Continuing Education Activity

Transhiatal esophagectomy is an alternative to the three incisions Ivor Lewis esophagectomy, which aims to provide decreased morbidity and improve clinical outcomes by a lower pulmonary complication risk. The procedure is performed with an abdominal and a cervical incision and allows mobilization of the stomach as a conduit to the cervical esophagus. This activity reviews the transhiatal esophagectomy procedure and explains the role of the interprofessional team in managing patients who undergo a transhiatal esophagectomy.

Objectives:

• Identify the indications for transhiatal esophagectomy.
• Describe the preparation and technique required for performing a transhiatal esophagectomy.
• Review the potential complications of transhiatal esophagectomy.
• Outline interprofessional team strategies for improving care coordination and communication to advance transhiatal esophagectomy and improve outcomes.

Introduction

Dr. Orringer popularized transhiatal esophagectomy in the 1980s as an alternative to the three incisions Ivor Lewis esophagectomy, involving a cervical, a thoracic, and an abdominal incision.[1][2][3] The morbidity of the Ivor Lewis procedure was primarily due to pulmonary complications, and Dr. Orringer thought that the pulmonary complications could be lowered without the thoracic incision.[4][5] The procedure was performed with an abdominal and a cervical incision and allowed mobilization of the stomach as a conduit to the cervical esophagus. A single anastomosis was made in the neck. If there was an anastomotic leak, the morbidity of this leak was far less than a devastating intrathoracic leak with the Ivor Lewis esophagectomy.

The procedure is still used today in patients requiring esophagectomy; however, it is not without its complications. The transhiatal esophagectomy procedure requires a skilled surgeon and a trained interprofessional team that works together to provide quality patient outcomes.

Anatomy and Physiology

The transesophageal esophagectomy requires an excellent understanding of both gastric and colonic blood supplies as well and thoracic and cervical anatomy. Since the majority of the thoracic dissection is done bluntly and without direct visualization, a surgeon's touch, feel, and knowledge of anatomy is paramount for a successful case. Preoperative planning requires a decision of the conduit that will be presumed as the primary choice. The primary choice for the transhiatal esophagectomy is the gastric tube created on the greater curvature of the stomach. This tube is brought to the neck for cervical esophagogastric anastomosis. The tube's blood supply is through the right gastroepiploic artery, and this needs to be preserved as the rest of the blood supply to the stomach is divided. This provides adequate length for the tube to reach into the neck. In the area of the left gastric artery arises an aberrant left hepatic artery at times, which needs to be sought if present and preserved. On occasion, the gastric tube cannot be used, and the left colon is used as the conduit in an isoperistaltic fashion. The blood supply to the left colon is maintained with the left colic artery, and the middle colic is divided. An antiperistaltic left colon can be used as well based on the middle colic artery but is less preferred. The blood supply to the colon conduit necessitates a patent marginal artery of Drummond and should be assessed prior to isolating the entire colon length.

In the chest, there are critical organs that are in reach of the surgeon's hand. The surgeon, for the transhiatal part, will use the esophagus as a landmark and bluntly take down all tissue attached to the esophagus to free it fully to the superior most extent of the chest cavity. The spine posteriorly guides the surgeon into a plane of thin areolar tissue, and anteriorly the plane is relatively thin until the posterior wall of the trachea and left bronchus is approached. On occasion, the tumor mass may be in this area, and if so, care is taken not to tear the posterior membranous wall of the trachea or bronchus. In this area, there is the azygous vein and its tributaries as well as the vena cava. Bleeding is brisk if these vessels are injured or torn during the blunt portion of this operation, or a massive air leak from the endotracheal tube is present if the trachea or bronchus is torn.

The cervical operation involves a standard incision in front of the sternocleidomastoid and dissection down to the esophagus dividing the omohyoid muscle. This allows access to the esophagus, but nearby in the tracheoesophageal groove are the recurrent laryngeal nerves that must be preserved. The nerve on the side of the dissection is usually visible, but the contralateral nerve needs to be found as the esophagus is encircled. Knowledge of the carotid, the vagus nerves with the recurrent laryngeal nerves, and the jugular and facial veins are critical to success in the small space. The inferior thyroidal artery is at the level of the upper esophageal sphincter and is a useful landmark but is ultimately divided.The goal of the operation is to remove the esophagus and restore intestinal continuity for oral feeding. The gastric tube makes a robust conduit; then, the second choice is a colon conduit. The conduits will lose their peristalsis, and postoperative instructions would be concerned with delayed emptying or poor emptying, so staying upright after oral intake is critical for the patient to avoid aspiration events.

Indications

Tranhiatal esophagectomy was first touted for patients with achalasia, then later was used for patients with esophageal cancer and strictures. In the current era, this operation is still done but has been mostly replaced with robotic or thoracoscopic assisted procedures to further decrease the morbidity from the pulmonary standpoint and to enhance recovery. The minimally invasive procedures allow direct visualization of the thoracic dissection to lower the risk of inadvertent injury. The procedure can still be used, however, and the list of indications includes achalasia, esophageal cancer, and strictures as outlined above.

Contraindications

Contraindications to a transhiatal esophagectomy in patients who otherwise require the procedure include:

• Tumor size and proximity of the tumor to vital structures in the chest. Esophageal malignancies are usually T1 lesions in the current diagnostic era and do not require operations for palliation.
• A surgeon's inexperience with the technique is a relative contraindication as well.
• An additional factor to consider is the prior treatment of the tumor. The tumor may have received neoadjuvant therapy with chemotherapy and/or radiation therapy, and with the timing after radiation, it may make the transhiatal approach difficult from scarring.

Equipment

The equipment for the procedure is relatively ubiquitous in all operating rooms. For anesthesia, some prefer a dual lumen endotracheal tube so lungs can be isolated if needed, two large-bore intravenous (IV) lines or central line, and an arterial line is common. A self-retaining retractor for the abdominal portion is most helpful. The energy choices for the takedown of the stomach or colon and ligation of the vessels are at the surgeon's choice. The hiatus is enlarged to about four finger breadths bluntly, then the whole thoracic portion is done slowly and cautiously, as it is done without directly seeing everything. A surgeon's hand is best when it is a glove size seven or smaller, as the larger hands can compromise cardiac diastole. The availability of vascular clamps and sutures, as well as anticipation of massive bleeding or air leak, is critical to be prepared for a catastrophic event. The anastomosis can be either stapled or hand-sewn at the surgeon's discretion. The cervical incision should be drained with a closed suction drain. Some surgeons prefer to place a jejunal feeding tube prior to abdominal closure.

Personnel

The transhiatal esophagectomy needs qualified personnel. The anesthesia team is comprised of an anesthesiologist and nurse anesthetist who ensures the positioning of the dual lumen endotracheal tube and monitor intraoperative vital signs and patients' physiology. Their input in critical dring the blunt thoracic portion as drops in blood pressure and alterations in heart rhythms are common. The surgeon and the assistant are needed for the abdominal portion and the blunt thoracic portion. A second surgeon and assistant sometimes are able to perform the neck dissection simultaneously to the abdominal and thoracic portions, which makes the operation more efficient and lessens the time under anesthesia. Postoperative recovery is made in a monitored setting for any arrhythmias and hypotension.

Preparation

Most patients are put through a rigorous workup prior to surgery. The patient must have a secured diagnosis with radiographic studies and endoscopy as needed. Tissue diagnosis and accurate preoperative staging are critical for cancers, so upper endoscopy and endoscopic ultrasound (EUS) are staples. The patient must have cardiac and pulmonary evaluations to make sure the patient can tolerate the operation, potential one-lung ventilation, and the possibility of an open conversion to thoracotomy if needed. Patients should be on a walking or exercise program and should be abstinent from cigarettes and tobacco at least 3 to 4 weeks prior to the operation. Underlying abnormalities in lab values should be corrected, and an assessment of nutritional status should be made. Positive gains in nutrition should be attempted with preoperative supplements as tolerated.

The day prior to surgery, the patient should have a mechanical bowel prep in case the colon needs to be used as a conduit, should receive incentive spirometry training, and be hydrated. In the operating room (OR), the patient should have two large-bore IV lines placed or a central line. The patient should have an arterial line, and then undergo general anesthesia with a dual lumen tube. The patient should be intubated in the Trendelenberg position and with cricoid pressure to prevent aspiration on induction. The patient is positioned supine with the neck turned to the right so that the left neck can be accessed. Foley catheter and pneumatic compression sleeve devices should be in place as well as a nasogastric tube. The procedure would begin with the abdominal exploration and then migrate to the cervical portion of the operation.

Technique or Treatment

After the induction of anesthesia and the appropriate lines and tubes have been secured, the patient is positioned supine with the head turned to the right. The preparation area is wide and includes the neck, the right, and the left chest, and the entire abdomen. The abdominal portions start with either a chevron or midline incision. The abdomen is explored, and metastatic disease is sought if done for cancer. Any abnormality is addressed. The colon is mobilized away from the stomach protecting the gastroepiploic vessels. The stomach is elevated, and the left gastric artery is divided. Care is taken to protect the right gastroepiploic artery as that is the vessel to keep the conduit alive. The lesser omentum is cleared, protecting the arcade on the lesser and greater curves of the stomach. The short gastric vessels are taken to hiatus. The distal esophagus and stomach are freed from the surrounding tissues.

A generous Kocher maneuver is done to mobilize the pyloric end as it should approach the level of the hiatus or xiphoid. All nodal bearing tissue around the stomach should be taken with the specimen. The hiatus is bluntly enlarged to four fingerbreadths to allow the surgeon's hand to enter the mediastinum. The surgeon then frees the posterior surface of the esophagus from the spine, followed by the anterior surface from the pericardium. On either side of the esophagus is the segmental blood vessel supply from the aorta. These small vessels are cauterized or sealed, or just torn. The vessels will bleed a little then stop with time. The esophagus is encircled and dissected bluntly staying on the esophagus at all times. The extent is to the thoracic inlet.

While the surgeon's hand and arm are in the chest, careful attention to the blood pressure and arrhythmias needs to be paid. If the blood pressure drops or if arrhythmias develop, the hand and arm must be removed to allow the heart time to fill and recover. Once the heart recovers, then continued dissection is done. Either with another team at the neck, or at this time, the cervical exposure needs to be made. The anterior cervical incision is placed anterior to the sternocleidomastoid and carried down to encircle the esophagus. Care must be taken to identify and preserve the recurrent laryngeal nerves and the thoracic duct. Once the esophagus is encircled in the neck, blunt dissection is used to gain access to the superior mediastinum. With one hand in the chest and one in the neck, then the surgeon's fingers should meet, and the esophagus should be completely mobile. The esophagus is divided in the neck, and a drain is connected to the distal esophagus, which is then pulled into the abdomen.

The gastric tube is created by stapling from the fundus across the cardia to the lesser curve of the stomach so that the apical most reach of the stomach is with the fundus. The specimen can be removed with the nodal tissue en bloc. The drain is then attached to the fundus, and with gentle traction on the drain in the neck, the stomach is fed into the chest through the thoracic inlet to the neck. Care should be taken here not to rotate the axis of the stomach. Once the location of the stomach is confirmed in the appropriate orientation, cervical anastomosis is performed. This can be either hand-sewn or stapled per the surgeon's choice. The stomach can be anchored to the cervical prespinal fascia to reduce tension on the anastomosis.

The closed suction drain is placed near the anastomosis, and the cervical incision is closed in layers. The abdomen is re-assessed, and determination for a jejunal feeding tube is made. The nasogastric tube should be confirmed in the stomach, and if a jejunal feeding tube is needed, it is placed distal to the ligament of Treitz. The decision for a pyloromyotomy or pyloroplasty needs to be made as well. If the surgeon deems this necessary, either pyloric drainage procedure can be done. In a classic transhiatal esophagectomy, a pyloroplasty about 2 cm in size is done, and a feeding jejunostomy is placed as well. The abdomen is then closed.[6][7]

Complications

Life-threatening intraoperative complications include bleeding, usually from a large vessel like the azygous vein. Massive bleeding requires packing of the chest and mediastinum and immediate thoracotomy for control of the bleeding vessel. Minor bleeding usually stops with gentle packing and time. Other complications include the massive air leak from a hole in the posterior membranous trachea or bronchus. This is noted intraoperatively as a large air leak, and the inability to ventilate the patient. Treatment of this is immediate recognition, and the surgeon and the anesthesiologist work together to advance the endotracheal tube past the tear and then using a thoracotomy incision, the hole is repaired. If the conduit is not viable because the blood supply has been compromised, then another conduit like the colon should be chosen. Finally, if the conduit will not reach the neck, then either another conduit is chosen, or a thoracotomy performed and the anastomosis placed in the chest. Injuries to one or both recurrent laryngeal nerves are known complications as well. If recognized at the time of injury, the nerve should try to be repaired but is often too small for this. An otolaryngologist (ENT) consult is necessary to assist with this, and a formal tracheostomy may be necessary during the hospital course.

Postoperative complications are similar to other operations. The usual gamut of bleeding, infection, hernias, pain, fevers, etc. prevails. Unique complications include pneumonia and cardiac arrhythmias. Others include deep vein thrombosis and pulmonary embolus, as well as urinary tract infections and superficial wound infections. Leaks from the cervical anastomosis tend to be minor, and if there is no drain in place, they can be managed by opening the cervical wound and either draining or packing the wound. These leaks are more forgiving than thoracic leaks, as most of the cervical leaks heal spontaneously. Thoracic leaks, on the other hand, are life-threatening and demand operative exploration. This is also what makes the transhiatal approach more desirable. Cervical incisions that become red or inflamed or fevers starting about three days postoperatively indicate a leak until proven otherwise. A water-soluble contrast study is indicated for any signs and symptoms suggestive of a leak.

Occasionally, other deep space abscesses may develop where a computed tomography (CT) scan is indicated. Findings of a leak demand attention and appropriate drainage with IV antibiotics as a secondary treatment. Delayed gastric emptying or conduit emptying is common as well. The patient should be upright eating and after oral intake for 2 to 3 hours minimum so that gravity can help move the bolus down the intestinal tract. Small frequent meals are better than larger meals at the initiation of oral intake. All patients should have a contrast study anywhere from 3 to 7 days postoperatively to rule out any type of leak. If the study is normal, then oral intake can commence. Longer-term complications include anastomotic strictures, which are common after leaks from the initial surgery are noted. These can be treated with endoscopic dilation and occasionally stenting.[8]

Clinical Significance

Tranhiatal esophagectomy is a useful operation in skilled hands. There are other options now available for a visualized thoracic dissection, which offers a better lymphadenectomy. Robotic and thoracoscopic techniques are used now for a well visualized and dissected thoracic component to the operation rather than a blunt and blind dissection. Though nodal status may not matter in patient outcomes, the tide is changing to a minimally invasive approach. The cervical anastomosis has a better-tolerated leak than its intrathoracic counterpart. Even the abdominal aspect of the operation can be done robotically or laparoscopically as well, further decreasing the morbidity associated with this high-risk operation. Enhanced recovery protocols exist for esophagectomies as well.[9][10][11]

Enhancing Healthcare Team Outcomes

Esophagectomy for diseases has been in evolution since the 1980s. Dr. Orringer supported the idea of transhiatal esophagectomy for its lower complication rate, especially in pulmonary morbidities. The process has again evolved and now is set into minimally invasive techniques and robotic techniques to further decrease the morbidities with an increase in overall operative time. A skilled surgeon is always needed for any blunt or blind operation. Communication with the team and especially with anesthesiologists during harrowing parts of this operation are key to success. A vigilant watch on the patient's vital signs and the condition is mandatory during the operation, especially the thoracic aspect. All team members should be allowed to speak up and be heard about concerns or what they see going on when the surgeon or the anesthesiologist may be otherwise in deep thought about an aspect of the case. Dr. Orringer has proved this a safe case with his case series and expertise.[12][13]

Nursing, Allied Health, and Interprofessional Team Interventions

All esophageal cancer patients should be evaluated by an interprofessional team to secure the best outcome. Medical oncologists, radiation oncologists, experienced esophageal surgeons should discuss and work with the patient to improve their preoperative condition prior to this type of operation and to put the patient into the best shape he/she can be in before the operation. With appropriate nursing oversight and care, allied health care, patients will have the best possible care delivered to them at a time they need to be the strongest and most positive for the best outcome.

Nursing, Allied Health, and Interprofessional Team Monitoring

Monitoring for these patients starts in the operating room. The recovery rooms and the intensive care units and nursing units need to be vigilant for aspiration events and leaks as well as arrhythmias. Even after discharge, these patients need to be monitored for strictures, weight loss, recurrent cancer, delayed conduit emptying, and overall failure to thrive. Depression and mood disorders can manifest as well as post-traumatic stress disorder from sustained hospital courses, especially when complicated.