Technical Aspects of Esophagectomy and Controversies​

Author: Jason Muesse, MD
Institution: University of Arkansas
Date Reviewed: December 2024
Learning Domain: General Thoracic
Learning Objective: Esophagectomy approaches and technical considerations
PowerPoint File: Technical Aspects of Esophagectomy and Controversies​

Surgeon’s Role before Esophagectomy

• Set expectations. 
• Assess if patient will ever be a surgical candidate.
  • If not surgical candidate, radiation doses will be adjusted. 
• Feeding gastrostomy or jejunostomy may be required preoperatively
• Laparoscopic / Robotic placement is ideal
  •  Along fundus well away from right gastroepiploic artery
  • PEG is ok, but ideal placement can be confirmed with laparoscopy
  • Laparoscopy can help staging but not required
  • IR placed gastrostomy tube is probably the most problematic for future conduit 
    • Can pin omentum, colon, colonic mesentery in it or can can hit gastroepiploic artery among other things
• If answering board question, always go with jejunostomy tube
• Document distance of tumor from incisors preoperatively 
  • May be difficult to locate after neoadjuvant treatment
• Bronchoscopy for mid thoracic tumors, especially squamous cell
  • To rule out invasion into membranous portion of airway

Surgeon’s Role before Esophagectomy

• There are several ways to perform esophagectomy
• We will discuss most common
• There are many undecided “controversies” about different parts of esophagectomy
• Stomach is acceptable for use in 99 percent of cases for a conduit
• Alternative conduits can be used (separate talk)

Right gastroepiploic artery

• To get stomach to reach into chest, typically divide 4 out of 5 blood vessels supplying stomach 
• Right gastroepiploic artery is then the main blood supply to conduit
• If possible preserve some of right gastric artery 
• Preserve replaced hepatics if possible
• Rarely, may need the left gastric artery if right gastroepiploic is taken from prior surgery, GDA embolization, etc (limits length)

Indocyanine Green for Conduit Perfusion

• Becoming more widely available and utilized
• Use is easy with the robot (Firefly), also make other versions (Strkyer PIN POINT)
• Data shows some reduction in leak rates with use – in McKeown 193 pts, 10.4 % with v. 1.2 % w/o
  • Luo RJ, et al. Efficacy of Indocyanine Green Fluorescence Angiography in Preventing Anastomotic Leakage After McKeown Minimally Invasive Esophagectomy. Front Oncol. 2021 Jan 8;10:619822.

Ivor Lewis Esophagectomy

• Anastomosis made in right chest, ends up at about 25-30 cm from incisors ~at level of azygous vein
• Lower leak rate than other approaches but troublesom when they do leak into chest
  • (2 percent for thoracic anastomosis v 10 percent for cervical)
• Good for tumors in lower and low-mid esophagus (no higher than ~ 28 cm)
• Not ideal for tumor extending above azyous vein (anastomosis will end up lying right about at level of azygous

Transhiatal Esophagectomy

• Anastomosis made in neck to cervical esophagus
• Higher leak rate, but don’t leak in chest, mediastinitis is rare
  • Managed by opening neck wound
• Higher risk of left recurrent laryngeal nerve injury (and with McKeown) – 10 %
• Take caution with squamous cell tumors – can be adherent to airway
• Bleeding can be frustrating (azygous vein, aortic perforators etc)
• Good for poor medical condition patients, quicker, less painful
• Review Orringer’s fire drill for boards (bleeding sequence, airway injury sequence etc)

McKeown (3 hole) Esophagectomy

• Start in chest and mobilize esophagus
• Then place supine and mobilize stomach and make connection in neck (proceeds like a transhiatal esophagectomy at that point)
• Excellent lymph node yield (never proven though to improve survival)
• Takes longest
• Most painful
• Can be used for any cancers at any distance
• Robotic or thoracscopic mobilization may be used to reduce post operative pain.  
• Be careful with energy sources around airway

Sweet / Left Sided Esophagectomy

• Start in abdomen supine and then either flip to left side up 
  • Alternatively can prep one field and perform transabdominal incision
• Distance of esophageal tumor can resect is limited by the aortic arch at around 30 cm
• Places the gastric conduit halfway in the chest and halfway in abdomen
• Try to avoid this operation if possible 
  • Patients don’t empty well due to position of stomach
  • Have terrible reflux of bile and food due to half the stomach being in abdomen and half in chest
• Rarely Used anymore 
• Good to keep in the tool box especially for esophgectomy after gastric sleeve when all you have is the left and right gastric artery to supply conduit and you don’t need to go high (assuming pt is not candidate for alternative conduit)

Hand Sewn Anastomosis

Pro

• Seem to work well for those that do them regularly
• Adaptive to any situation (short esophagus or short conduit)
  • End to end may be only option if shortened stomach or esophagus, may have to hand sew
• Works for alternative conduits 

Con

• Difficult to reproduce (tissue quality and handling, suture spacing, suture material, one versus two layers, running versus interrupted etc)
• Associated with higher leak rate
• Associated with higher stricture rate

EEA Anastomosis

Pro

• Reproducible
• If leaks, seems to hold a stent better
• I think you can take better gastric margin with this method, better if have cardia involvement 

Con

• Stricture rate seems to be a little higher, especially if leak
• Need to use a 28 mm or bigger to avoid stricture
• Handle v. rib space in MIE
• Can leak anywhere circumferentially, but usually medially (adjacent to the airway)

Orringer / Linear Side to Side Anastomosis

Pro

• Reproducible
• Wide anastomosis that rarely strictures
• Works for alternative conduits 
• If leaks, is often covered with right lung or omentum and can divert drainage to the chest tube, away from airway
• Equal leak rate with EEA

Con

• Medium difficulty to reproduce (suture spacing, suture material, one versus two layers, running versus interrupted etc)
• Need a little more stomach and a little more esophagus to make anastomosis (about 4 cm overlap)
• Difficult to stent if leaks -> doesn’t hold a stent well due to wide anastomosis; use chest tube and Endovac or NGT decompression 

Collard Side to Side Anastomosis

Pro

• Particularly useful for cervical anastomosis if can’t get esophagus to overlay on to the stomach without tension
• Nice wide anastomosis 
• Rarely strictures unless leaks 

Con

• Puts tension at the “crotch” of the anastomosis
• Leaves a little “pouch” that is difficult to follow radiographragically (often confused with a leak)
• Medium Difficulty to reproduce (tissue quality and handling, suture spacing, suture material, one versus two layers, running versus interrupted etc)

Anastomotic Tips Summarized

• Use stay sutures liberally – place as soon as cut esophagus, mucosa runs back
• Make sure NGT moves before stapling
• Position NGT after stapling
• With linear stapler, cartridge goes in the lumen of the esophagus - (prob doesn’t matter)
• Keep conduit about 4 cm wide
  • I use Ethicon Green 60 staplers unless thick stomach / Medtronic purple
• Keep anastomosis away from gastric conduit staple line
  • I use Ethicon Gold load 60 stapler, inserted to about 50 mm or powered 29 mm EEA, can use Medtronic purple 
• Can close common channel in single layer, two layer or TA staple
• If using EEA, don’t use ≤ 28/29 mm stapler because stricture rate is too high
• Wrap in omentum if possible
• Soft silicone chest tube near anastomosis   
  • I use 24 F Blake drain medially sometimes, always a 24 F chest tube along the spine

Controversies in Esophagectomy

• Robotic and laparoscopic (MIE/minimally invasive) v open
• Anastomosis technique
• Pyloric drainage procedure
• Kocherize duodenum or not?
• Vagal sparing for benign etiology?
• Does lymphadenectomy matter?
• Prophylactic ligation of thoracic duct
• Feeding jejunostomy placement or not
• Early feeding versus judicious advancement
• Timing of removal of NG Tube
• Esophagram post op or not
• Wrapping anastomosis with omentum
• Surveillance imaging and EGD schedule

Oversew Gastric Staple Line?

• Gastric staple line leaks are terrible and difficult to manage
  • Hard to stent the body of the conduit
    • Usually just rely on chest tube, ±EndoVac
• Most MIE surgeons do no oversew their gastric staple lines (but many bariatric surgeons do in VSG)
• Data is limited.  
  • Largest study of 151 patients, In 83 patients (55.0%) the longitudinal gastric staple line was not oversewn (group A). In 68 patients (45.0%) the staple line was reinforced by invaginating sutures (group B).  In group A, a leak within the staple line was observed in 4 of 83 patients (4.9%). No leak was found in group B (p = 0.09). 
  • Silberhumer GR, Zacherl J. et al.  The value of protecting the longitudinal staple line with invaginating sutures during esophageal reconstruction by gastric tube pull-up. Dig Surg. 2009;26(4):337-41. 
• I prefer to Lembert suture / oversew gastric staple line with interrupted 3-0 SH silk 
• In training I oversewed it with 4-0 PDS RB-1 running fashion
  • Faster, but may contract conduit some

Keep Omental Flap off right gastroepiploic or minimize bulk?

• I believe this helps with venous drainage
• I personally believe this helps form adhesion in mediastinum and prevent para-conduit herniation later (MIE patients have higher herniation rates)
• I think magical omentum helps contain leaks and keep badness away from airway

Ji Gang Dai, Zai Yong Zhang, Jia Xin Min, Xiao Bing Huang, Jing Si Wang. Wrapping of the omental pedicle flap around esophagogastric anastomosis after esophagectomy for esophageal cancer, Surgery, Volume 149, Issue 3, 2011. Pages 404-410.

Pylorus 

• Vagotomy from esophagectomy expected to affect gastric empyting
• Poor emptying can result in conduit distension, food reflux and pneumonia
• Pyloromyotomy may have less reflux
• Pyloroplasty may loose some length (about 2 cm) on conduit
• I Mark site of pylorus with clips to identify radiographically
• Needle tip bovie and fine instruments can help 
• Wrap omentum (usually harvested from over right colon) on pylorus
• Can do botox as well if pt is high risk 

Pylorus Data 

• Overall, no strong evidence to support doing one specific intervention pylorus over another.  Most MIE surgeons do nothing. 
  • I like a pyloromyotomy.  If pt is higher risk or perforated, I use Botox
• About 20 percent of people have delayed conduit emptying when nothing is done; doesn’t seem to make much difference on periop complications
  • Zhang L, Lee H et al. Risk factors for delayed gastric emptying in patients undergoing esophagectomy without pyloric drainage. J Surg Res. 2017 Jun 1;213:46-50. 
• Botox seems to be a good compromise and should probably be done at minimimum
  • Fuchs HF, Horgan S et al. Intraoperative Endoscopic Botox Injection During Total Esophagectomy Prevents the Need for Pyloromyotomy or Dilatation. J Laparoendosc Adv Surg Tech A. 2016 Jun;26(6):433-8.
• Gastric POEM seems to a reasonable long term option if delayed emptying persists once recovered from esophagectomy

J tube or not J tube? 

• Used to be a necessity, now being used less
• J tube problems are a common source of readmission post op
• Not used by many MIE surgeons
• Would place one your board exams
• Be careful not to narrow jejunum when placing
  • I use a 14F red rubber catheter
• Type of J tube used needs to managed a little differently 
  • Red rubber catheter with tip split at end
    + lowest profile.  Cheap.  Readily available. Easy to “Witzel” into place. Fast closure.
    - Clogs easily.  Needs to be hand flushed every 8-12 hours.  Longest install time.
  • Balloon jejunostomy
    + more resistant to clogging due to silicone construction
    - Balloon can be source of obstruction of bowel, difficult to “Witzel” into place thus if just tack up bowel can act as a source of volvulus
  • Tunneled J tube w/ cuff
    + very resistant to clogging (I.D. is 9F silicone), Witzel into place, cuff helps hold in, best option by far for long term use
    - can require trip to OR to remove, wound packing
  • Seldinger type (Cook brand, etc) 
    + easy to place, seem to be resistant to clogging if large enough lumen    
    - Not always available, expensive, still have to tack bowel to abdominal wall, can be a little difficult to replace if clogged

J tube data

• 8632 pts, 3900 with J tubes. Overall, the rate of prolonged hospital stay (P=0.006), in-hospital mortality (P<0.001) and 30-day mortality (P<0.001) were significantly higher in patients without concurrent jejunostomy in both univariable and multivariable models. 
  • Watson M, Trufan S, Benbow JH, Gower NL, Hill J, Salo JC. Jejunostomy at the time of esophagectomy is associated with improved short-term perioperative outcomes: analysis of the NSQIP database. J Gastrointest Oncol. 2020 Apr;11(2):421-430.
• 229 pts, Patients in the FJT group had higher progression-free and overall survival compared to patients in the no FJT group (P = 0.041 and P = 0.033, respectively). A similar trend toward better survival in the FJT group was observed after propensity score matching.
  • Omori A, Tsunoda S, Nishigori T, Hisamori S, Hoshino N, Ikeda A, Obama K. Clinical Benefits of Routine Feeding Jejunostomy Tube Placement in Patients Undergoing Esophagectomy. J Gastrointest Surg. 2022 Feb 9.
• 188 pts, 135 w/ J tube. The use of a routine intraoperative jejunostomy appears to be an unnecessary step in patients undergoing MIE. Intraoperative jejunostomy placement is associated with complications without improving weight loss or perioperative outcomes. 
  • Kroese TE, Tapias L, Olive JK, Trager LE, Morse CR. Routine intraoperative jejunostomy placement and minimally invasive oesophagectomy: an unnecessary step?†. Eur J Cardiothorac Surg. 2019 Oct 1;56(4):746-753.

Prophylactic Thoracic Duct Ligation?

• UPMC Data and others suggests up to a 4 percent incidence of chylothorax without ligation
• Probably a good idea to ligate it if you see lots of fluid welling up in lower chest 
• I have found prophylactic ligation sometimes hurts more than helps (cisterna chyli leak X2)
• Remember drainage from right upper half of body comes from different drainage system (if you see fluid in paratracheal region, might not help to ligate thoracic duct – thoracic duct crosses around T5-T6)
• If 653 patients, 325 had mass ligation with incidence of chylothorax of 0.3 percent, compared to 1.2 percent in unligated group
  • Li X et al . Prevention of chylothorax complicating extensive esophageal resection by mass ligation of thoracic duct: a random control study. Ann Thorac Surg. 2011 Jun;91(6):1770-4.

Does systematic thoracic lymphadenectomy improve survival? 

• Really a debate over Ivor Lewis/McKeown versus transhiatal esophagectomy 
• No doubt that improves staging
• Now that adjuvant chemo and immunotherapy are options – may be more important to know status of the thoracic lymph nodes

Is minimially invasive esophagectomy superior to open Esophagecotmy (updated 1.7.24)

• Until 2024 there was hard to prove a benefit
• STS Esophagectomy Risk Calculator Released in 2024 seemed to show a benefit in mortality and morbidity with exact same patients undergoing miniminlly invasive resection versus open resection
  • https://www.sts.org/resources/esophagectomy-cancer-risk-calculator
    • This data was based on General Thoracic Surgery Data Base from January 2015 to December 2022
    • Closest reference paper is 
    • Velotta JB, Seder CW, Bonnell LN, Hayanga JA, Kidane B, Inra M, Shahian DM, Habib RH; Society of Thoracic Surgeons General Thoracic Surgery Database Task Force. 2024 Update of The Society of Thoracic Surgeons Short-term Esophagectomy Risk Model: More Inclusive and Improved Calibration. Ann Thorac Surg. 2024 Oct;118(4):834-842.

Importance or preoperative nutritional assessment cannot be understated 

• G tubes or J tubes can be placed laparoscopically or robitically allowing for visualization of liver structure and omentum to look for metastatic disease
• Recent studies recommend peritoneal washing to be performed for GE junction tumors 
• On board exam, always answer jejunostomy tube if a preoperative feeding tube is needed
  • Always the right answer and never the wrong answer
• In practice, gastrostomy tubes placed well away from gastroepiploic artery are safe and easier to use for patients with feeding tube related issues
  • Blind PEG tubes can be dangerous if hit unintended structures and can risk seeding periteoneum because dragging tumor cells through esophagus to the abdominal wall, also can damage right gastroepiploic vessels
  • Interventional radiology placed G tube require inflating stomach with gas, so must be able to pass NGT (impossible with obstructing tumors) also risk damage to colon or right gastroepiploic vessel  

More Controversies in Esophagectomy...

• NGT use and duration
• Early feeding 
• Esophogram or not? 
• Checking drain amylase
• Kocherize duodenum or not?
• Vagal sparing for benign etiology?
• Surveillance imaging schedule
• Is routine surveillance EGD necessary?

What I’ve learned so far…

• Try not to perform esophagectomy on patients who are smoking
• If look like they are getting worse on chemo, reconsider surgery and rely heavily of imaging
• Ideally we like to operate 5-10 weeks after completion of chemoradiotherapy.   Sometimes patients who are not ready at 5 weeks will be markedly better at 10 weeks. 
• Must have good social support to tolerate post op period.  Especially when they have complications.