes are sampled, but an en bloc wide resection of the esophagus and adjacent regional lymph nodes is not attempted. Transhiatal dissection outside of the paraesophageal plane increases the risk of bleeding, tracheobronchial injury, or thoracic duct injury.
After the esophagus is resected, an inspection is carried out for bleeding and probable pleural entry. If there is bleeding, the source should be visualized and hemostasis ensured. Most bleeding will stop upon packing and resolves with time. If pleura is breached, an intercostal drainage tube is placed on the affected side. Conversion to a transthoracic approach may be required if the tumor is fixed to mediastinal tissues, if tracheobronchial tear has occurred, and for bleeding control. Tracheobronchial tears usually occur in the posterior membranous portion, and a right thoracotomy may be required for repair.
If the length of cervical esophagus is insufficient for a cervical esophagogastric anastomosis, the upper sternum may be partially split. Separation of manubrium only widens the space and provides exposure of the esophagus in superior mediastinum. Partial sternal split is useful in patients with a “bull neck” habitus, in obese patients, and in elderly patients with cervical osteoarthritis who cannot extend their neck.
The recurrent laryngeal nerve innervates the upper esophageal sphincter. Injury to the nerve may occur in 1%-3% of cases. It causes vocal cord paresis and dysphagia and may lead to aspiration, which is a life-threatening complication after transhiatal esophagectomy. The recurrent laryngeal nerve should be avoided. Placement of a metal retractor alongside the tracheoesophageal groove during the cervical dissection of esophagus should also be avoided. The surgeon should handle the trachea, thyroid, and cervical esophagus with fingers, when possible. [1, 2] . Hoarseness due to recurrent laryngeal nerve injury may resolve spontaneously, but cord medialization procedures may be required for persistent vocal cord paresis.
Pleural effusion may develop postoperatively. Although it may resolve spontaneously, thoracentesis or chest tube insertion may be required in some patients.
Chylothorax (1%) is a rare complication and is managed conservatively or by transthoracic thoracic duct ligation within 7-10 days of the esophageal resection.
Cervical esophagogastric anastomotic leak is another dreaded complication after transhiatal esophageal resection and may lead to stricture formation. It is more common after esophagectomy for carcinoma. The anastomotic leak rate is higher when the substernal/subcutaneous route is used for esophageal replacement. Use of a side-to-side stapled cervical esophagogastric anastomosis has reduced the incidence of anastomotic leak and stricture. [1, 2, 3]
Esophagogastric anastomotic leak is managed by opening the neck wound at the bedside and local wound packing until healing by secondary intent occurs. Patient may be put on jejunal feeds until the anastomotic leak is controlled. For fistula due to anastomotic leak, early bedside esophageal anastomotic dilatation (with 36F, 40F, and 46F dilators) within 1 week is very helpful and results in early closure of the fistula by allowing preferential flow of swallowed esophageal contents down the true lumen rather than through the leak.
Maloney tapered bougies are most effective in managing esophageal anastomotic leaks, and an aggressive follow-up dilatation program in the first few months after transhiatal esophageal resection is very important to prevent late stenosis and to provide comfortable swallowing.  Stent placement can also facilitate fistula closure and is perhaps the preferred avenue when an anastomotic leak is encountered.
Among the worst complications is gastric tip necrosis due to ischemia of the upper portion of the mobilized stomach. The guiding principle and dictum for stomach mobilization is “pink in the abdomen after complete gastric mobilization and pink in the neck after transposition of stomach through the posterior mediastinum.” The stomach should be handled with utmost care. No traction sutures should be applied to pull the stomach up in the neck. Ligation of the short gastric vessels too close to the stomach may cause focal gastric wall necrosis and leak or bleeding if the tie comes off.
Before transposing the stomach, ensure ample space in the posterior mediastinal tunnel. Adequate kocherization of duodenum will ensure that the stomach tube reaches the neck easily for a tension-free esophagogastric anastomosis. The stomach is manually manipulated upward through the hiatus and gently pushed up in the neck wound.
Gastroesophageal reflux is common after transhiatal esophageal resection. Performing an anastomosis about 3-5 cm below the highest point on the anterior wall of the stomach in the neck and creating an acute angle of entry of the esophagus into the stomach leaves some retroesophageal stomach to distend with air and may provide some type of antireflux mechanism. 
A pyloroplasty or pyloromyotomy ensures adequate gastric emptying and is performed routinely in some centers. However, it has been contended that avoiding the pyloromyotomy protects from the occurrence of severe complications, such as dumping syndrome, diarrhea, or leakage from the myotomy.  Mucosal breach at the pyloromyotomy site should be immediately repaired with interrupted silk sutures.
Delayed gastric emptying is rare if pyloromyotomy is performed. It is argued that pyloromyotomy can be avoided in transhiatal esophageal resection, since it was observed that symptomatic delayed gastric emptying on scintigraphic evaluation was very rare in patients who did not undergo pyloromyotomy; most of these patients can be managed with prokinetic agents. However, endoscopic balloon dilatation of the pylorus is occasionally required. 
Postoperatively, early removal of the drain from the cervical wound may result in formation of cervical abscess. A closed suction drain should be left for a sufficient period, and oral feeding should be delayed if an anastomotic leak is suspected.  Cervical abscess should be promptly treated, as it may lead to tracheogastric fistula.
Controversy was raised that the operation violated basic surgical principles of adequate hemostasis and cancer surgery. It was pointed out that exposure is inadequate and blind and blunt dissection of esophagus is required. The operation also precluded an en bloc mediastinal lymph node dissection. However, in numerous studies, no statistically significant difference in terms of overall and disease-free survival was found between transhiatal resections and transthoracic esophageal resections. Thus, it is now accepted that esophageal carcinoma is a systemic disease and that the biological behavior and tumor stage rather than technique plays the major role in the condition. [6, 7]
In 2001, a meta-analysis of 7527 patients who underwent transhiatal and transthoracic esophagectomies showed a statistically significant difference favoring transhiatal esophageal resection over the transthoracic approach in terms of hospital mortality, blood loss, pulmonary complications, chylothorax, ICU stay, and hospital stay. However, patients who underwent transthoracic esophagectomy (TTE) had lower anastomotic leak rates and a lower incidence of vocal cord paralysis.
In a study of transhiatal esophagectomy in profoundly obese patients by Scipione et al, esophagectomy outcomes in obese patients does not differ much from esophagectomy in nonobese patients. Obese patients had significantly greater intraoperative blood loss (mean, 492.2 mL vs 361.8 mL; P = 0.001), need for partial sternotomy (18 vs 3; P = 0.001), and frequency of recurrent laryngeal nerve injury (6 vs 0; P = 0.04). However, rates of chylothorax, wound infection, or dehiscence; length of hospital stay or need for intensive care unit stay; or hospital or operative mortality did not differ significantly between the two groups. Follow-up results for dysphagia, dumping, regurgitation, and overall functional score were also comparable between the two groups. 
Overall hospital mortality rates associated with transhiatal esophageal resection varies from 1%-10% in various studies. The various causes of death include respiratory insufficiency, pneumonia, sepsis, intraoperative hemorrhage, posterior mediastinal abscess, intraperitoneal or retroperitoneal abscess due to delayed pyloromyotomy leak, hepatic failure, pulmonary embolism, myocardial infarction, and aspiration.
Increasing age was found to be a significant risk factor in multivariate analysis for both 30-day mortality and morbidity. Patients aged 70 years or older had worse survival rates than younger patients. Overall long-term survival was significantly worse in older patients (median survival, 16 months; 5-year survival, 26%] compared than in the younger cohort (median survival, 33 months; 5-year survival, 35%). Complication rates are also significantly higher with advancing age, possibly owing to limited physiologic reserve. 
R0 status defined as clear circumferential and longitudinal margins is a recognized independent prognostic factor for survival. Longitudinal margin involvement, either at the proximal esophageal margin or positive gastric margin, has been shown to independently affect survival via increased loco regional recurrence. Of patients who had a positive gastric margin, 80% died with distant metastases. Adjuvant therapy for a positive gastric margin is usually unhelpful.
R0 resection is associated with significantly improved overall survival, so patients with early (T1-T2) tumors benefit most from this operative approach. Circumferential margin positivity is seen predominantly in patients with T3 or T4 tumors, and this is the main limiting factor in achieving an R0 resection. 
As of this writing, only one randomized controlled trial has compared transthoracic and transhiatal approaches, and this failed to show any significant differences in radicality of surgery or survival. [6, 7] There was an increased postoperative morbidity rate in the transthoracic group.
Regardless of the operative technique, it is often difficult to obtain circumferential clearance owing to the proximity of vital structures and the lack of any fascial boundaries. Meta-analyses comparing the two approaches have favored the transhiatal approach in terms of early morbidity and mortality, with no long-term survival disadvantage.
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