What is an esophagectomy?

Esophagectomy: Surgical Removal of the Esophagus

Esophagectomy is a major surgical procedure involving the removal of all or part of the esophagus, typically performed for the treatment of esophageal cancer, with reconstruction using a gastric conduit or other tissue to restore continuity of the gastrointestinal tract. 1

Indications

Esophagectomy is primarily indicated for:

• Resectable esophageal and esophagogastric junction (EGJ) cancers
• Specific stages of disease:
  • T1-T3 tumors are considered resectable, even with regional nodal metastases 1
  • T4 tumors with involvement of pericardium, pleura, or diaphragm may be resectable 1
  • Early-stage (T1a) esophageal adenocarcinoma, though endoscopic therapy is now preferred for this stage 1

Contraindications

Esophagectomy is contraindicated in:

• T4 tumors with involvement of heart, great vessels, trachea, or adjacent organs (liver, pancreas, lung, spleen) 1
• Distant metastases, including non-regional lymph node involvement 1
• EGJ tumors with supraclavicular lymph node involvement 1
• Patients who are not physiologically fit to tolerate major thoracic and abdominal surgery 1
• Cervical esophageal cancers less than 5 cm from the cricopharyngeus (these should be treated with definitive chemoradiation) 1

Surgical Approaches

Several surgical approaches are available:

1. Ivor Lewis Esophagectomy: Laparotomy + right thoracotomy; recommended for distal esophageal and EGJ tumors 1, 2

2. McKeown Esophagectomy: Right thoracotomy + laparotomy + cervical anastomosis 1

3. Transhiatal Esophagectomy: Laparotomy + cervical anastomosis without thoracotomy; associated with lower morbidity but potentially less thorough lymph node dissection 1, 3

4. Minimally Invasive Approaches:

   • Minimally invasive Ivor Lewis (laparoscopy + limited right thoracotomy)
   • Minimally invasive McKeown (thoracoscopy + limited laparotomy/laparoscopy + cervical anastomosis)
   • Robotic-assisted esophagectomy 1

5. Left Transthoracic Approach: Used primarily for distal esophageal lesions 1

Technical Considerations

• Conduit Options:

  • Gastric conduit (preferred) 1, 2
  • Colon interposition
  • Jejunum 1

• Lymph Node Dissection:

  • At least 15 lymph nodes should be removed for adequate staging in patients not receiving induction chemoradiation 1, 2
  • Can be performed using standard or extended (en bloc) technique 1
  • The number of lymph nodes removed is an independent predictor of survival 1

• Gastric Conduit Preparation:

  • Complete mobilization of the stomach while preserving blood supply
  • Preservation of the gastroepiploic and right gastric arteries
  • Division of the left gastric artery with lymph node dissection 2

Postoperative Complications

Esophagectomy is associated with significant morbidity, including:

1. Pulmonary Complications: Most common and serious complications 4, 5

   • Pneumonia
   • Respiratory failure
   • Acute respiratory distress syndrome

2. Anastomotic Complications:

   • Leaks (major cause of morbidity and mortality) 6
   • Strictures (can occur in up to 40% of cases) 2

3. Conduit-Related Issues:

   • Necrosis
   • Delayed emptying
   • Reflux 6

4. Other Complications:

   • Recurrent laryngeal nerve injury
   • Chylothorax
   • Wound infections 7

Perioperative Management

• Enhanced Recovery After Surgery (ERAS) protocols have been developed specifically for esophagectomy to improve outcomes 7

• Pretreatment nutritional support should be considered for patients with significant dysphagia and weight loss 1

• Enteral nutrition via jejunostomy feeding tube is preferred over gastrostomy tube 1

• Strategies to reduce pulmonary complications include:

  • Minimally invasive approaches when appropriate
  • Optimal pain management (typically epidural analgesia)
  • Early mobilization
  • Respiratory physiotherapy 4, 5

Emerging Trends

• Minimally Invasive Esophagectomy (MIE): Associated with decreased morbidity and shorter recovery times compared to open procedures, though long-term oncologic outcomes are still being evaluated 1

• Endoscopic Therapy: For early-stage cancers (T1a), Barrett's esophagus with high-grade dysplasia, and intramucosal adenocarcinoma, endoscopic mucosal resection (EMR) with or without ablation is now preferred over esophagectomy 1

• Salvage Esophagectomy: Can be considered for patients who develop localized, resectable esophageal recurrence after definitive chemoradiation if no distant recurrence is present 1

Esophagectomy remains a complex procedure that should be performed in high-volume centers by experienced surgeons to minimize morbidity and mortality 1.