Oesophagectomy

Indications

Cancer of the oesophagus and GOJ (see separate topic)

Pre-operative decisions

Extent of operation
- Radical en bloc - as wide as possible peri-tumoural resection with en bloc lymph node resection of the middle and distal thirds of the posterior mediastinum
  - Borders: right and left parietal pleura, aortic adventitia, vertebral bodies, posterior pericardium, membranous airway at carina
  - Includes oesophagus, vagus nerves, peri-oesophageal lymph nodes (levels 7 and 8), azygos vein, thoracic duct, bilateral parietal pleura, base of bilateral inferior pulmonary ligament, level 9 lymph nodes bilaterally, posterior pericardium
- Two-field lymph node dissection - WLE of the primary tumour + lymphadenectomy of the entire posterior mediastinum + lymphadenectomy of upper abdominal nodes (coeliac trunk + common hepatic + splenic artery + lesser curvature + lesser omentum)
- Three-field lymph node dissection - two-field dissection + cervical nodes (paraoesophageal + nodes lateral to carotid + supraclavicular nodes). May offer a survival advantage for supra-carinal tumours.
- Cancers at GOJ need an oesophagectomy plus partial (or extended) gastrectomy
Neoadjuvant chemoradiotherapy
- cN+
- cT3-4
Operative approach
- Trans-thoracic
  - Two-hole approach: Ivor Lewis - most commonly done
  - Three-hole: McKeown (right thoracotomy, laparotomy, neck incision and cervical anastomosis)
  - Proximal and middle thirds (supra-carinal), or suspicious paratracheal nodes - approach via right thoracic cavity in open surgery - allows assessment of airway, azygos, pericardium
  - Distal tumours and GOJ - left thoracic cavity easier, since it facilitates reconstruction after a total gastrectomy, and allows upper abdominal lymph node dissection, and allows assessment of aorta, pericardium and crus
  - Need to deflate the lung on the operative side
- Trans-hiatal
- Minimally invasive
  - Typically performed via a right thoracoscopy regardless of location
  - Best for T1a or Barrett's indications
  - Avoid in difficult cases - bulky tumours with possible adherence to the membranous part of the trachea, or after definitive chemoradiotherapy
Location of anastomosis
- Dependent on location of tumour -
- Cervical anastomosis historically thought to leak more, possibly because it is in the watershed region, further away from feeding blood vessels from the stomach. However modern rates of leak are comparable.
- Cervical leaks are easier to control than intra-thoracic.
- Try to keep it out of radiotherapy field
Type of anastomosis
- Hand sewn
  - Running absorbable (PDS?)
  - Posterior layer - full thickness
  - Advance NGT into gastric tube
  - Anterior in two layers
  - Usually covered with a pleural flap to protect the chest cavity from an anastomotic leakage
- Circular stapled (more expensive, more likely to cause stricture, easier, faster)
  - Sew anvil head into oesophagus using 4/0 Prolene purse-string
  - Incision in top of gastric tube to insert gun
  - Perforate with tip of gun - posterior, away from longitudinal staple lines and greater curvature vessels
  - Connect gun to head
  - Anastomosis in conventional manner
  - Can add some reinforcing sutures
  - Advance NGT into gastric tube
  - Close hole in stomach with stapler and inverting sutures
- Side to side now preferred technique, to increase area of anastomosis - triangular/droplet-shaped
  - Can be hybrid stapled/sutured
Optimal number of nodes
- One source says aim 10 for T1, 20 for T2 and 30 for T3
- Typical trans-thoracic lymphadenectomy includes levels 8, 9, 7, 4R, and 5. That typically gives >15 nodes.

Pre-operative evaluation/preparation

TTE
RFTs
Nutrition
Consider bowel prep if planning to use colon
G+H
ICU booking
Review radiotherapy field

Set-up

Epidural
Art line
Intubated with double-lumen ETT
Central line
IDC

Right-sided Ivor Lewis approach:

Abdomen:

- Midline laparotomy
- Check for metastases
- Prepare gastric tube
  - Start on greater curvature - identify right gastroepiploic arcade near the midpoint of greater curvature and start dividing the omentum 2cm peripheral, working towards the fundus, preserving the arcade for the conduit
  - Divide short gastrics 1cm off the stomach, and separate stomach from splenic hilum
  - Incise phreno-oesophageal ligament
  - Identify left gastric artery (elevate stomach towards hiatus and look for the band of fat between retroperitoneum and lesser curvature. Left gastric dissected and ligated (using EndoGIA tan 45mm), with resection of lymphatics around it. Avoid splenic artery near origin of left gastric artery.
  - Lesser omentum opened
  - Divide hepatic branches of the vagal nerves
  - Right gastric artery divided close to pylorus
  - Identify resection margins required - aim for 10cm distal to known tumour
  - Fashion a 4-5cm gastric tube using linear staplers (narrower tubes have better emptying, whereas wide tubes retain better perfusion). Start on greater curvature at level of division, then work on an oblique line towards incisura/pylorus.
  - Kocher manoeuvre - pylorus should reach caudate lobe when the conduit is pulled up
  - Consider pyloroplasty/pyloromyotomy - Incise over pylorus, then spread muscle fibres, trying to avoid using diathermy.
- Mobilise left hepatic lobe (divide falciform ligament and left triangular ligament, and incise pars flaccida)
- Finalise dissection of the oesophagus - expose the junction of left and right crura posteriorly
- Suture the two halves of stomach together with 3x interrupted, so they can be pulled up into the chest.
- Remove all nodes from coeliac axis, and along splenic artery to splenic hilum
- Clear common hepatic nodes up to IVC and PV
- Place jejunostomy 40cm distal to ligament of Treitz
- 24Fr Blakes drain alongside pylorus

Thorax:

- Positioned left lateral decubitus
- Thoracotomy in 5th intercostal space, with resection of part of rib, and rib spreader
- Exposure:
  - Retract right lung to expose thoracic oesophagus
  - Incise right inferior pulmonary ligament and remove level 9 nodes
  - Continue dissection along the posterior hilum, past the right mainstem bronchus up to arch of azygos
  - Ligate and divide azygos vein (not always done for GOJ tumours)
- Oesophagus mobilised with all surrounding tissues - en bloc resection, including thoracic duct, subcarinal and paraoesophageal lymph nodes together with oesophagus
  - Dissect between pericardium and oesophagus, continuing superiorly and laterally
  - Then dissect posteriorly, being sure to take the thoracic duct
  - Divide and ligate all oesophageal arterial branches and venous tributaries
  - Dissect as far down as the oesophageal hiatus and as far up as the carina
  - Isolate thoracic duct in the top of the chest (where it crosses posteriorly from right to left near the arch of the azygos) and above the diaphragm, clip and transect it
- Once superior to the arch of azygos, should stay directly on the oesophageal wall to avoid RLN injury, especially once you get up towards the thoracic inlet
  - Remove paratracheal nodes and fatty tissue, aware of right recurrent nerve
    - Can do frozen section here, proceeding to three-field lymphadenectomy if positive
  - Remove aortopulmonary and left recurrent nodes too
- Divide oesophagus around level of azygos arch, although can be higher or lower
- Anastomosis in chest
  - Make small oesophagotomies and insert 45mm EndoGIA purple to create a side-to-side anastomosis
  - NGT passed distally to hiatus, sutured to nose
  - Complete anterior wall with interrupted 3/0 PDS
  - Leak test with 100mL air
  - Cover with pleura/fat
- 10Fr silastic drain alongside anastomosis
- 28Fr ICC
- Close chest

Left sided Ivor Lewis approach:

Right lateral position, with left hip rolled slightly back to facilitate abdominal exposure
Posterolateral thoracotomy through 6th intercostal space, extended across the costal margin into the abdomen, and peripheral phrenotomy (leaving a peripheral rim of 2cm of diaphragm on the chest wall to permit closure)
Oesophagus mobilised from aortic arch down to hiatus
- Pericardium can be resected en bloc if needed
- Spleen and tail of pancreas mobilised, to expose the LUQ widely
Greater curvature mobilised fully to the level of the pylorus, gastrohepatic ligament divded, right gastric vessels divided, left gastric vessels divided, gastric tube fashioned
Abdominal lymph node dissection (D11)
- Splenic hilum back down to left gastric artery stump
- Common hepatic nodes up to IVC and PV
- Coeliac axis nodes
Back to chest for anastomosis
- Usually between inferior pulmonary vein and aortic arch
- Free thoracic oesophagus from behind the aortic arch using blunt dissection, after incising the pleural above the arch (watch for the recurrent nerve)
Thoracic lymph node dissection completed
Transect oesophagus

Mobilisation of cervical oesophagus

Easiest from left side
Omohyoid and middle thyroid veins divided
Oesophagus found behind trachea, encircled (beware left RLN)
Note that first 1-2cm lies behind the larynx and is not easily separable from it, so 'total' oesophagectomy leaves this part behind

Post-op care

D0
- Strictly NBM
- Can commence water flushes through jejunostomy
- ICC on suction with post-op CXR
D1
- Start feeds
- Close monitoring of fluid status
- Chest PT
- Mobilise
D4
- GG swallow - if normal, can start sips water
Abdominal drain removed first, then ICC, then mediastinal drain
NGT out once tolerating soft diet - can start working up to this after successful swallow, normally happens around day 7-8
Discharge home with jejunostomy feeds
Minimal liquid diet for two weeks

Complications

Death
- 30-day mortality 3.4%
- Overall 5-year survival 35-45%
Major morbidity 33%
- RTT 15%
Sepsis
- Could reflect ischaemia of conduit if presents within first 2-3 days, and consider gastroscopy
  - This would dictate taking down the conduit and doing a staged reconstruction
Pneumonia 12%
Chyle leak (check for chylomicrons and triglycerides)
- Discontinue enteral feeds, provide TPN
- If high outputs (>2-4L/day), intervention may be indicated
- Otherwise TPN and mid-chain triglyceride diet
Leak 12.9%
- Risk factors
  - Inflammation
  - Shock
  - Hypoperfusion
  - Steroids
  - Nutritional status
  - Smoking
  - Alcohol consumption
- Investigation
  - Contrast CT
  - Evaluate with oesophagram using WSC or CT
  - Gastroscopy might also be helpful if careful - can determine viability of conduit
- Presentation
  - Usually becomes evident within the first week
  - Cervical leaks characteristically present on day 5 with wound erythema, drainage and fever
  - Intra-thoracic leaks can be more insidious, with low-grade fever, malaise and leucocytosis, but can deteriorate to sepsis and multi-organ failure quickly
  - Other features - empyema, mediastinal air, pneumothorax
  - Sepsis, excessive chest drain output (turbid)
- Small leak contained or appearing to drain back into the oesophageal lumen will usually heal without intervention, if asymptomatic
- Small leak with no conduit necrosis is likely amenable to drainage +/- stenting
- Larger uncontained leaks require drainage
  - Sometimes open at bedside
  - But generally require OT
- Control leak
  - Operate - refashion/repair/t-tube/divert/resect
  - Endoscopically manage - endosponge and suction
  - Aggressively manage and drain any pleural collections
- Persistent sepsis or multiloculated collections need thoracotomy
Conduit ischaemia
- Usually seen on CT or gastroscopy
- Resection (conduit take-down, debridement, return to abdomen), cervical oesophagostomy, and reconstruction at a later date
- Focal necrosis may be salvageable with debridement and flap buttressing
Anastomotic stricture (14-50%)
- Usually technical factors or ischaemia
- Can be dilated or stented
- Balloon dilatation best initially
- Recalcitrant strictures - monthly dilatation +/- steroid injections
Delayed gastric emptying
- Prevent intra-operatively with pyloromyotomy, avoidance of intra-thoracic redundancy, and securing the conduit to the edges of the hiatus
- Consider - lack of a pyloric drainage procedure, obstruction at a tight hiatus, or a redundant intra-thoracic stomach
- Promotility agents
- Can attempt balloon dilatation of the pylorus
- UTD says don't routinely do pyloromyotomy, but pyloric dilatation when necessary is extremely effective
GORD
- Common
- Lower anastomoses more common
- Lifestyle measures
AF
- Usually a/w leak or pulmonary complications
RLN injury
Incomplete resection
- Even T3 R0 rates are >90% in most published series
- Positive lymph nodes - increased likelihood with stage and tumour volume
  - T1 5%
  - T2 30-40%
  - T4 80%
- Aim for a margin of 5cm at both sides