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Surgery for Cancers of the Gastrointestinal Tract pp 39–47Cite as

Open Radical En Bloc Esophagectomy

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Abstract

The poor outcome of patients following conventional esophagectomy for cancer is partly due to the high rates of locoregional failure. Despite the controversy over its efficacy, we believe that radical en bloc esophagectomy maximizes locoregional control and provides the most thorough staging information. En bloc resection involves a wide resection of tissues surrounding the esophagus with a two-field or three-field lymphadenectomy. With an experienced surgical team and careful patient selection, the procedure can be done with low mortality and similar morbidity compared to conventional transthoracic or transhiatal esophagectomy. From our studies, extensive lymphadenectomy appears to have a favorable impact on survival, especially in patients with nodal metastases. En bloc esophagectomy should be recommended for patients with stage II or greater disease with good performance status and adequate cardiopulmonary reserve. This chapter details each step of this operation and summarizes our experience.

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References

  1. Orringer MB, Marshall B, Iannettoni MD. Transhiatal esophagectomy: clinical experience and refinements. Ann Surg. 1999;230(3):392–400; discussion 3.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  2. Ellis Jr FH, Heatley GJ, Krasna MJ, Williamson WA, Balogh K. Esophagogastrectomy for carcinoma of the esophagus and cardia: a comparison of findings and results after standard resection in three consecutive eight-year intervals with improved staging criteria. J Thorac Cardiovasc Surg. 1997;113(5):836–46; discussion 46–8.

    Article  PubMed  Google Scholar 

  3. Lieberman MD, Shriver CD, Bleckner S, Burt M. Carcinoma of the esophagus. Prognostic significance of histologic type. J Thorac Cardiovasc Surg. 1995;109(1):130–8; discussion 9.

    Article  CAS  PubMed  Google Scholar 

  4. Putnam Jr JB, Suell DM, McMurtrey MJ, Ryan MB, Walsh GL, Natarajan G, et al. Comparison of three techniques of esophagectomy within a residency training program. Ann Thorac Surg. 1994;57(2):319–25.

    Article  PubMed  Google Scholar 

  5. Altorki NK. The rationale for radical resection. Surg Oncol Clin N Am. 1999;8(2):295–305.

    CAS  PubMed  Google Scholar 

  6. Herskovic A, Martz K, al-Sarraf M, Leichman L, Brindle J, Vaitkevicius V, et al. Combined chemotherapy and radiotherapy compared with radiotherapy alone in patients with cancer of the esophagus. N Engl J Med. 1992;326(24):1593–8. doi:10.1056/nejm199206113262403.

    Article  CAS  PubMed  Google Scholar 

  7. Kelsen DP, Ginsberg R, Pajak TF, Sheahan DG, Gunderson L, Mortimer J, et al. Chemotherapy followed by surgery compared with surgery alone for localized esophageal cancer. N Engl J Med. 1998;339(27):1979–84. doi:10.1056/nejm199812313392704.

    Article  CAS  PubMed  Google Scholar 

  8. Law S, Fok M, Chow S, Chu KM, Wong J. Preoperative chemotherapy versus surgical therapy alone for squamous cell carcinoma of the esophagus: a prospective randomized trial. J Thorac Cardiovasc Surg. 1997;114(2):210–7.

    Article  CAS  PubMed  Google Scholar 

  9. Logan A. The surgical treatment of carcinoma of the esophagus and cardia. J Thorac Cardiovasc Surg. 1963;46:150–61.

    CAS  PubMed  Google Scholar 

  10. Skinner DB. En bloc resection for neoplasms of the esophagus and cardia. J Thorac Cardiovasc Surg. 1983;85(1):59–71.

    CAS  PubMed  Google Scholar 

  11. Orringer MB, Sloan H. Esophagectomy without thoracotomy. J Thorac Cardiovasc Surg. 1978;76(5):643–54.

    CAS  PubMed  Google Scholar 

  12. Isono K, Onoda S, Okuyama K, Sato H. Recurrence of intrathoracic esophageal cancer. Jpn J Clin Oncol. 1985;15(1):49–60.

    CAS  PubMed  Google Scholar 

  13. Isono K, Sato H, Nakayama K. Results of a nationwide study on the three-field lymph node dissection of esophageal cancer. Oncology. 1991;48(5):411–20.

    Article  CAS  PubMed  Google Scholar 

  14. Fujita H, Kakegawa T, Yamana H, Shima I, Toh Y, Tomita Y, et al. Mortality and morbidity rates, postoperative course, quality of life, and prognosis after extended radical lymphadenectomy for esophageal cancer. Comparison of three-field lymphadenectomy with two-field lymphadenectomy. Ann Surg. 1995;222(5):654–62.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  15. Nishihira T, Hirayama K, Mori S. A prospective randomized trial of extended cervical and superior mediastinal lymphadenectomy for carcinoma of the thoracic esophagus. Am J Surg. 1998;175(1):47–51.

    Article  CAS  PubMed  Google Scholar 

  16. Altorki N, Skinner D. Should en bloc esophagectomy be the standard of care for esophageal carcinoma? Ann Surg. 2001;234(5):581–7.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  17. Altorki NK, Girardi L, Skinner DB. En bloc esophagectomy improves survival for stage III esophageal cancer. J Thorac Cardiovasc Surg. 1997;114(6):948–55; discussion 55–6.

    Article  CAS  PubMed  Google Scholar 

  18. Hulscher JB, van Sandick JW, de Boer AG, Wijnhoven BP, Tijssen JG, Fockens P, et al. Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus. N Engl J Med. 2002;347(21):1662–9. doi:10.1056/NEJMoa022343.

    Article  PubMed  Google Scholar 

  19. Lee PC, Mirza FM, Port JL, Stiles BM, Paul S, Christos P, et al. Predictors of recurrence and disease-free survival in patients with completely resected esophageal carcinoma. J Thorac Cardiovasc Surg. 2011;141(5):1196–206. doi:10.1016/j.jtcvs.2011.01.053.

    Article  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Department of Cardiothoracic Surgery, New York Presbyterian Hospital, Weill Cornell Medical Center, 525 East 68th Street, New York, NY, 10021, USA

    Paul C. Lee M.D.

  2. Department of Cardiothoracic Surgery, New York Presbyterian Hospital, Weill Cornell Medical Center, 525 East 68th Street, M-404, New York, NY, 10021, USA

    Nasser K. Altorki M.D.

Authors
  1. Paul C. Lee M.D.
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  2. Nasser K. Altorki M.D.
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Corresponding author

Correspondence to Nasser K. Altorki M.D. .

Editor information

Editors and Affiliations

  1. Division of Surgical Oncology, City of Hope, Los Angeles, California, USA

    Joseph Kim

  2. Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA

    Julio Garcia-Aguilar

Key Operative Steps

Key Operative Steps

  1. 1.

    Perform right fifth interspace thoracotomy.

  2. 2.

    Incise mediastinal pleura over the anterior azygos vein from the azygos arch to the aortic hiatus and leftward across the aorta and to the opposite pleura.

  3. 3.

    Ligate the thoracic duct at the aortic hiatus and where it crosses over to the left side.

  4. 4.

    Resect azygos arch en bloc with the operative specimen.

  5. 5.

    Clear the hilar and subcarinal nodes.

  6. 6.

    Resect a patch of pericardium en bloc with esophagus if the tumor is adherent to the pericardium.

  7. 7.

    Divide bilateral pulmonary ligaments.

  8. 8.

    Thoracic lymphadenectomy with clearance of all nodal tissue including right and left paraesophageal, parahiatal, para-aortic, subcarinal, and bilateral hilar lymph nodes.

  9. 9.

    Dissection of the third field begins in the thorax including the superior mediastinal lymph nodes and the nodes along the right and left recurrent laryngeal nerves.

  10. 10.

    Complete the third-field dissection with a cervical incision removing the lower deep cervical lymph nodes.

  11. 11.

    Laparotomy requires an upper abdominal midline incision.

  12. 12.

    Enter the lesser sac through the avascular plane between the omentum and colon.

  13. 13.

    The omentum is resected and the short gastric vessels are divided.

  14. 14.

    Retroperitoneal tissues along the superior border of the pancreas are swept up to the esophageal hiatus.

  15. 15.

    The left gastric artery is divided.

  16. 16.

    The common hepatic artery lymph nodes are dissected and swept towards the specimen.

  17. 17.

    The lesser curvature lymph nodes are included with the specimen.

  18. 18.

    Retrieve the esophagus from the prevertebral space in the neck.

  19. 19.

    Divide the esophagus and retrieve the specimen in the abdomen.

  20. 20.

    Dissect the lymph nodes posterior and lateral to the carotid sheath along with the supraclavicular lymph nodes.

  21. 21.

    In the abdomen create the gastric conduit.

  22. 22.

    Perform cervical esophagogastrostomy, completed posteriorly with side-to-side stapled technique and anteriorly with 3–0 absorbable running suture.

  23. 23.

    Place feeding jejunostomy tube.

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© 2015 Springer Science+Business Media New York

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Lee, P.C., Altorki, N.K. (2015). Open Radical En Bloc Esophagectomy. In: Kim, J., Garcia-Aguilar, J. (eds) Surgery for Cancers of the Gastrointestinal Tract. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-1893-5_4

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  • DOI: https://doi.org/10.1007/978-1-4939-1893-5_4

  • Published:

  • Publisher Name: Springer, New York, NY

  • Print ISBN: 978-1-4939-1892-8

  • Online ISBN: 978-1-4939-1893-5

  • eBook Packages: MedicineMedicine (R0)

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