Transhiatal Esophagectomy

Transhiatal esophagectomy may be performed for malignant or benign indications. Esophageal resection should be considered in all fit patients with resectable tumors. Optimal results can be obtained by carefully assessing operative risk and operating on a fit patient. Laparoscopic, mediastinoscopic, and robotic approaches to the procedure have also been described.

Malignant indications

Transhiatal esophagectomy is most frequently performed for carcinoma of the esophagus. It is recommended for early esophageal cancers of the middle (below the level of the carina) and lower third of esophagus (type I and II tumors of the esophagogastric junction [EGJ]). However, transhiatal esophageal resection may be feasible in some upper esophageal carcinomas. ^[1]

Transhiatal esophageal resection is also performed for advanced esophageal cancers in patients who are not fit to undergo a thoracotomy.

Adenocarcinoma and squamous cell carcinoma are the more common cancers resected transhiatally. The less common esophageal malignancies include the following:

• Adenosquamous carcinoma
• Lymphoma
• Poorly differentiated carcinomas
• Neuroendocrine tumors
• Stromal malignancies
• Carcinosarcoma

Benign indications

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)
• Scleroderma
• Recurrent gastroesophageal reflux (GER)/recurrent hiatal hernia (multiple failed fundoplications)
• Acute perforation
• Acute caustic injury

Contraindications for 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) found on computed tomography (CT), endosonography, or bronchoscopy
• Stage IV cancers with liver metastasis, malignant ascites, or pleural effusion
• Adherence of the esophagus to adjacent mediastinal structures, which usually is seen after previous surgery or radiation therapy causing mediastinal fibrosis; this is discovered intraoperatively 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

The surgeon should ensure that the esophagus can be safely dissected in the thorax. If any fixation of the esophagus to the tracheobronchial tree or mediastinal structures is found or if excessive bleeding occurs, conversion to a transthoracic approach is indicated.

The preoperative workup should include evaluation for long-segment esophageal replacement to enable a tension-free anastomosis with the cervical esophagus. More commonly, stomach or colon is used for esophageal replacement. Thus, colonoscopy should also be done preoperatively to ensure the presence of an adequate length of normal colon for replacement, if a stomach conduit is not likely to be available.

Best practices

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 radical en-bloc esophagectomy improves 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 preoperative chemoradiation. ^[2]

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 cure. 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.

Neoadjuvant chemoradiation is advised for clinical stage T1b to T4a, N0-N+ esophageal carcinomas in patients with good performance status. ^[2]

Complication prevention

Major complications of transhiatal esophagectomy include the following:

• Atelectasis
• Pneumonia
• Pleural effusion
• Intrathoracic or abdominal hemorrhage
• Tracheal laceration
• Esophagogastric anastomotic or pyloromyotomy site leak
• Recurrent laryngeal nerve (RLN) paralysis
• Chylothorax
• 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. Bleeding sources 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 needed 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 bleeding is found, 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 a 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 the superior mediastinum. A 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 RLN 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 RLN 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. ^{[3, 4]}  Hoarseness due to RLN 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, thoracocentesis 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. ^{[3, 4, 5]}

Esophagogastric anastomotic leak is managed by opening the neck wound at the bedside and local wound packing until healing by secondary intent occurs. The patient may be placed 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. ^[4]  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 the 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.

In a study of 211 patients who underwent transhiatal esophagectomy, increased intraoperative fluid administration was associated with high (44%) perioperative morbidity. Patients with lower preoperative albumin levels may be at higher risk of complications from volume overload. ^[6]

GER 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. ^[7]

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 against severe complications, such as dumping syndrome, diarrhea, or leakage from the myotomy. ^[8]  Mucosal breach at the pyloromyotomy site should be immediately repaired with interrupted silk sutures.

Delayed gastric emptying is rare if pyloromyotomy is performed. It has been argued that pyloromyotomy can be avoided in transhiatal esophageal resection, in that symptomatic delayed gastric emptying on scintigraphic evaluation has been found to be 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. ^[8]

Postoperatively, early removal of the drain from the cervical wound may result in formation of a 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. ^[8]  Cervical abscess should be promptly treated, as it may lead to tracheogastric fistula.

Hiatal herniation of the small or large bowel has been reported after esophagectomy, and a transhiatal approach has been cited as an independent risk factor for this event. ^[9]

A review of the outcomes of 4321 esophagectomies performed at 164 participating centers found that of the seven procedures included in the analysis, transhiatal esophagectomy was the second most commonly performed procedure (21.7%) and had one of the lowest perioperative mortality rates, at 2.4% (range, 2.3-3.8%). However, the morbidity rate was among the highest, at 35.7% (range, 29.3-38.2%). Independent predictors of combined perioperative morbidity or mortality included the following ^[10] :

• Age >65 years
• Congestive heart failure
• Zubrod score >1
• Past or current smoking status
• Body mass index (BMI) >35 kg/m ²
• Squamous histology

Overall hospital mortality rates associated with transhiatal esophageal resection have ranged from 1% to 10% in various studies. Causes of death include the following ^[4] :

• Respiratory insufficiency
• Pneumonia
• Sepsis
• Intraoperative hemorrhage
• Posterior mediastinal abscess
• Intraperitoneal or retroperitoneal abscess due to delayed pyloromyotomy leak
• Hepatic failure
• Pulmonary embolism (PE)
• Myocardial infarction (MI)
• 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 than in younger ones (median survival, 16 and 33 months, respectively; 5-year survival, 26% and 35%, respectively). Complication rates are also significantly higher with advancing age, possibly owing to limited physiologic reserve. ^[11]

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 a positive gastric margin, has been shown to independently affect survival via increased locoregional 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; 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 is the main limiting factor in achieving an R0 resection. ^[12]

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.

Sugita et al assessed long-term oncologic outcomes of laparoscopic transhiatal esophagectomy (LTH; n = 43) vs open transhiatal esophagectomy (OTH; n = 29) transhiatal resection in patients with Siewert type II adenocarcinoma of the EGJ, focusing on overall survival (OS), recurrence-free survival (RFS), status of adjuvant chemotherapy, late-phase complications, and recurrence patterns. ^[13] The 5-year OS rates were 74% with OTH and 98% with LTH. After stratification by pathologic stage to adjust for selection bias, 5-year OS and RFS rates were longer, but not significantly different, among patients in the LTH group with pStage III. Recurrence patterns were similar in the two groups.

A similar study by Lee et al found LTH to be feasible and safe in patients with adenocarcinoma of the EGJ, with short- and long-term oncologic outcomes comparable to those of OTH. ^[14]