A detailed dicussion on surgical procedures & steps to be followed during surgery for Carcinoma esophagus. Source- Schwartz's Principles of Surgery, 9th Edition

1. Surgeries for
Carcinoma Esophagus
Dr. Loveleen Garg
Junior Resident, Deptt. of Surgery

2. Anatomy
• 25 cm long muscular tube
• Extends from lower border of cricoid to
stomach
• C6 to T11
• 3 constrictions

4. Contd…
• ESOPHAGUS is mainly studied in 3 parts:
– CERVICAL
– THORACIC
– ABDOMINAL

5. Relations of cervical Esophagus
• Anteriorly- trachea
• Posteriorly- prevertebral muscles an fascia
covering 6th to 8th cervical vertibrae
• Laterally- carotid sheath, lower poles of the
thyroid gland
• The thoracic duct is found on left side at C6
level

6. Relations of abdominal part
• Very short segment of variable length
• Anteriorly- esophageal groove on posterior
surface of the liver
• Related to greater sac anteriorly and on the
left.
• Lesser sac peritoneum found on the right side
• Closely related to the vagus nerves

8. Blood supply
• CERVICAL PART- Inferior thyroid artery
• THORACIC PART- Bronchial and esophageal
branches of the descending aorta
• ABDOMINAL PART- Ascending branches of the
left phrenic and left gastric arteries.

9. Venous drainage
• Submucosal plexus
Periesophageal venous plexus
Esophageal veins
• CERVICAL- Inferior thyroid vein
• THORACIC- Azygos vein, Hemiazygos veins,
Intercostal veins, Bronchial veins
• ABDOMINAL- Left gastric vein
• Porto systemic anastomosis

10. Nerve supply
• ENTERIC NERVOUS SYSTEM-
– Auerbach’s plexus in the intermuscular plane
– Meissner’s plexus in the submucosal plane
• EXTRINSIC NERVOUS SYSTEM-
– Parasympathetic supply from the vagus via
recurrent laryngeal nerves
– Sympathetic supply from thoracic spinal cord
segments

11. Lymphatic drainage
• Lymphatic plexuses in submucosa and muscularis
regional lymph nodes
• Cervical esophagus-
– Paratracheal,
– Deep cervical,
– Internal jugular nodes
• Thoracic part-
– Mediastinal nodes,
– Paratracheal,
– Subcarinal,
– Retro cardiac
– Infracardiac lymph nodes
– Thoracic duct.

12. Carcinoma Esophagus

13. TNM Staging

14. Tumors of cervical esophagus
• Cervical esophageal cancer is frequently
unresectable because of early invasion of the
larynx, great vessels, or trachea.
• Radical surgery including esophagolaryngectomy
may occasionally be performed for these lesions.
• High morbidity.
• Stereotactic radiation with concomitant
chemotherapy is the most desirable treatment.

15. Tumors of middle third esophagus
• Squamous carcinomas most commonly and are
frequently associated with LN metastasis (thorax,
neck or abdomen)
• Midthoracic ca + abdominal LN mets incurable
with surgery.
• Isolated cervical LN metastases can be resected.
• T1 and T2 cancers without LN metastases are
treated with resection only.
• LN involvement or transmural cancer (T3)
neoadjuvant chemoradiation therapy followed by
resection.

16. • Resection of midesophageal cancer should be
performed under direct vision with either
thoracoscopy [video-assisted thoracic surgery
(VATS)] or with thoracotomy.

17. Tumors of the lower esophagus
• Tumors of the lower esophagus and cardia are
usually adenocarcinomas.
• If possible, resection in continuity with a LN
dissection should be performed.
• Because of the propensity of GI tumors to spread
for long distances submucosally, long lengths of
grossly normal GI tract should be resected.
• Local recurrence at the anastomosis can be
prevented by obtaining a 10-cm margin of normal
esophagus above the tumor.

18. • Considering that the length of the esophagus
ranges from 17 to 25 cm, and the length of the
lesser curvature of the stomach is
approximately 12 cm, a curative resection
requires a cervical division of the esophagus
and a >50% proximal gastrectomy in most
patients with carcinoma of the distal
esophagus or cardia.

19. Exclude surgery
• Factors that make surgical cure unlikely
include
– advanced stage of carcinoma,
– Tumor >8 cm in length,
– Abnormal axis of the esophagus on a barium
radiogram,
– >4 enlarged LNs on CT,
– weight loss more than 20%, and loss of appetite.

20. Advanced stage
• Advanced stage of ca esophagus:
– recurrent nerve paralysis,
– Horner's syndrome,
– persistent spinal pain,
– paralysis of the diaphragm,
– fistula formation, and
– malignant pleural effusion.

21. Functional Grades of Dysphagia
• Grade I- Eating normally.
• Grade II- Requires liquids with meals.
• Grade III- Able to take semisolids but unable
to take any solid food.
• Grade IV- Able to take liquids only.
• Grade V- Unable to take liquids, but able to
swallow saliva.
• Grade VI- Unable to swallow saliva.

22. Surgical Treatment
• The surgical treatment of esophageal cancer is
dependent upon the
– location of the cancer,
– the depth of invasion,
– LN metastases,
– the fitness of the patient for operation,
• Esophagectomy should not be performed if an
R0 resection is not possible.

23. MUCOSALLY BASED CANCER
• In patients with BE, and especially with high-
grade dysplasia, subcentimeter nodules should
be resected, as they often harbor
adenocarcinoma.
• EMR done with very high-resolution EUS offers
another method for removing intramucosal
cancer.
• Tumors invading the submucosa are generally not
felt amenable to EMR because of the high-
frequency (20 to 25%) concurrent finding of
positive LNs.

24. Steps of EMR
• The area beneath the nodule is infiltrated with saline
through a sclerotherapy needle.
• A specialized suction cap is mounted on the end of the
endoscope and the nodule is drawn up into the cap,
following which a snare is applied to resect the tissue.
• Alternatively, a rubber band can be delivered and the snare
can be used to resect above the level of the rubber band.
This specimen is then removed and sent to pathology.
• As long as the tumor is found to be confined to the mucosa
and all margins are negative, the resection is complete.
• A positive margin or involvement of the submucosa
warrants esophagectomy.

25. • Routine surveillance on a 3- to 6-month basis
must be continued indefinitely due to high risk
for developing small nodular carcinomas
elsewhere in Barrett's segment.
• Radiofrequency ablation of the remainder of
the high-grade dysplasia can be done.

27. MINIMALLY INVASIVE TRANSHIATAL
ESOPHAGECTOMY
• Minimally invasive transhiatal esophagectomy
is an increasingly popular procedure.
• This combines the advantages of transhiatal
esophagectomy at minimizing pulmonary
complications with the advantages of
laparoscopy (less pain, quicker rehabilitation).
• For the earliest lesions, such as high-grade
dysplasia or intramucosal carcinoma vagal
sparing procedure can be entertained.

28. • MIS transhiatal esophagectomy is usually performed through
five or six small incisions in the upper abdomen and a
transverse cervical incision for removing the specimen and
performing the cervical esophagogastrostomy.
• To remove the esophagus from the posterior mediastinum,
especially the area behind the pulmonary vessels and the
tracheal bifurcation, which cannot be visualized even with a
long laparoscope placed in the posterior mediastinum, it is
preferred to use a vein stripping "inversion" technique.
• It include the laparoscopic creation of a 4-cm neoesophagus
(gastric conduit) along the greater curvature of the stomach
using the right gastroepiploic artery as the primary vascular
pedicle.

29. • The conduit can be created through a mini-laparotomy
or laparoscopically.
• A Kocher maneuver releases the duodenum, and a
pyloroplasty may be performed (optional).
• Retrograde esophageal stripping is performed by
dividing the esophagus below the GEJ and sliding a
vein stripper from the neck down into the abdomen
followed by an inversion of the esophagus in the
posterior mediastinum and removal through the neck.
• This technique is reserved for patients with high-grade
dysplasia and only microscopically detectable cancer.

31. • For small cancers at the GEJ, the esophagus can be stripped
in an antegrade fashion by sliding the vein stripper down
from the cervical incision and out the tail of the lesser
curvature. The tail of the lesser curvature is pulled out a
port site high in the epigastrium and used as a wound
protector while the esophagus is inverted on itself.
• For GEJ cancers, a wide celiac access LN dissection, splenic
artery, hepatic artery, and posterior mediastinal LN
dissection can be performed better than through a
laparotomy.
• The gastric conduit is pulled up to the neck with a chest
tube and anastomosed to the cervical esophagus in an end-
to-side fashion using a surgical stapler or with a handsewn
anastomosis.

34. • This method of esophagogastrectomy may
mitigate the need for intensive care unit care,
and shorten the hospitalization to the time
necessary for anatomic healing.
• Complications of this technique have been
rare and primarily limited to leak from the
esophagogastric anastomosis, which is self-
limited and usually heals within 1 to 3 weeks,
spontaneously.

35. OPEN TRANSHIATAL ESOPHAGECTOMY
• Transhiatal esophagectomy, also known as blunt
esophagectomy or esophagectomy without a
thoracotomy, was popularized in the last quarter of
the twentieth century by Mark Orringer.
• This operation may violate many of the principles of
cancer resection, including extended radical LN
dissection.
• The elements of dissection are similar to that
described in the Minimally Invasive Transhiatal
Esophagectomy including the creation of the gastric
tube and the posterior mediastinal dissection
through the hiatus.

36. • Because this dissection is performed with the fingertips
rather than under direct vision with surgical
instruments, it requires an enlargement of the
diaphragmatic hiatus.
• The lower mediastinal LN basins can be resected as can
the upper abdominal LNs, making this an attractive
option for GEJ cancers. The mediastinal LNs above the
inferior pulmonary vein are not removed with this
technique, but rarely result in a point of isolated cancer
recurrence.
• Of all procedures for esophageal cancer, this operation
is the quickest to perform in experienced hands and
lies in an intermediate position between minimally
invasive esophagectomy and the Ivor Lewis procedure
with respect to complications and recovery

39. MINIMALLY INVASIVE TWO- AND THREE-
FIELD ESOPHAGECTOMY
• Minimally invasive esophagectomy using a thoracic
dissection through VATS has become reasonably popular.
• This operation is performed with an anastomosis created in
the neck (three-field), but may be performed with the
anastomosis stapled in the high thorax (two-field). Both
procedures will be described.
• With a minimally invasive three-field esophagectomy, the
patient is placed in the left lateral decubitus position.
Double lumen intubation is required.
• Videoscopic access to the thorax is obtained in the
midaxillary line in the ninth intercostal space and an angled
telescope illuminates the chest superiorly.

40. • A mini-thoracotomy at about the sixth intercostal
space anteriorly allows introduction of conventional
surgical instruments, and a high trocar allows
retraction of the lung away from the esophagus.
• In a three-field approach, the esophagus is dissected
out along its length to include division of the azygos
vein and harvesting of the LNs in the upper, middle,
and lower posterior mediastinum.
• Hilar, aortopulmonary window, and posterior
mediastinal nodes are all removed and sent with the
specimen or individually.
• The thoracic duct is divided at the level of the
diaphragm and removed with the specimen.

41. • Following complete intrathoracic dissection, the
patient is placed in the supine position and five
laparoscopic ports are placed as with the MIS
transhiatal esophagectomy.
• The abdominal portions of the operation are identical
to those described previously in the section Minimally
Invasive Transhiatal Esophagectomy, and the gastric
conduit is then sewn to the tip of the fully mobilized
GEJ and lesser curvature sleeve.
• A feeding tube is placed and the pyloroplasty may be
performed laparoscopically if the surgeon feels so
inclined.

42. • A transverse cervical incision and dissection between
the sternomastoid and the anterior strap muscles
allows access to the cervical esophagus.
• Great care is made to avoid stretching the recurrent
laryngeal nerve.
• The esophagus and proximal stomach is then pulled
up into the neck with the gastric conduit following.
Cervical anastomosis is then performed.

43. • In MIS transthoracic two-field esophagectomy is slightly different,
the abdominal portions of the operation are done first, including
placement of the feeding tube, the creation of the conduit, and the
sewing of the tip of the conduit to the fully dissected GEJ.
• The patient is then rolled into the left lateral decubitus position
and, through right thoracoscopy, the esophagus is dissected out
and divided 10 cm above the tumor.
• Once freed, the specimen is pulled out through the mini-
thoracotomy and an end-to-end anastomosis stapler is introduced
through the high corner of the gastric conduit and out a stab wound
along the greater curvature.
• The anvil of the stapler is placed in the proximal esophagus and
held with a purse-string, the stapler is docked, the anastomosis is
created, and a gastrotomy is then closed with another firing of the
GIA stapler.

44. • The three-field esophagectomy has the advantage of
placing the anastomosis in the neck where leakage is
unlikely to create a severe systemic consequence.
• On the other hand, placement of the anastomosis in the
high chest minimizes the risks of injury to structures in the
neck, particularly the recurrent laryngeal nerve.
• Although the leak of the intrathoracic anastomosis may be
more likely to bear septic consequences, the incidence of
leak is diminished. Other complications of this approach
relate to pulmonary and cardiac status.
• In many series, the most common complication is
pneumonia, the second is atrial fibrillation, and the third is
anastomotic leak.

45. IVOR LEWIS (EN BLOC) ESOPHAGECTOMY
• The theory behind radical transthoracic
esophagectomy is that greater removal of LNs and
periesophageal tissues diminishes the chance of a
positive radial margin and LN recurrence.
• Although there are no randomized data demonstrating
this to be superior to other forms of esophagectomy,
there are many retrospective data demonstrating
improved survival with greater numbers of LNs
harvested.
• As a time-honored operation, there is no doubt that en
bloc esophagectomy is the standard to which less
radical techniques must be compared.

46. • Generally, this operation is started in the abdomen with an upper
midline laparotomy and extensive LN dissection in and about the
celiac access and its branches, extending into the porta hepatis and
along the splenic artery to the tail of the pancreas.
• All LNs are removed en bloc with the lesser curvature of the
stomach.
• Unless the tumor extends into the stomach, reconstruction is
performed with a greater curvature gastric tube.
• For GEJ cancers extending significantly into the gastric cardia or
fundus, the proximal stomach is removed and reconstruction is
performed with an isoperistaltic section of left colon between the
upper esophagus and the remnant stomach, or the colon is
connected to a Roux-en-Y limb of jejunum, if total gastrectomy is
necessary.
• In the majority of cases, colon interposition is unnecessary, and a 4-
cm gastric conduit is used.

47. • Following closure of the abdominal incision, the patient is placed in
the left lateral decubitus position and an anterolateral thoracotomy
is performed through the sixth intercostal space.
• The azygos vein is divided and the posterior mediastinum is entirely
cleaned out to include the thoracic duct, all periaortic tissues, and
all tissue in the upper mediastinum along the course of the
recurrent laryngeal nerves and in the peribronchial, hilar, and
tracheal LN stations.
• The proximal stomach is pulled up into the thorax where a conduit
is created (if not performed previously) and a handsewn or stapled
anastomosis is made between the upper thoracic esophagus and
the gastric conduit or transverse colon.
• Chest tubes are placed, and the patient is taken to the intensive
care unit.

48. • Complications are most common and includes
– pneumonia,
– respiratory failure,
– atrial fibrillation,
– chylothorax,
– anastomotic leak,
– conduit necrosis,
– Gastrocutaneous fistula, and
– if dissection is too near the recurrent laryngeal nerves,
hoarseness or other vocal cord dysfunction.
– Tracheobronchial injury resulting in fistulas between
the bronchus and conduit may also occur rarely.

49. • Although this procedure and three-field
esophagectomy are fraught with the highest
complication rate, the long-term outcome of
this procedure provides the greatest survival.

50. THREE-FIELD OPEN ESOPHAGECTOMY
• Three-field open esophagectomy is very similar to a
minimally invasive three-field except that all access is
through open incisions.
• This procedure is preferred by certain Japanese
surgeons and LN counts achieved through this kind of
operation may run from 45 to 60 LNs.
• Most Western surgeons question the benefit of such
radical surgery when it is hard to define a survival
advantage.
• Nonetheless, high intrathoracic cancers probably
deserve such an aggressive approach if cure is the goal.

51. SALVAGE ESOPHAGECTOMY
• "Salvage esophagectomy" is the nomenclature applied
to esophagectomy performed after failure of definitive
radiation and chemotherapy.
• The most frequent scenario is one in which distant
disease (bone, lung, brain, or wide LN metastases)
renders the patient nonoperable at initial presentation.
• Then, systemic chemotherapy, usually with radiation of
the primary tumor, destroys all foci of metastasis, as
demonstrated by CT and CT-PET, but the primary
remains present and symptomatic.

52. • Following a period of observation, to make sure no
new disease will "pop up," salvage esophagectomy is
performed, usually with an open two-field approach.
• Surprisingly, the cure rate of salvage esophagectomy is
not inconsequential. One in four patients undergoing
this operation will be disease free 5 years later, despite
the presence of residual cancer in the operative
specimen.
• Because of the dense scarring created by radiation
treatment, this procedure is the most technically
challenging of all esophagectomy techniques.