Oesophagectomy

The following are “knows” from the syllabus

• Resection/reconstruction options

Approaches

• Two stage
• Three stage
• Trans-Hiatal

Ivor-Lewis Oesophagectomy

• Ivor-Lewis Oesophagectomy
  • Laparotomy and Right Lateral Thoracotomy
  • GA with single lung ventilation
• Op Viva
  • Abdominal portion
  • Thoracic portion

Abdominal Portion

• Laparosopic or open
  • Rooftop incision, Fixed – table retraction – Adjuncts overview
• Check for peritoneal or nodal disease
• Mobilise stomach
  • Greater curve
    • Entering lesser sac through gastrocolic ligament, proceeding towards spleen first, then towards duodenum.
    • Take care to preserve the right gastroepiploic vessel
    • Divide all posterior adhesions so stomach can slide
    • Divide short gastrics (place pack behind spleen to bring forward)
  • Mobilise lesser curve.
  • Kocherise duodenum
  • Lymphadenctomy
    • Divide Left gastric vessels at origin and perform lymphadenctomy
      • Left Gastric, Coeliac, Common Hepatic, proximal splenic
• Conduit
  • Create the gastric conduit with multiple firing of a stapler parallele to the GC with proximal aspect going toward apex of fundus
  • Aim 5cm margin distal to GEJ. If radioRx, may need a 5cm margin from field for healing
  • Suture conduit to transected oesophagus in correct orientation to allow pull through into the thorax if thoroscopic
• GOJ dissection
  • Develop space between crura up into mediastinum.
  • Divide a rim of diaphragm around the hiatus, including the crura themselves, so that a circumferential rim is resected with the oesophagus.
  • Resect pleura bilaterally along oesophagus.
  • Mobilise the lower 1/3 of oesophagus from pericardium and aorta up to level of tracheal bifurcation – all tissue from anteriorly is taken enblock up to pericardium
• Consider insertion of a feeding jejunostomy
• Consider pyloroplasty because you have interrupted vagal input (100U of botox in 4 quad at NSH)
• 2 drains.
• Close abdomen.

Thoracic Portion

• Position
  • Left lateral decubitus position and break table to spread ribs – held by bean bag/supports.
    • Right arm on padded rest, left arm stretched in front.
• Incision
  • Right Posterolateral thoracotomy 4th/5th rib space:
    • Curvilinear incision from spinous process of T3, inferior to tip of scapula, then forward to 3-4cm below right nipple
  • Divide through muscles and enter 4th intercostal space. Excise 1 inch of posterior aspect of 5th rib to allow retraction of the rib cage
  • Insert Finichetto retractor and ask anaesthetist to collapse lung
• Mobilise
  • Divide inferior pulmonary ligament
  • Retract lung forward to expose posterior mediastinum
• Dissection
  • Pleura incised anterior to esophagus, along posterior edge of pericardium up to azygous arch and down to hiatus posteriorly along the aortic edge
  • Divide pleura anterior to azygous and divide azygous vein
  • Incircle the oesophagus and put a Penrose drain around it
  • Dissection of thoracic oesophagus to proximal extent with en bloc resection of surrounding fatty tissue containing nodes
  • Careful not to injure the Vagus, L) main bronchus, phrenic nerve, thoracic duct
    • Out my institution we take the Thoracic duct just above the level of the aortic hiatus
  • Transect proximal oesophagus
• Anastomose
  • Anastamosis via side-to-side with purple endoGIA stapler
  • Close the common enterotomy hand-sewen
  • Ensure no tension, fire stapler.
  • Omemntum inbetween bronuch and join
  • Close opening in lesser curve and oversew entire staple line
  • Alternatively do handsewn anastomosis with interrupted single all layer 3/0 vicryl
• Insert 2 chest drains between 8th and 9th intercostal spaces, anterior one to apex near anastomosis, and posterior one to lower chest.
• Approximate ribs and close wound in layers
• Pass NG tube into duodenum.
  • Routine NG necessary until bowel function returns
  • Prevents tracheal acid aspiration and may prevent respiratory complications

Trans-Hiatal Oesophagectomy

• Has fallen out of favour given concern of inadequate LN harvest in chest
• Trans-hiatal approach with cervical incision
• Indications:
  • Carcinoma of hypopharynx/cervical oesophagus (+ neck dissection)
  • Intraepithelial SCC /high grade Barrett’s
  • If unable to be treated with treated with EMR
• Does not remove mediastinal LNs
• Abdominal incision and through hiatus, then stomach pulled up, left cervical incision to perform anastomosis
• Pros:
  • Avoids leak into chest, quicker
  • No sig difference in survival between operations
• Cons:
  • Higher rate of strictures (blood supply poorer)
  • Risk to great vessels & airway from blind pull of conduit through mediastinum
• Mortality 4%, leak rate 3%

Three Phase Oesophagectomy (McKeown)

• En-bloc Oesophagectomy
• Aggressive with radical Thoracic & Abdominal Lymphadenectomy & WLE
• Removes
  • Azygous
  • Hemiazygous
  • Intercostal veins
  • Thoracic Duct
• 3 incisions (left neck, right chest, abdomen)
• Cervical anastomosis
• Mortality 4.5%, morbidity 50%, leak 8%
• No improvement in 5YS but has demonstrated increased morbidity

Lymphadenectomy Fields in Oesophagectomy

• Three-field Lymphadenectomy
  • Removal of the first and second fields along with a neck dissection clearing the Brachiocephalic, deep lateral and external Cervical nodes, as well as right and left Recurrent Nerve lymphatic chains (deep anterior cervical nodes)
• Two-field Lymphadenectomy
  • Removal of Para-aortic nodes, right and left pulmonary hilar, Paraoesophageal nodes, Subcarinal and Right Paratracheal nodes
• One-field Lymphadenectomy
  • Removal of Diaphragmatic, Right and Left paracardiac, Lesser Curvature, Left Gastric, Coeliac, Common Hepatic and Splenic Artery nodes

Route of Reconstruction

• Pre-sternal
  • Only if both other routes compromised by previous reconstructions
• Retrosternal
  • Used if emergency treatment of anastomotic dehiscence causing posterior mediastinal sepsis
• Posterior mediastinal
  • Preferred rout

Presternal Route

• Historical only
• Longest route
• 4cm longer than posterior mediastinal
• 2cm longer than retrosternal
• Only indication is if both other routes compromised by previous reconstructions

Retrosternal Route

• Potential space between sternum and anterior mediastinum developed
• 2cm longer than posterior mediastinal
• Unnatural position of cervical oesophagus in front of trachea, causes unpleasant sensation when swallowing
• Used for reconstruction when anastomotic leak causes posterior mediastinal sepsis

Posterior Mediastinal Route

• Preferred route of reconstruction in primary surgical excision of the oesophagus
• Shortest route between abdomen, apex of thorax and neck
• Gastric or colonic substitutes easily passed through posterior mediastinum after completion of mediastinal dissection in thorax
• No attempt made to close pleura

Organ of Reconstruction

• Determined by site of the primary lesion
• Should be kept as simple as possible
• Stomach
• Colon
• Jejunum

Reconstruction Using Stomach

• Best conduit if anatomy allows

• Five broad principles and practices to prepare stomach as conduit

  • Use isoperistaltic stomach maintaining vascular supply
  • Excision of the lesser curve
  • Preservation of the intramuscular vascular arcade
  • High point of the stomach
  • Gastric Drainage

• Additional methods of stomach lengthening

  • Kocher manoeuvre
  • Excision of lesser curve of stomach
  • Incision of serosa on gastric wall

• Isoperistaltic stomach maintaining vascular supply

  • Right Gastroepiploic and Right Gastric Arteries and Veins are vital to stomach viability when used as conduit
  • Greater omentum opened
    • Gastroepiploic Artery is carefully identified and preserved
  • Vascular arcade interrupted at point where right gastroepiploic meets Left
  • Short Gastrics ligated and divided

• Excision of the Lesser Curve
  • Any cancer of lower 2/3 oesophagus requires clearance of lesser curve nodes
    • +Left gastric, common hepatic, and proximal splenic A nodes
  • Left Gastric Artery should be ligated at its origin
  • Resect proximal ½ of lesser curve, including cardia
    • Preserve Right Gastric
      • Maintains intramural vascular network
  • Aim gastric conduit 5cm width or greater
    • Less risk ischaemia

• Preservation of the Intramuscular Vascular Arcade

  • Extensive intramuscular anastomoses exist between greater and lesser curves
  • Need to maintain this by not resecting too much of lesser curve
    • Maintain right gastric supply to lesser curve
  • Take care when ligating short gastrics, do away from greater curvature to avoid damage to intramural network
  • Fundus blood supply from Right Gastroepiploic Artery through this intramural arcade
    • Important as this is the region for anastomosis

• High Point of the Stomach

  • Stomach very flexible
  • High point is the logical place for anastomosis
  • Easily identified
  • Traction in upward direction after all mobilisation complete

• Gastric Drainage
  • Pyloroplasty or pyloromyotomy contentious
    • Some evidence pyloroplasty reduces incidence of gastric outlet obstruction
    • Minimal short-term complications
  • Pyloroplasty routinely done by Companion series authors
    • Reduces early life-threatening complications of:
      • Gastric stasis and aspiration
    • And late complications of
      • Vomiting and bloating
  • Heineke-Mikulicz Pyloroplasty
    • Longitudinal incision, closed horizontally

Reconstruction Using Colon

• Indications

  • Tumours needing extensive oesophageal and gastric resection
    • NB: With thorough staging, very few are actually suitable for resection
  • Previous gastric resection
  • Can consider if failed gastric conduit (necrosis) in initial attempted anastomosis

• Colon recommended over jejunum as gives larger reservoir

• Disadvantage

  • Function of the conduit deteriorates over time
  • Not as durable as stomach in the long term

• Aim to use isoperistaltic segment depending on individual variations in vascular anatomy

  • Transverse Colon based on Left Colic vessels
    • Cannot perform if Marginal Artery not sufficient at Splenic Flexure
  • Right Colon based on Middle Colic vessels

• Technical Considerations

  • Colonoscopy and CT-Angio prior
  • Pre-op mechanical bowel prep and PO antibiotic cover to sterilise bowel for 48hrs pre-op
  • Free omentum from hepatic flexure, transverse, splenic flexure
  • Mobilise entire colon to deliver outside, to inspect blood supply
  • Sigmoid mobilisation gives length to tunnel transverse to chest
  • Divide proximal colon, make anastomosis to oesophagus, then get rid of redundancy by anchoring sutures to hiatus
  • Re-establish continuity of colon (end-to-end anastomosis)
  • Perform colo-jejunostomy or colo-gastrostomy with the conduit

Reconstruction Using Jejunum

• Third choice after stomach and colon

• Can do

  • Roux-en-Y
  • Segmental interposition
  • Free jejunal transfer with microvascular anastomosis
    • If high in the neck

• Anastomotic Principles

  • Adequate blood supply
  • Tension free
  • Epithelial to epithelial approximation
  • Precise layer to layer sutures
  • No difference in single/double layer
  • No difference in sutures/staples
  • ? wrap with transposed omentum

Post-operative care

• Standardised unit pathway/ERAS
• HDU/ICU
• Fluid balance
• Epidural analgesia
• Early, intensive physiotherapy
• Antithrombotic measures
• Routine PPI
• Early nutrition from jejunostomy (day 1)
• Antibiotics 48hrs
• Gastrograffin swallow check after 4-5 days
  • NB: No evidence for this to be done routinely
  • Companion series suggest only do if sepsis, effusion or haemodynamic instability
  • But ⇒ Most people do anyway
• Begin PO feeding after this, COFs > FOFS

Complications of Surgery

• 60% get complications
  • Clavien-Dindo ≥ 3 17%
  • 30-day mortality 2%
  • 90-day mortality 4.5%
• Generic
  • Pneumonia 14%
  • Cardiac 17%
  • AF 15%
  • DVT/PE
  • CVA
  • Haemorrhage - rare
• Specific
  • Anastomotic leak 12%
  • 3% get anastomotic leak needing intervention
  • Conduit necrosis 1.2 %
  • Chyle leak 4-5%
  • RLN palsy 4%
  • Trache-oesophageal fistula 1%
  • Gastric outlet obstruction
  • Dumping syndrome
  • Duodeno-gastro-oesophageal reflux
  • Benign anastomotic stricture

Long Term Issues

• GORD 60%
• Diarrhoea 50%
• Bloating 45%
• Dysphagia 40%
• Dumping Syndrome 15%

Anastomotic Leak and Leak from Gastric Conduit

• Early leak (48-72hours)
  • Technical fault
  • If condition of patient good – reoperate to correct fault
• Late leak (5-10 days)
  • Usually due to conduit ischaemia or tension on anastomotic line
  • If leak at the oesophagogastric join
    • Operating at this time is hazardous and often detrimental
    • Use intensive non-operative management
      • NG decompression
      • Radiologically guided percutaneous drains – chest and mediastinum
      • Antibiotics
      • Jejunostomy feeding
      • Don’t stent
    • Late anastomotic leakage does not result in high mortality
  • If leak at Gastric resection line dehiscence
    • Need to re-operate as large amounts of leakage
  • Anastomotic leak, cervical oesophagogastrostomy ≈ 20%
    • Can drain

Conduit Necrosis

• Can be catastrophic complication
• Must diagnose early with endoscopy
• Resuscitate
• IV abx
• Return to theatre
  • Exclude with cervical oesophagostomy
  • Close viable gastric remnant
  • Place feeding jejunostomy (if haven’t already)
• Once stable – colonic interposition

Chylothorax

• Fat absorption
• Transthoracic 2-3%, trans-hiatal up to 10%
• Apparent by day 7
  • Increase in chest fluid after commencement of diet
• Results in massive malnutrition, immunosuppression and reduction in CD4 count due to loss of WCC/fat nutrition
• Chyle = intestinal lymphatic fluid enriched with fat
  • Confirm by measuring TAG concentration of drain output
• Low output leak < 500ml/day
  • Treat with enteral feed with medium chain fatty acids or TPN
    • Thoracic duct should transport 4L/day
• Large leak
  • Should be managed with return to OT and ligation of thoracic duct
• Prophylactic abx with Cotrimoxazole (covers pneumocystis)

RLN Palsy

• At risk during cervical oesophagectomy or high anastomosis
• Usually only unilateral – usually contralateral nerve can compensate
• Unilateral RLN injury
  • Varying degrees of hoarseness
  • Microaspiration
  • Coughing
  • Other symptoms seriously affecting patients’ quality of life
• Bilateral RLN injuries
  • May induce aphonia
  • Dyspnoea
  • Asphyxia
  • Can be life threatening

Gastric Outlet Obstruction

• Prevented by routine pyloroplasty
• Always bring entire stomach conduit into chest
• Prevents changes of pressure across stomach
• Low dose erythromycin or metoclopramide can reduce effects

Other Complications

• Dumping Syndrome
  • Relatively common but most resolves in 12 months
  • Manage by avoidance of high carb loads
• Duodeno-gastro-oesophageal reflux
  • Common, can be acid or alkaline reflux
  • Control with motility agents and PPI
  • Symptoms can be troublesome
  • More common for thoracic anastomosis than cervical
• Benign anastomotic stricture
  • Common
  • Usually respond to single dilation