Esophageal Cancer Operations

Mark F. Berry
Rebecca A. Schroeder

Key Points

1. Esophagectomy is associated with considerable morbidity and mortality despite improvements in surgical technique and perioperative care.

2. The optimal technique in a particular patient depends on specific patient characteristics as well as surgeon- and center-specific experience and preference more than tumor morphology or staging.

3. Multimodal anesthetic management utilizing thoracic epidural analgesia, protective ventilation, prevention of tracheal aspiration, and judicious fluid management helps reduce postoperative morbidity, particularly pulmonary complications and anastomotic leakage.

Case Vignette

A 65-year-old male patient who presents with advanced Barrett esophagus is scheduled to undergo an esophagectomy. He has a long standing history of gastroesophageal reflux, a 20 pack-year history of smoking and consumes 2 to 4 drinks per night.

His only medication is omeprazole.

Vital signs: BP 140/80, HR 80, RA SpO₂ 94%.

Laboratory examination is notable only for marginally elevated AST and ALT. An exercise-stress echocardiogram was normal.

Esophageal cancer is the most common indication for esophagectomy. The incidence of esophageal cancer is increasing and the epidemiology is changing such that adenocarcinoma, which is linked to obesity and gastroesophageal reflux disease, is now more common than squamous cell carcinoma. Mortality following esophagectomy has decreased but still exceeds that of most surgical procedures and long-term survival remains poor. Consequently, it is of critical importance to minimize perioperative morbidity in any manner possible. Esophageal resection can be performed via several different techniques, with the most appropriate technique for any specific individual patient being dependent on both patient and surgeon factors.

ESOPHAGEAL CANCER

Epidemiology

With less than 14,000 new cases annually in the United States, esophageal cancer is relatively uncommon. However, its incidence is steadily increasing and its epidemiology is changing significantly.^1–3 Recent evidence indicates that the incidence among white males has almost doubled while the incidence among blacks has decreased by almost 50%.¹

Esophageal cancers are differentiated by histologic type and location, but also have many features in common. More than 90% of esophageal cancers in the United States are either adenocarcinomas (57%) or squamous cell carcinomas (37%).^1,3 The distribution of tumor types varies according to race: 64% cases in whites are adenocarcinomas, while among the black population, 82% are of squamous cell origin.¹ Tobacco use and a history of mediastinal radiation are risk factors for both tumor types. Other risk factors for adenocarcinoma include gastroesophageal reflux disease (GERD), obesity, and Barrett esophagus. Barrett esophagus with high-grade dysplasia is considered a premalignant condition as 50% are found to harbor occult malignant disease at the time of biopsy.⁴ Additional risk factors for squamous cell carcinoma are conditions that cause chronic esophageal irritation and inflammation such as alcohol abuse, achalasia, esophageal diverticuli, and frequent consumption of extremely hot beverages.² Tumor location also distinguishes these two common cell types. Approximately three quarters of all adenocarcinomas are found in the distal esophagus, whereas squamous-cell carcinomas are more evenly distributed throughout the distal two-thirds.² Survival rates are similar for patients with either adenocarcinoma or squamous cell carcinoma regardless of treatment modality, suggesting that both cell types share significant physiologic and cellular features.⁵ Overall 5-year survival for patients with esophageal cancer remains poor, although some improvement has been achieved with an increase from 5% to 17% over the last four decades.¹

Clinical Presentation and Workup

The most common presenting symptoms of esophageal cancer are dysphagia (74%) and weight loss (57%) with less common symptoms being heartburn, odynophagia, shortness of breath, chronic cough, hoarseness, and hematemesis.⁶ The physical examination is usually unremarkable.² A contrast study of the upper gastrointestinal (GI) tract is usually the initial diagnostic study and typically shows a stricture or ulceration when malignancy is present. Upper GI endoscopy is usually part of the initial workup and often shows a friable, ulcerated mass, which is then biopsied for pathologic examination. A computed tomographic (CT) scan of the chest, abdomen, and pelvis with intravenous contrast should be obtained when esophageal cancer is detected to evaluate for distant metastatic disease. Positron-emission tomography scans improve staging and will detect previously unsuspected metastatic disease in up to 15% of patients.⁷ The extent of loco-regional disease is defined by the depth of tumor invasion and the extent of lymph-node involvement, and may be evaluated with endoscopic ultrasound.²

STAGING AND PROGNOSIS

Staging of esophageal cancer has been defined by the American Joint Committee on Cancer Staging System, 6th edition. This system establishes tumor-node-metastasis (TNM) subclassifications in which the primary tumor (T) is defined by depth of invasion (Figure 17–1), lymph node involvement (N) is defined as present or absent, and extent of metastatic disease (M) is noted as none, regional or distant. The current system is described in Tables 17–1A and 17–1B.⁸ The likelihood of nodal metastases is almost zero in TIS lesions, but increases with increasing depth of invasion and as many as 50% patients with T1 lesions will have lymph node involvement.^9,10 At the time of diagnosis, approximately 50% of patients have evidence of distant metastatic disease.^1,2

Figure 17–1. Definition of T stage for esophageal cancer.

Table 17–1A. Esophageal Cancer Staging: Definitions

Table 17–1B. Esophageal Cancer Staging: Classification System

Survival is related to the stage at diagnosis and subsequent treatment. Current short- and long-term survival rates are listed in Table 17–2.^1,2 In general, patients who undergo complete resection of their cancer have a 5-year disease-free survival of 32%, while for patients with residual disease following surgical resection, overall survival is less than 5%.¹¹

Table 17–2. Surgical Treatment of Esophageal Cancer and Long-Term Outcomes

Treatment Options

Choice of treatment for esophageal cancer depends heavily on stage and tumor location. However, as outcomes remain poor with all strategies, most remain somewhat controversial and an area of active research.¹² Treatment options include local mucosal therapies, esophagectomy, chemotherapy, and radiation therapy. Mucosal treatments such as endoscopic mucosal resection, photodynamic therapy, or radiofrequency ablation are considered for patients with carcinoma in situ or high-grade dysplasia but are not appropriate for patients with stage-T1 (or greater) disease due to the likelihood of lymph node involvement. For patients with stage I-III disease who receive surgical treatment, 5-year survival is 28%, compared to 10% for those treated medically.¹³ Therefore, primary nonsurgical treatment should be reserved for those who refuse surgery, have unresectable tumors, or are not thought to be surgical candidates for other reasons. Patients with distant metastatic disease (M1b) generally receive palliative treatment with chemotherapy and possibly radiation. To summarize, esophagectomy with chemotherapy and radiation therapy as possible adjuncts should be considered for all patients other than those who are stage T0 or IVb.

Most patients with T1-2 (stage I-II) esophageal cancer without lymph node involvement undergo surgery without other preoperative treatment.¹⁴ Patients with T3, N1, and M1a (stage III or IVa) disease who are resection candidates are considered for induction therapy and then surgery. Use of either induction chemotherapy or radiation alone followed by surgery does not improve survival compared with surgery alone.^11,15,16 However, patients who receive induction chemotherapy and radiation therapy followed by surgery may have a modest survival advantage compared with surgery alone.^12,17–20 Postoperative radiation alone may reduce the incidence of local recurrence in those patients who have residual tumor after resection but is not beneficial in the absence of residual disease.^2,21,22 Postoperative chemotherapy has not been shown to have an additive effect on survival compared with surgery alone, although additional therapy may be warranted in patients who have a high likelihood of metastatic disease based on a large number of tumor positive nodes.²³

Techniques of Esophagectomy

Resection of the esophagus for malignancy is a very complex procedure. The esophagus traverses three body regions or cavities and the anatomy of the esophagus in the posterior mediastinum is such that its accessibility is very different at different positions in the chest. In addition, an appropriate conduit must be prepared in order to reestablish gastrointestinal continuity, and this conduit must be placed in a location such that its blood supply will remain viable. Esophageal resection generally requires access to at least two body cavities, and often requires at least two incisions and patient repositioning intraoperatively. Structures at significant risk include the spleen, trachea, and main stem bronchi as well as major vascular structures in the chest.

The most common surgical techniques used for esophagectomy are listed in Table 17–3. Minimally invasive techniques with either laparoscopy and/or thoracoscopy have been reported for most approaches (except the left thoracoabdominal approach). The final approach chosen for a particular patient depends on surgical experience and preference, institutional tradition and patient characteristics. Relevant factors include stage of disease, associated lesions such as Barrett esophagus or achalasia, other medical comorbidities, pulmonary function, and previous surgical history. In general, a proximal and distal disease-free margin of at least 5 cm should be achieved; thus, the location of the tumor is a critical factor in determining the surgical approach.^12,24 Also, as the total number of lymph nodes involved and removed is an important predictor of survival, the transthoracic approaches may be preferred over others that do not provide equivalent access to the relevant nodes.^23,25–27

Table 17–3. Characteristics of the Different Esophagogastrectomy Procedures

Surgeons overwhelmingly choose to use the stomach as the final conduit and the majority of these patients have good or excellent functional results.²⁸ On the other hand, the colon may be the conduit of choice if the patient has had prior gastric surgery or another disqualifying condition such as diabetic gastroparesis. Its use carries similar morbidity and mortality and provides good long-term eating capability.^29,30

The optimal location for the esophageal anastomosis after resection (cervical versus intrathoracic) is controversial, although almost 60% are placed in the cervical region.²⁸ The advantages of a cervical anastomosis include better access for a wider primary esophageal resection, avoidance of highly morbid thoracotomy incisions, and less severe postoperative symptoms of reflux.^12,31 Conversely, advantages of an intrathoracic anastomosis include a lower incidence of anastomotic leak and injury to the recurrent laryngeal nerves as well as a lower risk of postoperative stricture formation.^12,31,32 In the current era, mortality associated with cervical and intrathoracic leaks is similar, although intrathoracic leaks are more likely to require surgical intervention.^12,31,33,34

Specifics for each surgical technique are described below with advantages and disadvantages listed in Table 17–4. In general, all patients undergo preoperative upper endoscopy to confirm tumor location prior to resection; patients with tumors in the mid-esophagus should have bronchoscopy to rule out airway involvement. A nasogastric (NG) tube should be placed prior to the start of the procedure to assist with esophageal mobilization and is manipulated during the procedure as requested and guided by the surgical team. Also, a jejunostomy feeding tube is placed at the end of the procedure, as there is often a delay in the return of normal eating during the postoperative period.

Table 17–4. Advantages and Disadvantages of Specific Esophagogastrectomy Procedures

THREE-INCISION ESOPHAGECTOMY (MCKEOWN)

The three-incision esophagectomy or modified McKeown approach combines left cervical, right thoracic, and abdominal incisions (Figure 17–2A). This approach is especially useful for tumors of the mid and upper esophagus and for tumors where a long Barrett segment is present. The patient is initially positioned in the left lateral decubitus position for a right thoracotomy or thoracoscopy. One-lung ventilation (OLV) is instituted for the thoracic portion of the case. The esophagus is mobilized from the thoracic inlet to the esophageal hiatus and a lymph node dissection performed. Azygous vein and recurrent laryngeal nerve injury are significant risks during this portion of the procedure. The thoracic incisions are closed after placement of a chest tube and the patient is repositioned in the supine position with a roll under the scapula to extend the neck, and the head turned to the right to maximally expose the left neck. An upper midline laparotomy or laparoscopy is then performed and the esophageal hiatus is mobilized.

Figure 17–2. Incisions used for esophagectomy. A. Three-Incision; B. Transhiatal; C. Ivor-Lewis; D. Left Thoracoabdominal.

The third and final incision, a left cervical incision, is then made and the cervical esophagus is dissected free in the neck. The recurrent laryngeal nerve is again at significant risk at this point. The nasogastric tube is partially withdrawn and the cervical esophagus is divided. A suture or a rubber drain is fastened to the distal end of the divided esophagus and the distal esophagus is withdrawn through the esophageal hiatus into the abdominal incision. The prepared gastric conduit is then pulled back through the hiatus and up into the neck with care to avoid torsion. The cervical anastomosis is then performed and the NG tube is guided through the anastomosis under direct supervision by the surgical team.

TRANSHIATAL ESOPHAGECTOMY

The transhiatal esophagectomy combines left cervical and abdominal incisions. (Figure 17–2B) This approach is probably ideal for patients with Barrett and high-grade dysplasia where lymph node dissection is not as critical for staging purposes. The abdominal portion of this procedure is performed as described above for the three-incision technique. The hiatus is dilated, and the surgeon’s hand is inserted into the mediastinum to bluntly dissect the esophagus free from other intrathoracic structures. A cervical incision is then made, and the esophagus is dissected in a similar manner from the neck into the chest but with special care to avoid injury to the recurrent laryngeal nerve. After complete esophageal mobilization, the esophagus is divided and the anastomosis is performed in the neck as described above for the three-incision technique.

IVOR-LEWIS ESOPHAGECTOMY

The Ivor-Lewis esophagectomy resembles the modified McKeown approach, but involves only two incisions: right thoracic and upper abdominal. (Figure 17–2C) Although it also requires OLV, the Ivor Lewis begins with the patient in the supine position for laparotomy or laparoscopy for preparation of the gastric conduit. The gastric tube is then advanced into the chest as far as possible and the abdomen is closed. The patient is then repositioned in the left lateral decubitus position for right thoracotomy or thoracoscopy. In the chest, the esophagus is mobilized and divided. The gastric conduit is pulled further into the chest and the anastomosis performed. The thoracotomy or thoracoscopy incisions are closed after placement of a chest tube.

LEFT THORACOABDOMINAL ESOPHAGECTOMY

The left thoracoabdominal approach can be performed with acceptable morbidity and mortality, but is only considered for patients with tumors limited to the distal esophagus, and even in those cases is associated with high rates of residual disease.³⁵ This approach necessitates OLV, and the patient is positioned in the right lateral decubitus position but with the abdomen rolled back approximately 45°. A thoracoabdominal incision is made along the 7th intercostal interspace across the costal margin, and the diaphragm is taken down circumferentially from the chest wall (Figure 17–2D). Esophageal and gastric mobilization and resection are performed as described for the Ivor-Lewis technique but with reconstruction of the diaphragm prior to closure.

Anesthetic Management for Esophagectomy Procedures

Anesthetic care is an important component of the multidisciplinary approach to management of esophagectomy patients that has been shown in clinical studies to improve perioperative. Good results have been achieved with multimodal care plans utilizing thoracic epidural analgesia, early extubation, early mobilization, and a restrictive approach to fluid management.^36,37 Other anesthetic concerns include preoperative assessment, the need for OLV, management of intraoperative events including dysrhythmias, hemorrhage and airway injury, and use of protective ventilation strategies. In addition, it is important to be aware of the specific surgical plan, as each approach to esophagectomy has its own requirements and implications for the anesthesia care team.

General Considerations

In general, patients presenting for esophagectomy for malignant disease have significant comorbidities and these will guide preoperative assessment and the need for invasive monitoring to a greater degree than the procedure itself. Invasive arterial blood pressure monitoring is routinely used both for blood gas sampling during OLV and for continuous blood pressure measurement during procedures that may involve significant dysrhythmias or sudden changes in cardiac output or blood loss. Central venous pressure monitoring is not routinely used, but if necessary, should be placed in the great veins on the right-hand side in cases in which a cervical anastomosis is planned.

Prior to surgical incision, an NG tube should be placed and left either to intermittent low suction or to gravity drainage. In cases of an obstructing lesion, most surgeons will still request an NG tube be placed in the proximal esophagus to assist with the cervical dissection. As discussed above, prior to stapling or dividing the distal esophagus, the NG tube should be withdrawn either into the pharynx or as specifically directed by the surgical team, and then advanced through the esophageal anastomosis, again under direct surgical supervision. When the tube is in final position, it should be firmly secured to avoid displacement during extubation or patient transfer or movement. It is also helpful to place a reference mark on the tube itself so that it can be easily determined if its position has changed.