Transhiatal Esophagectomy 

Updated: Aug 25, 2018
Author: Pradeep Saxena, MBBS, MS; Chief Editor: Dale K Mueller, MD 

Overview

Background

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.

Indications

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). 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/recurrent hiatal hernia (multiple failed fundoplications)
  • Acute perforation
  • Acute caustic injury

Contraindications

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) found on CT scanning, 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

Technical Considerations

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 transthoracic approach should be done.

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 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 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 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.[3, 4] 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.[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 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]

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.[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 is argued that pyloromyotomy can be avoided in transhiatal esophageal resection, since symptomatic delayed gastric emptying on scintigraphic evaluation was 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.

Outcomes

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 of 35.7% was among the highest (range: 29.3%-38.2%). Independent predictors of combined perioperative morbidity or mortality included the following[9] :

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

Overall hospital mortality rates associated with transhiatal esophageal resection range from 1%-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
  • Myocardial infarction
  • 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 versus 33 months respectively; 5-year survival, 26% versus 35%, respectively). Complication rates are also significantly higher with advancing age, possibly owing to limited physiologic reserve.[10]

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 is the main limiting factor in achieving an R0 resection.[11]

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.

 

Periprocedural Care

Patient Education and Consent

Patient Instructions

Patients are instructed to do breathing exercises with regular use of an incentive inspirometer.

Elements of Informed Consent

Informed consent for the procedure is obtained. The diagnosis, treatment options, operative procedure to be performed, possible complications, and risks are explained to the patient and attendants, in their own language. The list of risks includes the following:

  • Infection
  • Bleeding
  • Anastomotic leak
  • Chylothorax
  • Respiratory complications, with possible need for ventilator support
  • Cardiac arrest
  • Death

Preprocedural Planning

Optimal results can be obtained by carefully assessing operative risk and operating on a fit patient. The assessment includes review of the following:

  • Nutritional status
  • Pulmonary function
  • Cardiac reserve
  • Hepatic function
  • Renal function
  • Other comorbidities

Patients with poor nutritional status who have difficulty swallowing may require esophageal dilatation or feeding jejunostomy to improve nutritional status before surgery. Nutritional status may 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 are 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 studies, 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.

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.

Videoesophagography may be useful in the assessment of aspiration tendency, and the vocal cords should be evaluated via indirect laryngoscopy.

Patient Preparation

The patient is kept nil by mouth 6 hours prior to surgery. Bowel preparation to prepare the colon is done if colonic interposition is anticipated.

Anesthesia

General anesthesia with endotracheal intubation is used.

Positioning

Because the cervical esophagus is best approached through a left-sided neck incision, the patient is positioned supine on the operating table with the left arm at the side and the right arm extended on an armrest or at the side. A long roll is placed between the shoulder blades vertically so as to extend the neck and let the shoulders fall down. The patient’s head is supported on a head ring and is turned to the right side.  Avoid hyperextension of the neck without head support, which can result in spinal cord injury.

A nasogastric tube and Foley catheter drainage are routinely used. A central venous line, if required, should be placed on the right side of the neck. Arterial blood pressure monitoring is useful.

The patient’s neck, chest, and abdomen are prepared and draped, exposing the operative field in the neck and upper abdomen.

Lastly, a table-mounted “upper hand” retractor is secured to the table with the cross bar at the nipple line. Two suction catheters are placed on the table, one at the head and one near the abdomen.[12]

Monitoring & Follow-up

Postoperative care

Postoperatively, the patient is kept in intensive care under close monitoring.

Extubation may be done immediately postoperatively, or the patient may be electively ventilated overnight.

Breathing exercises, chest physiotherapy, and regular use of an incentive inspirometer are helpful in early postoperative ambulation.

Jejunal feeds through a feeding jejunostomy are initiated once bowel sounds appear and the patient passes flatus.

A water-soluble contrast study is performed on the seventh postoperative day; if no leak is detected, oral feeding is resumed. The closed suction drain in the patient’s neck should be left for a sufficient period, usually until the tenth postoperative day; oral feeding should be delayed if an anastomotic leak is suspected.[8]

The patient is usually discharged in the second postoperative week.

If the histology report indicates positive surgical margins, adjuvant chemoradiotherapy is offered.

Long-term monitoring

To assess long-term functional results after transhiatal esophageal resection, the patient is evaluated for the presence and degree of dysphagia, regurgitation, and postvagotomy diarrhea and dumping syndromes. Patients should be preoperatively counseled about the changes in eating habits and the need for dilatations. 

Patients with an esophagogastric anastomosis leak should be placed on an aggressive follow-up dilatation program in the first few months after transhiatal esophageal resection to prevent late stenosis and to provide comfortable swallowing. Esophageal bougienage is initiated from the second postoperative week onward, with passage of 36F, 40F, and 46F Maloney esophageal dilators. After discharge, patients undergo follow-ups with regular dilatation with a 46F or larger Maloney bougie if they experience any degree of cervical dysphagia.

Most patients do not experience regurgitation of gastric contents. Regurgitation, if it occurs, may be graded as mild if it occurs upon reclining or in the prone position shortly after eating. This is a minor problem and requires no treatment. Troublesome nocturnal regurgitation compels patients to sleep with their head elevated at night. Severe regurgitation with pulmonary complications is caused by aspiration and occurs in 1% of cases.

About 33% of patients who undergo truncal vagotomy and pyloromyotomy report varying degrees of diarrhea and dumping syndrome (postprandial nausea, cramping, diaphoresis, palpitations, flushing, weakness, dizziness, hypotension, syncope). For mild symptoms, no treatment is required, and most of these symptoms usually resolve over time. Minor dietary changes, such as eating frequent small meals, avoiding meals rich in carbohydrates, and separating liquids and solids, may be helpful in controlling symptoms. Antispasmodics may be required for cramping. Diarrhea can be treated with supplemental dietary fiber, diphenoxylate, or Imodium.

 

Technique

Approach Considerations

Transhiatal esophagectomy is performed in 5 phases, as follows[12] :

  1. Abdominal phase
  2. Cervical phase
  3. Mediastinal dissection
  4. Creation and positioning of the gastric conduit, and abdominal closure
  5. Construction of the cervical esophagogastric anastomosis (CEGA)

Initially, the abdomen is opened and assessed for metastasis and resectability. The stomach is mobilized in preparation for resection. Next, the esophageal hiatus is widened and the mediastinal esophagus is mobilized. In the second and third phases, through a cervical incision, the cervical esophagus is mobilized and upper mediastinal dissection is performed. Finally, the esophagus is resected and a stomach tube created. The stomach tube is brought up in the neck and esophagogastric anastomosis is done.

Technique

Incisions

An upper midline incision is used for abdominal exploration, mobilization of the stomach and transhiatal dissection of the thoracic esophagus. In the neck, an oblique incision is made along the anterior border of the left lower sternocleidomastoid muscle, extending from the left side of the suprasternal notch to the level of thyroid cartilage. Through this incision, the upper esophagus is dissected and freed from the trachea.

Abdominal dissection

The abdomen is explored and carefully examined for the presence of liver metastasis or ascites. The resectability of the tumor is assessed. The stomach or colon that is to be used as a conduit for esophageal replacement is also examined. It should be long enough to reach the neck for a tension-free cervical anastomosis.

A table-mounted self-retaining upper-hand retractor is very useful for exposure and retraction of the left liver lobe. The left triangular ligament is divided with electrocautery, and the left lobe of the liver is retracted to the right with the blade of the upper-hand retractor.

Gastric mobilization

The lesser sac is entered by serially ligating vessels in the greater omentum about 2-3 cm from the greater curvature of the stomach, preserving the right gastroepiploic vessels.

The greater omentum is divided up to the pylorus, preserving the right gastroepiploic vessels, and the posterior aspect of the stomach is separated from the pancreas.

The greater curvature of the stomach is then freed by serially ligating the left gastroepiploic vessels and the short gastric vessels. These vessels should be ligated well away from the greater curve of the stomach to prevent ischemia and traumatic injury to the stomach.

The gastrophrenic ligament is similarly divided, and the entire greater curve from the pylorus to the gastroesophageal junction is freed. The posterior aspect of stomach is lifted up and dissected free from the retroperitoneum by dividing few avascular adhesions.

Incisions and mobilization of the stomach Incisions and mobilization of the stomach

The peritoneum over the lower esophagus is incised, and the esophagogastric junction is encircled and separated from the retroperitoneum.

The lesser curve of the stomach is then similarly freed by entering an avascular part of the gastrohepatic omentum well away from the right gastric vessels. While dividing the gastrohepatic omentum, the surgeon should carefully look for an aberrant left hepatic artery arising from the left gastric artery.

The greater curve of the stomach is retracted upward and to the right.

The left gastric vein is identified and doubly ligated and divided.

Dissection then proceeds upward toward the high lesser curve and esophageal hiatus.

The left gastric artery is identified and ligated at its origin from the celiac trunk and divided.

All the lymph nodes and soft tissue along the lesser curve are sequentially dissected and reflected toward the stomach, taking as much margin as is possible. In this way, the entire lesser curve and greater curve of the stomach is mobilized up to the esophageal hiatus.

Mobilization of the stomach Mobilization of the stomach

The peritoneum overlying the diaphragmatic hiatus is incised, and the phrenoesophageal ligaments are divided, separating the lower esophagus circumferentially from the hiatus. If the tumor adheres to the hiatus, a rim of diaphragm at the hiatus may be excised.

Once the stomach is completely mobilized, kocherization of the duodenum and pyloroplasty or pyloromyotomy is performed.

Mediastinal dissection and esophageal mobilization

Liebermann-Meffert documented that the larger arterial blood supply to the esophagus branches into small capillaries approximately 1 cm away from the esophageal wall. Dissection within this immediate paraesophageal space disrupts only these small capillaries, which rapidly spasm; subsequently, thrombosis occurs. Dissection of the esophagus should be carried out in this safe paraesophageal plane. Dissection outside this safe paraesophageal plane may cause injury to the larger vessels, resulting in more blood loss. 

Dissection of the esophagus in this para-esophageal plane is easy in the upper and lower esophagus, where it is done under vision. In the mid-esophagus, however, this dissection is performed blindly and may lead to hemorrhage from tearing of the larger vessels. Also, this blind dissection in mid-esophagus can lead to tearing of the posterior membranous portion of the distal tracheobronchial tree. The surgeon should be vigilant while performing dissection in this mid-portion of the esophagus, especially in patients with esophageal pathology in the mid-esophagus or pleural adhesions from infection or prior thoracic interventions in this region.

Thus, the mid-esophagus should be thoroughly evaluated by preoperative CT scan and endosonography. The use of laparoscopic instruments can be very helpful for safe dissection under vision in this region. 

Most of the esophageal dissection is performed under vision from below, through the esophageal hiatus. The hiatus is therefore widened adequately by incising the hiatus anteriorly. This usually requires ligation of the phrenic vein.

Widening of hiatus Widening of hiatus

A Devers retractor is placed in the hiatus to improve exposure. An infant feeding tube is used to encircle the lower end of the esophagus and keep it taut. It also helps to retract the esophagus on either side to facilitate dissection.

A long right-angled clamp is used to entangle adjacent paraesophageal tissue, which is divided using electrocautery. This way, by sequentially dividing small bits of paraesophageal tissue on both sides and by dividing branches of vagal trunk entering the esophagus, the whole of the esophagus is gradually mobilized and completely freed up to the level of carina. Care is taken to not to breach the pleura during this portion of the dissection. If the pleural cavity is entered, a chest tube should be inserted on that side.

While retraction and dissection is performed near the left atrium, the surgeon should be watchful for hypotension.

Once esophageal mobilization is complete, a pack is placed in the mediastinum through the hiatus, and preparation is done for the cervical part of operation.

Cervical incision and upper mediastinal dissection

An oblique incision is made along the anterior border of left lower sternocleidomastoid muscle, extending from the left side of the suprasternal notch to the level of thyroid cartilage.

The platysma is incised in the line of the incision and the sternocleidomastoid muscle exposed. The sternocleidomastoid is retracted laterally, and the central tendon of omohyoid muscle is identified. The omohyoid is divided, and, upon incising the omohyoid fascia, the carotid sheath with its contents is exposed.

The larynx and trachea are retracted medially, and the middle thyroid vein entering the thyroid is identified and divided between ligatures.

Similarly, the inferior thyroid artery is identified and divided between ligatures.

Cervical Incision Cervical Incision

With gentle medial retraction of the trachea with fingers and lateral countertraction on the internal jugular vein, the tracheoesophageal groove, recurrent laryngeal nerve, and cervical esophagus are visualized.

The prevertebral fascia is then incised, and a finger is insinuated along the esophagus into the superior mediastinum via blunt dissection.

The esophagus is freed all around and carefully separated from the trachea.

Both the recurrent laryngeal nerves are identified and excluded from the esophagus, which is then encircled by finger. An infant feeding tube can then be used to encircle the upper esophagus for retraction and further dissection.

While keeping the esophagus taut, blunt finger dissection of the esophagus is further continued.

The esophagus is dissected and freed carefully, first posteriorly from the prevertebral fascia and then anteriorly from the trachea. This way, the upper thoracic esophagus is mobilized and freed as much as possible through the cervical incision.

Exposure of the cervical esophagus Exposure of the cervical esophagus

Once again, the thoracic esophagus is visualized through the diaphragmatic hiatus. While traction is maintained on the lower end of esophagus, one hand is inserted through the hiatus and is advanced along the wall of the esophagus. The remaining filmy periesophageal attachments are divided via blunt dissection. The vagal branches are hooked in a right-angled clamp and divided with electrocautery. This way, complete mobilization of the thoracic esophagus is done.

Mobilization of the cervicothoracic esophagus Mobilization of the cervicothoracic esophagus
Esophageal mobilization on anterior aspect Esophageal mobilization on anterior aspect
Esophageal mobilization on posterior aspect Esophageal mobilization on posterior aspect

With traction on the upper infant feeding tube, the mobilized cervicothoracic esophagus is brought out through the cervical wound. The nasogastric tube is pulled out; and about 5-7 cm below the cricopharyngeus a linear cutting stapler is applied anteroposteriorly on the esophagus. The length of cervical esophagus in the neck is always kept a little long, as it may be useful if the stomach tube fails to reach the neck. The esophagus is transacted obliquely, keeping the anterior tip a little longer than the posterior. The stomach and the thoracic esophagus are then pulled and delivered out of the abdominal wound. The mediastinum is inspected for any bleeding or breach of pleura. Hemostasis is achieved, and, if the pleural cavity is breached, a chest tube is placed in the fifth or sixth intercostal space along the anterior axillary line.

Transection of cervical esophagus Transection of cervical esophagus

Esophageal resection and stomach tube creation

After ensuring a safe distal margin from the tumor, the stomach is transected approximately 4-6 cm below the esophagogastric junction via successive application of a linear cutting stapler, TLC 55 (heavy). Two or three fires of the linear cutter may be required. The resected specimen is then removed from the operating field. The staple line is oversewn with 2-0 silk continuous seromuscular sutures. Thus, a stomach tube approximately 4-6 cm wide is created with fundus forming its tip.

Creation of stomach tube Creation of stomach tube
Stomach tube Stomach tube

The stomach is then manually manipulated upward through the hiatus and gently pushed up in the neck wound.[7] 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 or to secure the stomach in the neck. Adequate space should be ensured while passing the stomach tube through the hiatus, mediastinum, and thoracic inlet. Care should be taken to avoid twisting of the stomach tube while it is passed and manipulated up in the neck.

Stomach tube pushed through hiatus toward the neck Stomach tube pushed through hiatus toward the neck

If the length of the gastric tube is insufficient for a tension-free cervical esophagogastric anastomosis, the upper sternum may be partially split. Separation of the manubrium only will widen the space and provides exposure of the esophagus in the superior mediastinum. Partial sternal split is also useful in patients with a “bull neck” habitus, obese patients, and elderly patients with cervical osteoarthritis who cannot extend their neck.

A Babcock forceps passed from the cervical wound is used to gently grasp the stomach tube and guide it up in the neck as it is pushed from below. The stomach tube is brought up for about 4-5 cm above the clavicle. At this stage, the tip of the stomach visible in the cervical wound should be pink and healthy, and there should not be any twist on the stomach tube.

Esophagogastric anastomosis and closure of neck wound

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 an antireflux mechanism.[7] Use of a side-to-side stapled cervical esophagogastric anastomosis has reduced the incidence of anastomotic leak and subsequent stricture formation.[3, 4]

The stapled suture line of the cervical esophagus is cut and submitted for histology as a proximal margin.

A small 1.5- to 2-cm vertical gastrotomy is made on the anterior wall of the stomach. The gastrotomy should be low enough to allow insertion of a 3-cm–long stapler cartridge for the esophagogastric anastomosis.

The posterior wall of the cervical esophagus is aligned with the anterior wall of the stomach. A stay suture is taken, suturing the superior edge of the vertical gastrotomy to the posterior edge of the transected esophagus.

The anvil of the TLC 55 linear cutting stapler is inserted through the gastrotomy into the stomach approximately 3 cm, and the cartridge of the stapler is inserted into the esophagus. The alignment of the posterior wall of the esophagus and the anterior wall of the stomach is checked again. The anvil and cartridge are engaged. Two interrupted 3-0 sutures are then taken between the anterior wall of the stomach and adjacent esophagus on either side of the stapler. The stapler is then fired to create a 3-cm–long esophagogastric anastomosis. The stapler is then removed, and a nasogastric tube is passed and advanced across the anastomosis into the distal stomach.

The remaining gastrotomy and esophageal defect is closed in two layers. Continuous 3-0 Vicryl full-thickness sutures are used for the inner layer and interrupted 3-0 silk sutures are used for the outer seromuscular layer. The stomach is gently pushed down and the neck wound irrigated with saline.

Esophagogastric anastomosis with a linear cutting Esophagogastric anastomosis with a linear cutting stapler
Completion of the esophagogastric anastomosis Completion of the esophagogastric anastomosis

A 14F closed suction drain is kept near the anastomosis and brought out from the side. The wound is then closed with interrupted 2-0 Vicryl for the muscle layer and 3-0 silk for the skin.

Abdominal closure

The edge of the diaphragmatic hiatus is sutured to the anterior wall of the stomach via a few interrupted 3-0 silk sutures to prevent herniation of intestines. A feeding jejunostomy is created, and the jejunostomy tube is brought out from the left upper quadrant.