Surgical Managemnt

Esophageal resection can be accomplished through various approaches. Currently the most accepted approaches include transhiatal resection and the Ivor-Lewis thoracoabdominal approach. Each has its advantages and disadvantages but there is no difference in long term and disease free survival between resection groups.

Thoracoabdominal Approach (Ivor-Lewis)

A midline incision is made and the stomach is mobilized. Preservation of the right gastric and gastroepiploic arteries is essential to utilize the stomach as an esophageal substitute. A pyloroplasty is performed to facilitate gastric emptying. A feeding jejunostomy may be placed. Once mobilization is complete the abdominal incision is closed and the patient is rotated to a left lateral decubitus position. Some surgeons advocate placing the patient in a modified supine/left decubitus position so both approaches can be done without moving the patient. A right thoracotomy through the 5th intercostal space is done with completion of the esophageal mobilization. The anastomosis is done with a single layer PDS or double layer chromic and silk.

Transhiatal Approach

This is similar to the Ivor-Lewis in terms of abdominal mobilization but without a thoracotomy. The esophagus is mobilized with blunt dissection through the esoph-ageal hiatus. The anastomosis is performed in the neck with the esophageal substitute.

Disadvantages to the Ivor-Lewis include an intrathoracic anastomosis with a high mortality associated with leak and pulmonary complications associated with a thoracotomy. The transhiatal approach is done blindly with questionable margins. There is no difference in survival between the approaches. There are only three current randomized controlled studies that compare transhiatal to transthoracic resection. Survival was similar between groups with 29% and 26% for transthoracic and transhiatal resections respectively.4

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