Esophagectomy: Ivor Lewis and Other Procedures

 Transthoracic esophagectomy: Usually performed through right intercostal approach (Ivor Lewis procedure)


image Other options include minimally invasive (laparoscopic) procedures


• Stomach is ideal conduit, as it has reliable blood supply and can reach high into thorax or neck for anastomosis
image Esophagogastric anastomosis is created high in thorax, above level of azygous arch

• Perioperative complications
image Hemorrhage

image Injury to recurrent laryngeal or vagus nerve (5-10%)

image Injury to tracheobronchial tree

image Chylothorax (2-4%)

• Postoperative complications
image Essentially all patients have some degree of dysphagia, early satiety, and reflux following esophagectomy

image Anastomotic leak (10-16%)

image Anastomotic stricture (15-25%)

image Diaphragmatic hernia (1-6%)

image Delayed emptying of conduit
– Causes: Redundant conduit (excess length of gastric tube), mechanical obstruction, twisted conduit, functional delay

image Recurrent carcinoma

• Complication rates vary substantially according to experience and skill of surgical team
image Open surgical procedures tend to result in higher perioperative morbidity and mortality

image High (cervical) anastomoses result in slightly higher incidence of injury to laryngeal nerve



image
(Left) Graphic illustrates the 1st step in an esophagectomy with gastric interposition. The stomach is divided along its long axis, creating a gastric tube or conduit 5 or 6 cm in diameter, which is pulled up into the chest. This can be done through a right (Ivor Lewis) or left thoracotomy or even through laparoscopic ports. A pyloroplasty image is done to facilitate gastric emptying.


image
(Right) Graphic shows the gastric conduit anastomosed to the mid esophagus image and the pyloroplasty image.

image
(Left) Graphic shows the gastric conduit image anastomosed to the cervical esophagus. Note the position of the gastric staple line image along the right side of the conduit.


image
(Right) Axial CT shows a mildly dilated, gas-filled gastric conduit image in the paravertebral location. Note the position of the gastric staple line image. The conduit is not filled with retained fluid, and there is no evidence of lung injury from reflux.


TERMINOLOGY


Definitions




• Surgical resection of portion of esophagus and replacement by conduit formed by another portion of alimentary tube


IMAGING


Surgical Procedures




• Usual indication for surgery
image Curative or palliative resection of esophageal carcinoma

image Resection of Barrett esophagus with severe dysplasia

• Many surgical options for surgical excision of portion of esophagus

• Transthoracic esophagectomy
image Usually performed through right intercostal approach (Ivor Lewis procedure)
– Generally begins with laparotomy for mobilization of stomach, which is then used to create gastric tube/conduit that will replace resected esophagus
image Either entire stomach or tubularized portion (divided along long axis) is used

image Stomach is ideal conduit, as it has reliable blood supply and can reach high into thorax or neck for anastomosis

– As part of laparotomy, upper abdominal lymph nodes (celiac, gastrohepatic) are resected

– Pyloroplasty or pyloromyotomy is performed to facilitate gastric emptying and to minimize gastroesophageal reflux

– At thoracotomy, esophagus and thoracic duct are dissected from vertebral column

– Esophagus and regional lymph nodes (mediastinum and neck) are resected en bloc

– Esophagogastric anastomosis is created in thorax, above level of tracheal carina
image Some surgeons make anastomosis in lower neck

– Gastric conduit is usually placed in pre- or paravertebral space of posterior mediastinum
image Less commonly in retrosternal, intrapleural, or subcutaneous position

– Colon and jejunum are used much less commonly to bypass or replace resected (or obstructed) esophagus
image Usually after failed gastric interposition

image Many variations exist
– e.g., left thoracotomy approach, transhiatal open approach (without thoracotomy), minimally invasive procedures (performed through ports in thorax and abdomen without open incision into either)

– Surgical approach may be affected by patient condition (site and depth of tumor, mediastinal scarring from prior surgery, etc.)

– Experience and preference of surgeon play larger role in surgical approach

image Complication rates
– No proof of significantly different morbidity or mortality among various surgical approaches
image Complication rates vary substantially according to experience and skill of surgical team

– Open surgical procedures tend to result in slightly higher perioperative morbidity and mortality

– High (cervical) anastomoses result in slightly higher incidence of injury to laryngeal nerve

image Contraindications to esophagectomy (relative or absolute)
– Tumor invasion of trachea or aorta

– Extensive mediastinal scarring, e.g., from prior perforation, surgery, radiation therapy


Complications




• Perioperative complications
image Hemorrhage
– Can be substantial problem during dissection and removal of esophagus

image Injury to recurrent laryngeal or vagus nerve (5-10%)
– Mediastinal and lower cervical nodes lie close to vagus and recurrent laryngeal nerves
image Nerves may be damaged during lymph node resection

– Results in impaired cough and increased risk of aspiration pneumonia

image Injury to tracheobronchial tree
– Esophageal tumor may invade tracheobronchial tree; attempts to separate tumor may damage bronchus

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Nov 16, 2016 | Posted by in GASTROINTESTINAL IMAGING | Comments Off on Esophagectomy: Ivor Lewis and Other Procedures

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