SCA2014 Esophagectomy talk
March 30, 2014
11:00 – 12:30
SCA annual meeting
New Orleans
Jens Lohser
Advantages of transhiatal esophagectomy versus open transthoracic
approach: an anesthesiologist perspective
At the conclusion of this educational activity, the participants will be able to:
1. Appreciate the differences in the surgical approaches to esophageal
resection.
2. Appreciate potential advantages of the transhiatal versus the transthoracic
approach to esophageal resection.
Discussion
The esophagus is a simple muscular tube, however, due to the fact that it spans
three anatomic territories (neck, thorax and abdomen) surgical resection is
difficult and associated with a high complication rate. Adenocarcinoma is the
most common pathology and tends to occur at the gastro-esophageal junction in
patients with longstanding history of gastro-esophageal reflux. There is an
increasing incidence of squamous carcinoma in patients from endemic areas,
which tends to occur more proximal in the esophagus. Treatment of esophageal
cancer commonly involves adjuvant therapy with chemo-radiotherapy, however
surgical resection remains the cornerstone of therapy. Esophageal resections
involve removal of the diseased esophagus with surrounding tissue, commonly
distal esophagus and proximal stomach. The esophagus is reconstructed with a
neo-esophagus created most commonly from a gastric tube and occasionally
from a colon interposition graft.
Lymph-node dissections are undertaken for staging purposes, although there is
also some support for more aggressive node dissections affording better survival.
While some argue for three field dissections, most centers perform two-field
dissections for lower esophageal cancers and only add cervical field dissections
for cervical or upper-thoracic cancers.
Mortality rates vary widely based on institution and age, but mortality rates up to
20% were not unheard of about a decade ago. Recent decreases in mortality to
less than 5% have been documented, particularly in high-volume centers.
The list of complications is long and includes both cardiac and pulmonary
complications, anastomotic leaks, recurrent laryngeal nerve injury and
chylothorax. Pulmonary complications are responsible for most of the morbidity
and are responsible for 2/3 of the mortality rate. Pneumonia and respiratory
failure are common diagnoses, with the common thread often being aspiration of
gastric contents. Anastomotic leaks are another significant contributor to major
morbidity and mortality, particularly with intrathoracic anastomoses.
A large number of surgical approaches have been described. Different
approaches may be required depending on the location of the mass, the
intrathoracic disease burden and the particular lymph node territories involved.
Transhiatal (midline upper abdominal incision and left anterior neck incision).
Most commonly used for GE junction tumors, but can be used for high thoracic or
cervical lesions. Unable to reach mid-to upper thoracic lymph nodes. Uses a
cervical anastomosis. Does require epidural, but NOT lung isolation.
Left thoraco-abdominal approach (lower thoracotomy incision extended into the
upper abdomen, includes division of the diaphragm for exposure): used for distal
esophageal, GE junction and gastric lesions. Intrathoracic anastomosis most
common (but can be used with cervical anastomosis). Requires lung isolation
and epidural analgesia.
Ivor Lewis approach (consists of midline upper abdominal incision and right
thoracotomy): used primarily for cancer of the lower 2/3 of the esophagus.
Intrathoracic anastomosis most common (but can be used with cervical
anastomosis). Requires lung isolation and epidural analgesia.
McKeown (Three-hole) approach (right thoracotomy followed by simultaneous
upper abdominal and right anterior neck incision). Cervical anastomosis.
Requires lung isolation and epidural.
En Bloc resection entails resecting tumor bearing esophagus with a wide margin
of surrounding peri-esophageal tissue including pleura and pericardium. May be
performed via any open transthoracic approach.
Minimally invasive esophagectomy; any combination of laparoscopy,
thoracoscopy +/- neck incision.
There is no clear evidence for any approach being superior in terms of outcomes,
which is why all of these approaches continue to be practiced worldwide.
Surgeon comfort and experience are more important in determining outcome
than the particular approach itself and are a major consideration in why particular
approaches are chosen.
Irrespective of the actual approach, the extent of lymph node resection appears
to influence survival, as was shown in a small RCT comparing standard
transhiatal resection to en bloc transthoracic resection. This has been confirmed
in multiple population based registry studies which indicate that all-cause
mortality appears better in individuals who had a higher number of lymph nodes
resected.
Long-term outcomes for tumors located at the GE junction are not significantly
different between transhiatal and transthoracic approaches. More proximal
tumor locations are likely to derive a long-term survival benefit from a more
aggressive transthoracic lymph node resection. Short-term morbidity is
substantially reduced for patients undergoing transhiatal resections, with shorter
ICU and hospital stays and earlier return to a higher quality of life. Minimally
invasive approaches may further improve on this trend, however are not widely
practiced due to a significant operator learning curve and the fact that surgical
time may be extended significantly. Studies have shown substantially higher
operating room costs with minimally invasive esophagectomy, which translate
into higher overall hospital costs despite the overall shorter hospital stay when
compared to transhiatal and transthoracic approaches.
Epidural analgesia is the mainstay of postoperative pain control and is required
for all open approaches. Epidural analgesia may have additional benefits in
terms of anastomotic blood flow and has been shown to reduce the risk of
respiratory failure even after minimally invasive esophagectomy. Epidural
placement is established prior to anesthesia induction.
Lung isolation is required for intrathoracic approaches whether 3-hole or
thoracoabdominal but not transhiatal procedures. The provision of OLV in itself
has been shown to be a risk factor for acute lung injury. Protective one-lung
ventilation with low tidal volumes and PEEP is now widely accepted and has
been shown to reduce inflammatory markers during esophageal surgery. This is
particularly relevant considering that acute lung injury has been shown to occur
in 23% of elective esophagectomy patients, with 14% suffering the more severe
form of ARDS.
Further reading
Stiles, Brendon M, and Nasser K Altorki. "Traditional Techniques of
Esophagectomy." The Surgical clinics of North America 92, no. 5 (2012).
Levy, Ryan M, Dhaval Trivedi, and James D Luketich. "Minimally Invasive
Esophagectomy." The Surgical clinics of North America 92, no. 5 (2012).
Enestvedt, C K, K A Perry, C Kim, et al. "Trends in the Management of
Esophageal Carcinoma Based on Provider Volume: Treatment Practices of 618
Esophageal Surgeons." The Surgical clinics of North America 92, no. 5 (2012).
Sanghera, Sartaj S, Steven J Nurkin, and Todd L Demmy. "Quality of Life After
An Esophagectomy." The Surgical clinics of North America 92, no. 5 (2012).
Pennathur, Arjun, Michael K Gibson, Blair A Jobe, and James D Luketich.
"Oesophageal Carcinoma." Lancet 381, no. 9864 (2013).
Mariette, C, and G Piessen. "Oesophageal Cancer: How Radical Should Surgery
Be?" European Journal of Surgical Oncology (EJSO) 38, no. 3 (2012): 210-213
Ng, Ju-Mei. "Update on Anesthetic Management for Esophagectomy." Current
opinion in anaesthesiology 24, no. 1 (2011).
Zingg, Urs, Bernard M Smithers, David C Gotley, et al. "Factors Associated with
Postoperative Pulmonary Morbidity After Esophagectomy for Cancer." Annals of
surgical oncology 18, no. 5 (2011).
Pennefather, Stephen H. "Anaesthesia for Oesophagectomy." Current opinion in
anaesthesiology 20, no. 1 (2007).
McKevith, James M, and Stephen H Pennefather. "Respiratory Complications
After Oesophageal Surgery." Current opinion in anaesthesiology 23, no. 1 (2010).
Tandon, S, A Batchelor, R Bullock et al. "Peri-operative Risk Factors for Acute
Lung Injury After Elective Oesophagectomy." British journal of anaesthesia 86,
no. 5 (2001): 633-8.
Paul, Diana J, Glyn G Jamieson, David I Watson, Peter G Devitt, and Philip A
Game. "Perioperative Risk Analysis for Acute Respiratory Distress Syndrome
After Elective Oesophagectomy." ANZ journal of surgery 81, no. 10 (2011): 700-6.
Michelet, Pierre, Xavier-Benoît D'Journo, Antoine Roch, et al. "Protective
Ventilation Influences Systemic Inflammation After Esophagectomy: A
Randomized Controlled Study." Anesthesiology 105, no. 5 (2006): 911-9.
Leong Chau, Edmond Hung, and Peter Slinger. "Perioperative Fluid
Management for Pulmonary Resection Surgery and Esophagectomy."
Seminars in cardiothoracic and vascular anesthesia (2013).
Bussières, Jean S. "Open or Minimally Invasive Esophagectomy: Are the
Outcomes Different?" Current opinion in anaesthesiology 22, no. 1 (2009).
Dantoc, Marc M, Michael R Cox, and Guy D Eslick. "Does Minimally Invasive
Esophagectomy (MIE) Provide for Comparable Oncologic Outcomes to Open
Techniques? A Systematic Review." Journal of gastrointestinal surgery 16, no.
3 (2012).
de Boer, A G E M, J J B van Lanschot, J W van Sandick, J B F Hulscher, P F M
Stalmeier, J C J M de Haes, H W Tilanus, H Obertop, and M A G Sprangers.
"Quality of Life After Transhiatal Compared with Extended Transthoracic
Resection for Adenocarcinoma of the Esophagus." Journal of clinical oncology
22, no. 20 (2004):
Low, Donald E, Sonia Kunz, Drew Schembre, Henry Otero, Tom Malpass, Alex
Hsi, Guobin Song, Richard Hinke, and Richard A Kozarek. "Esophagectomy-it's Not Just About Mortality Anymore: Standardized Perioperative Clinical
Pathways Improve Outcomes in Patients with Esophageal Cancer." Journal of
gastrointestinal surgery 11, no. 11 (2007)..
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Dhamija, Anish, Ankit Dhamija, Jacquelyn Hancock, Barbara McCloskey,
Anthony W Kim, Frank C Detterbeck, and Daniel J Boffa. "Minimally Invasive
Oesophagectomy More Expensive Than Open Despite Shorter Length of Stay."
European journal of cardio-thoracic surgery
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