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What are the contraindications to Transhiatal Esophagectomy?
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| Our clinical experience with Transhiatal Esophagectomy (THE) at the University of Michigan Medical Center now includes more than 1,000 patients operated upon during the last 20 years. Of all esophagectomies (both for benign and malignant disease), 9 7%are performed using the transhiatal method. In 3%, a transthoracic approach has been required. For patients with esophageal carcinoma, an absolute contraindication to THE is documented tracheobronchial invasion by a mid- or upper-third tumor. In patients with documented distant metastatic disease, even an apparent solitary small hepatic metastasis, we will not perform an esophagectomy since survival with stage IV esophageal carcinoma averages six months, and these patients invariably have a greater tumor burden than is apparent on pre-operative assessment, their complication rate is higher, and the benefit of operation is so short-lived that I do not believe that the risk of a major esophageal resection is justified. The most important contraindication to THE is the surgeon's assessment upon palpation of the esophagus through the diaphragmatic hiatus that tumor invasion into adjacent vital structures or severe periesophageal adhesions to the aorta or tracheobronchial tree preclude performance of a safe transhiatal resection. An esophagectomy for benign disease is typically technically more difficult than that for carcinoma since in the former patient a history of multiple prior esophageal operations is common and periesophageal fibrosis is often more prominent. |
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2.
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What are the basic preoperative studies in patients being considered for THE for carcinoma?
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| The history and physical examination remains basic in the evaluation of the patient with esophageal carcinoma. Particularly important historical points include the duration of symptoms, the extent of weight loss, symptoms raising the possibility of metastatic disease (epigastric pain radiating to the back suggesting celiac neural invasion, bone pain, or neurologic symptoms), and pulmonary symptoms from aspiration due to the esophageal obstruction. Physical findings are generally absent, but cervical and supraclavicular adenopathy justifies a fine needle aspiration for cytology; if stage IV disease is documented in this fashion, esophagectomy is contraindicated. Many patients are referred with an endoscopy and biopsy report but no barium esophagogram. The latter study is important in localizing the tumor and relating it to adjacent structures (e.g., the tracheobronchial tree or aorta), defining the length of the tumor, the axis of the esophagus in the region of the tumor, and the degree of narrowing of the lumen. The CT scan of the chest and upper abdomen is currently the cornerstone of our staging evaluation. This study better than any other shows the relationship of the esophageal tumor to contiguous structures and identifies possible distant metastatic disease (which should be corroborated with a fine needle aspiration and tissue diagnosis before the patient is denied an operation). It bears emphasis, however, that contiguity of the esophageal tumor and the adjacent aorta, for example, is not synonymous with invasion, and many tumors which appear to be "unresectable" on the basis of CT findings prove to be resectable at operation. I do not personally use esophageal ultrasonography routinely in my practice, since on the basis of esophagoscopy, the barium swallow, and CT findings, I am relatively accurately able to determine which tumors are resectable. Since the advent of ultrasound probes now small enough to pass through the work channel of a bronchoscope, however, esophageal ultrasonography may become much more reliable and possible in the majority of patients with esophageal carcinoma. Bronchoscopy is a fundamental study in the evaluation of patients with upper- and middle-third esophageal carcinomas which may invade the tracheobronchial tree. Anterior bowing of the posterior membranous trachea at bronchoscopy does not equate with actual tracheal invasion that excludes an esophagectomy. |
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3.
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Does preoperative chemotherapy and radiation therapy have a role in the treatment of esophageal carcinoma?
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| Although the majority of published reports have been anecdotal, the majority representing phase II (non-randomized) trials, growing evidence suggests improved survival after preoperative radiation therapy and chemotherapy, particularly in those patients rendered T0N0 ("complete responders"). Unfortunately, only approximately 25-30% of patients so treated have no residual tumor within the resected esophagus, and therefore radiation and chemotherapy cannot yet be relied upon to eradicate esophageal carcinoma. At the present time, we offer chemotherapy and radiation therapy preoperatively in a protocol setting to those operable patients with esophageal carcinoma who are physically able to withstand this rigorous treatment. Our findings are consistent with those of others who report that esophageal adenocarcinoma and squamous cell carcinoma respond to combined chemoradiation therapy equally well. Each year we see patients whose oncologist has treated their esophageal carcinoma with chemotherapy and radiation therapy alone declaring esophagectomy unnecessary. When local tumor recurrence again results in dysphagia and a "salvage esophagectomy" is requested, the surgeon is dealing with established radiation fibrosis, and the esophagectomy may be a formidable undertaking. There is, in my opinion, no justification at this time for using combination chemotherapy/radiation therapy alone as primary treatment for esophageal carcinoma in those in whom the tumor is resectable. |
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4.
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Are there special "tips" for minimizing intraoperative disasters associated with THE?
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| The intraoperative "disaster" feared most during transhiatal esophagectomy is bleeding from injury to either the aorta or azygos vein. While such a complication can certainly occur, as greater experience with THE is gained, the procedure be comes less of a "blind" esophagectomy. Rather, with deep retractors within the diaphragmatic hiatus, paraesophageal tissues are identified under direct vision, clamped with extra long (13") right angle clamps, divided and ligated. The only truly "blind" part of THE is the subaortic dissection, and if the fingers are kept closely applied to the esophagus, major bleeding is simply not a frequent complication. In fact, intraoperative bleeding with the now seldom exceeds 500 ml., and we no longer cross match blood for these patients. For patients with benign esophageal disease undergoing THE, periesophageal adhesions may lead to major bleeding. This is particularly true in patients who have had a prior esophagomyotomy, since the exposed submucosa typically becomes adherent to the descending thoracic aorta, and a very deliberate effort must be made to visualize and dissect the area of the myotomy away from the aorta in the process of the transhiatal dissection. The patient undergoing a THE for achalasia may have larger than usual aortic esophageal vessels nourishing the hypertrophied esophageal muscle. Particular attention must be paid to identifying and ligating these vessels during the esophagectomy to avoid major postoperative bleeding from the esophageal bed. With middle- third esophageal tumors and in the patient with benign disease who has had multiple prior esophageal operations, the surgeon must have a low threshold for discontinuing the transhiatal approach and converting to a transthoracic esophagectomy if the difficulty of the dissection suggests that it is unsafe to proceed with the transhiatal dissection. Maintaining the dissection against the esophagus in the upper mediastinal dissection minimizes the incidence of injury to the tracheobronchial tree, which occurs in less than 1% of patients undergoing THE. Avoidance of placement of any metal retractors against the tracheoesophageal groove during the neck dissection similarly avoids recurrent laryngeal nerve injury that may be a disastrous intraoperative complication that does not manifest itself until the postoperative period when the patient begins to experience life-threatening aspiration due to impaired vocal cord function and neuromotor upper esophageal sphincter dysfunction. Of patients, 75% require one or more chest tubes because of entry into one or both pleural cavities during THE; this is determined by direct inspection and palpation of both sides of the mediastinal pleura through the diaphragmatic hiatus once the esophagectomy has been completed. |
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5.
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What are the most common postoperative complications associated with THE and how are they best managed?
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| Recurrent laryngeal nerve injury associated with transhiatal esophagectomy results from traction against the tracheoesophageal groove during the cervical portions of the operation. Prevention is the best treatment. We use only a finger, not a metal retractor, to retract the trachea and thyroid gland medially during the cervical portion of the operation. Our incidence of recurrent laryngeal nerve injury is less than 3%, and the injury is generally transient. Chylothorax after an esophagectomy may be a disastrous occurrence since the nutritionally depleted patient can ill afford the loss of protein and lymphocytes which occurs with a high output chyle leak. This complication has occurred in 2% of our patients. If a thoracic duct leak results in a loss of chyle in the range of 400-600 ml. per eight hour shift after two or three days of a low residue elemental tube feeding diet, a transthoracic ligation of the thoracic duct should be undertaken relatively quickly. Such an aggressive approach is almost always successful and is certainly preferable to conservative management of a chylothorax, which in a patient who has undergone an esophagectomy for carcinoma, is associated with a 50% mortality.
While a cervical esophagogastric anastomotic leak is seldom a fatal complication in contrast to an intrathoracic esophageal anastomotic leak, it is nonetheless a serious complication. Approximately 30% of patients who experience a cervical esophagogastric anastomotic leak ultimately develop an anastomotic stricture for which chronic dilation therapy is necessary. This is not a good outcome in a patient who has undergone a major operative procedure to relieve dysphagia. Once again, prevention is the best treatment of a cervical esophageal anastomotic leak. The tendency when performing a THE is to focus upon the esophageal resection as the critical portion of the operation. While this part of the operation is certainly important, the most critical part of the operation is construction of the cervical esophagogastric anastomosis. As we have gained more experience with this operation, it has become clear that avoidance of an anastomotic leak is possible if trauma to the stomach is kept at a minimum. While the tip of the gastric fundus reaches to the neck in virtually every patient, it is relatively ischemic as a result of the gastric mobilization which requires division of the left gastroepiploic and short gastric vessels as well as the left gastric artery. I no longer suture the tip of the gastric fundus to a drain which is then used to draw the stomach through the mediastinum. Most often, I simply manipulate the stomach through the posterior mediastinum with one hand until the gastric fundus can be grasped gently with Babcock clamp inserted through the cervical wound and drawn into the neck. While I initially advocated suspension of the gastric fundus from the cervical prevertebral fascia, I no longer utilize this technique, as a few of our patients have developed cervical vertebral osteomyelitis from seeding of the intervertebral disc by sutures used to tack the stomach to the cervical prevertebral fascia. Rather than suspend the mobilized stomach from t he cervical prevertebral fascia, after positioning the tip of the gastric fundus behind the divided cervical esophagus, the posterior esophageal wall is sutured to the anterior gastric wall with three 4-0 absorbable sutures, and the anastomosis is then constructed several centimeters distal to this point on the anterior gastric wall. A 1.5 to 2 cm. vertical gastrotomy is performed, and after amputating the stapled end of the divided cervical esophagus, a single layered interrupted 4-0 absorbable suture manual anastomosis is carried out. All knots are tied on the inside of the lumen until the final three or four anterior sutures, for which the knots are tied on the outside. Nasogastric tube decompression for approximately three days is routine. Using this anastomotic technique, the incidence of postoperative leak has fallen to under 3%.
Postoperative pulmonary complications following THE are infrequent if the patient is properly prepared preoperatively. It is my practice not to proceed with an esophagectomy until the patient has totally discontinued cigarette smoking for a minimum for two weeks before surgery. All of our patients are issued an incentive inspirometer to begin home chest pulmonary physiotherapy prior to surgery, and they also walk one to two miles a day. They come to the hospital for surgery "conditioned" to walk and breath deeply and with the expectation that active participation in deep breathing and ambulation will facilitate an early discharge from the hospital.
Herniation of intestine through the diaphragmatic hiatus alongside of the intrathoracic stomach may occur in the early postoperative period or several years after the esophagectomy. This complication is avoided by narrowing the diaphragmatic hiatus with heavy nonabsorbable sutures until the hiatus will only accommodate three fingers alongside of the intrathoracic stomach. In addition, several 3-0 sutures can be used to secure the stomach t o the edge of the diaphragmatic hiatus, and then the liver capsule is secured to the edge of the diaphragmatic hiatus to further prevent migration of bowel into the chest.
A gastric drainage procedure (a pyloromyotomy is most optimal) is performed routinely after THE to prevent problems with gastric outlet obstruction associated with pylorospasm from the vagotomy.
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6.
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What are the most important points about the immediate postoperative care of the patient?
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For years it was our practice to utilize mechanical ventilatory assistance the night of the operation and to then extubate the patient the following day. The theoretic rationale was that:
- The status of vocal cord function would not be immediately apparent, and the patient who was extubated "too early" might experience life-threatening aspiration with swallowing.
- If the nasogastric tube malfunctioned shortly after surgery, the patient with a dilated intrathoracic stomach and a suppressed gag reflex following prolonged general anesthesia might experience regurgitation and aspiration pneumonia.
- A small percentage of patients develop traumatic bronchorrhea after their esophagectomy, and early extubation postoperatively would not provide optimal pulmonary hygiene.
Despite these theoretic considerations, managed care pressure to decrease length of stay and utilization of costly resources has caused us to change our postoperative routine rather dramatically during t he past year. Our patients are well prepared preoperatively by routine abstinence from cigarette smoking and use of an incentive inspirometer. If the operation has proceeded uneventfully (3-4 hour duration, 500 ml. or less of blood loss), the endotracheal tube is removed at the conclusion of the operation, and the patient no longer goes to the intensive care unit. This approach has been used very successfully in our last 50 patients undergoing THE. The use of epidural anesthesia has greatly diminished postoperative wound discomfort and splinting that interferes with proper pulmonary hygiene. Nasogastric tube decompression of the intrathoracic stomach is maintained for three days after which point a clear liquid diet is begun, followed the next day by a full liquid diet, and then a mechanical soft diet. There is no rationale for keeping these patients NPO, since they are swallowing 1-1.5 liters of saliva a day beginning as soon as they awaken from general anesthesia. A feeding jejunostomy tube is routine in our patients undergoing THE. On the third postoperative day, jejunostomy tube feedings are begun. Once the volume of tube feedings is adequate, the intravenous is discontinued, and ambulation is encouraged with the patient having been instructed how to disconnect the jejunostomy tube from the tube feedings temporarily so that unencumbered movement is possible. A postoperative barium swallow examination is obtained routinely between 7 and 10 days after operation to be
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