Hi, my name is Rishi Reddy. I'm one of the thoracic surgeons here at the University of Michigan. Today I'd like to review the principles of an esophagectomy and specifically go over the different approaches. Here are my disclosures. None of them are relevant to this talk. The objectives for today's talk are to define the different types of esophagectomies, to review the differences in long term outcomes between transthoratic and transhiatal approaches and to understand the different complications that can occur depending on the type of approach. Now to go over our pre lecture questions. Complications associated with a Transthoracic Esophagectomy include all the following except, A, Chylothorax, B, Pneumonia, C, Recurrent laryngeal nerve injury, or D, Anastomotic leak. First I'd like to go over a little bit of the history of the Esophagectomy. The transhiatal esophagectomy was developed and popularized by doctor here at the University of Michigan over the last 40 years. He is giving actually one of our other lectures in this course on esophagectomy and esophageal cancer. Transthoracic esophagectomy has been around for 70 to 80 years and has been the main stay of how to proceed and how to perform the esophagectomy in the Unites States. It still constitutes over two-thirds of the esophagectomies in the US. A 3-field esophagectomy is slightly longer and is more complicated, but does allow for an increased resection of lymph nodes and it has been the approach of choice for surgeons who perform unblock esophagectomy. Now, let's review the principles of an esophagectomy regardless of the approach. The number one principle is to perform an excellent lymph node dissection to make sure that you have enough lymph nodes for both prognostic value as well as curative intent. Also a principle of the esophogectomy is how you make the conduit. Normally we use a gastric pull up in either the transthoracic of the or the 3-field approach. Alternatively if you use the colon or the small bowel, you have to make sure that your blood supply is adequate for your conduit. Also you want to your anostomosis above the level of the azygous vein. This will improve conduit function and allow better emptying of the conduit whether it's the colon, stomach, or the small bowel. And lastly, especially when using a gastric conduit, you want to make sure that you perform a pylorus emptying procedure. This can be either a pyloroplasty or pyloromyotomy, or sometimes now using Botox to relax the pelorus muscle as you are concurrently doing the vagotomy when you do the esophagectomy. The most common complications from any approach include dysphagia and problems with the conduit emptying, chylothorax or a lymphatic leak, an anastomotic leak, whether it's in the chest or in the neck, and also pneumonia. Now, we'll outline the different technical approaches. So, first, we'll here, review a Transthoracic approach, where you can see, making incision, first in the abdomen, mobilizing the stomach. After the stomach is mobilized, it is pushed up through the hiatus into the chest, the patient is repositioned laterally and then an incision is made in the chest and usually a posterolateral thoracotomy or sometimes now using VATS or robotic incisions in a mininal evasive approach. A Transhiatal approach is slightly different. First we perform the abdominal operation very similarly to the transthoracic approach, mobilizing the stomach. Then we push the stomach all the way up into the neck where we create a esophagogastric anastomosis in the neck versus the upper chest as the transthoracic approach. The 3-field esophagectomy is slightly different where the first we start in the chest, mobilizing the esophagus and trying to resect as many lymph nodes at the same time. We then reposition the patient supine, performing next the abdominal incision and lastly, the neck incision where we then bring the stomach conduit or other conduit up to the proximal esophogus in the neck and perform the Anastomosis there. When comparing the different approaches and here, specifically comparing the Transthoracic versus the Transhiatal approach, here we've shown the results of three different matter analysis comparing anywhere from 44 to 52 studies. And you can see here anywhere from over 5000 to almost 8000 patients in each study. The thing to highlight is no matter what the approach is, the five year overall survival was not statistically significant in any of these matter analysis between the transthoracic and transhiatal approach. There were statistically significant differences in the pulmonary complications, notably in the two studies to the right, favoring the transhiatal approach, which had slightly lower pulmonary complications. There was no statistical difference in the chylous leak rate between the approaches. There was a higher anastomotic leak rate in the transhiatal approach compared to the transthoracic approach. And this has been well documented in a number of studies. Interestingly enough, there was a vocal cord paralysis noted in the transthoracic approach in this meta-analysis. In most single institution series, there is an almost zero rate of vocal chord paralysis for the Transthoracic approach as you are rarely in the area of the of the nerve. Having said that, the Transhiatal approach does have a higher rate of vocal chord paralysis. There's no difference in wound infection rates. The pros as shown here, from a Transthoracic approach include having a higher lymph node count because you're performing a chest dissection. You generally have lower anastomotic leak rates and in most high volume centers, there is almost a zero rate of recurrent nerve injury despite what was shown on the previous slide. The cons of transthoracic approach though include more pain with the chest incision, higher rates of pneumonia, and then high mortality when you have an anastomotic leak into the chest versus anastomotic leak into the neck. When looking at the transhiatal approach, there's slightly different pros and cons. The Pros include a lower risk of mortality with a leak in the neck, less pain because there's no chest incision and reduced rates of pneumonia. The cons of the transhiatal approach tho, again include the higher leak rate in the neck and this is thought to be due to potentially increased tension by bringing the conduit higher up in the neck versus lower in the chest. There is generally lower lymph node counts with a transhiatal approach and there's a higher risk of recurrent laryngeal nerve injuries, again, because of the neck anastomosis and the neck dissection. When you're doing a 3-Field esophogectomy or planning or one, there's better potential for an en bloc resection with higher lymph node count, as well as better radial margins. Again there is lower mortality with a leak in the neck, if one occurs. There are cons with a 3-filed approach and notably that you maximize a complication rate from other approaches by having both a chest incision as well as a neck incision which can result in recurrent laryngeal nerve injury. Going back now to our post-lecture question, complications associated with a Transthoracic Esophagectomy include all of the following except, A, Chylothorax, B, pneumonia, C, recurrent laryngeal nerve injury, or D, anastomotic leak. The generally accepted answer is, C, recurrent laryngeal nerve injury. You can have a Chylothorax, Pneumonia or Anastomotic leak with any surgical approach to esophagectomy, especially Transthoracic, Transhiatal or 3-field. There is a general consensus that there is a much lower risk, if almost a zero risk of a recurrent laryngeal nerve injury with a Transthoracic Esophagectomy approach because of no neck dissection. The take home points from this lecture include, the fact that different approaches for esophagectomy has similar long term outcomes despite different pros and cons. There is definitely a higher success rate with higher volume of surgical procedures and the different approaches as noted have different complications. Again, the transthoracic approach favors a slightly higher pneumonia rate, while the transhiatal approach has higher rates of recurrent laryngeal nerve injuries. Understanding the different complications is necessary when explaining to patients the different approaches and understanding how to manage their post operative care.
