Overview
Definition:
Transhiatal esophagectomy is a surgical procedure to remove the esophagus, performed through an abdominal and cervical incision without a thoracotomy
It is typically performed for esophageal cancer, benign strictures, or achalasia
The esophagus is dissected and mobilized from the mediastinum via an abdominal approach, and then transected at the thoracic inlet
A reconstruction is achieved by bringing up a gastric tube or a segment of colon through the mediastinum to the neck
This approach avoids the morbidity associated with thoracotomy but carries a higher risk of certain complications like recurrent laryngeal nerve injury and bronchial/tracheal injury.
Epidemiology:
Esophageal cancer is a significant cause of cancer-related mortality globally, with squamous cell carcinoma and adenocarcinoma being the most common histological types
The incidence varies geographically, with higher rates in certain parts of Asia and Africa
Benign strictures and achalasia also necessitate esophagectomy in a subset of patients
The choice of surgical approach, including transhiatal esophagectomy, is dictated by tumor stage, location, patient comorbidities, and surgeon preference.
Clinical Significance:
Transhiatal esophagectomy is a crucial surgical intervention for managing advanced esophageal diseases, particularly cancer
Its performance requires a thorough understanding of surgical anatomy, meticulous technique, and vigilant postoperative care
For surgical residents preparing for DNB and NEET SS examinations, a deep grasp of its indications, contraindications, surgical steps, potential complications, and long-term outcomes is essential for patient management and successful board certification.
Indications
Malignancy:
Mid-esophageal and distal esophageal cancers (squamous cell carcinoma and adenocarcinoma) that are resectable
Tumors that invade local structures but are not metastatic and are amenable to en bloc resection
Esophagectomy is a cornerstone of curative-intent treatment for localized esophageal cancer
Adequate lymphadenectomy is a critical component of oncologic resection.
Benign Conditions:
Severe esophageal strictures refractory to endoscopic dilation, such as those caused by corrosive ingestion or radiation
Advanced achalasia where medical or endoscopic therapies have failed or are contraindicated
Extensive esophageal diverticula that are symptomatic and cannot be managed endoscopically
Dysphagia and aspiration pneumonia are common presentations.
Contraindications:
Distant metastatic disease
Extensive local invasion into adjacent vital structures (e.g., aorta, vertebral bodies) making R0 resection impossible
Severe cardiopulmonary comorbidities that render the patient unfit for major surgery
Patients with a history of extensive mediastinal radiation therapy can have dense adhesions, making dissection difficult and increasing the risk of injury.
Surgical Technique
Preoperative Preparation:
Nutritional assessment and optimization
Bronchoscopy to assess airway and rule out endobronchial invasion
Esophagogastroduodenoscopy (EGD) with biopsy for definitive diagnosis and staging
Endoscopic ultrasound (EUS) for local staging and lymph node assessment
CT scan of chest, abdomen, and pelvis for distant metastasis evaluation
PET-CT scan for further staging if indicated
Cardiopulmonary assessment and optimization
Informed consent covering risks, benefits, and alternatives.
Abdominal Phase:
Midline laparotomy or sub-xiphoid incision
Mobilization of the greater curvature of the stomach with ligation of short gastric arteries
Division of the gastrocolic omentum
Mobilization of the anterior and posterior gastric wall
Transection of the stomach at the gastroesophageal junction
Creation of a gastric tube (gastric pull-up) or mobilization of a colon segment
Creation of a gastric conduit through the diaphragm into the mediastinum.
Mediastinal Dissection And Esophageal Mobilization:
Access to the mediastinum is gained through the esophageal hiatus
The esophagus is carefully dissected from the mediastinal pleura, trachea, bronchi, and vascular structures
Recurrent laryngeal nerves must be identified and preserved if possible, especially on the left
Careful attention is paid to control bleeding from mediastinal vessels
The esophagus is mobilized up to the level of the thoracic inlet.
Cervical Anastomosis And Closure:
A left cervical incision is made
The mobilized esophagus is brought up to the neck
An end-to-side anastomosis is performed between the gastric conduit and the cervical esophagus using absorbable sutures or staplers
Careful attention is paid to tension-free anastomosis and adequate blood supply to the conduit
A feeding jejunostomy tube may be placed for early enteral nutrition
Drains are placed in the mediastinum and cervical wound
Wound closure is done in layers.
Postoperative Care
Monitoring:
Close monitoring of vital signs, fluid balance, and urine output
Respiratory monitoring for signs of aspiration or pneumonia
Pain management with patient-controlled analgesia (PCA) or epidural analgesia
Early ambulation to prevent deep vein thrombosis and pneumonia
Nasogastric tube drainage initially to decompress the stomach.
Nutritional Support:
Initiation of clear liquids once bowel sounds return and gastric drainage is minimal, progressing to a soft diet
If a gastric pull-up is performed, liquids are typically started on postoperative day 3-5
Feeding jejunostomy provides an alternative route for nutrition if oral intake is delayed
Monitor for signs of malnutrition and fluid/electrolyte imbalances.
Complication Surveillance:
Vigilance for signs of anastomotic leak (fever, tachycardia, chest pain, cervical wound drainage)
Chest X-ray for assessment of pleural effusion, pneumonia, or atelectasis
Monitoring for chylothorax, recurrent laryngeal nerve injury (vocal cord paralysis), dysphagia, and gastric conduit necrosis
Regular assessment for signs of gastroesophageal reflux or dumping syndrome.
Complications
Early Complications:
Anastomotic leak is the most serious early complication, with a reported incidence of 5-15%
Symptoms include fever, tachycardia, neck or chest pain, and cervical wound drainage
Management may involve antibiotics, drainage, or re-operation
Recurrent laryngeal nerve injury, leading to vocal cord paralysis and hoarseness, occurs in 5-20% of patients
Mediastinal infection, pneumonia, pleural effusion, chylothorax, and bleeding are also potential early issues.
Late Complications:
Chronic dysphagia due to anastomotic stricture or inadequate gastric conduit mobilization
Gastroesophageal reflux disease (GERD) with potential for Barrett's metaplasia or adenocarcinoma in the gastric conduit (long-term risk)
Dumping syndrome (early or late) causing nausea, vomiting, abdominal cramps, and vasomotor symptoms
Weight loss and malnutrition
Gastric conduit ischemia or necrosis (rare but catastrophic)
Strictures at the diaphragmatic hiatus.
Prevention Strategies:
Meticulous surgical technique, careful dissection, and preservation of blood supply
Careful identification and avoidance of recurrent laryngeal nerves
Performing tension-free anastomoses using appropriate suture materials or staplers
Optimal preoperative nutritional optimization and postoperative care, including early mobilization and adequate pain control
Close postoperative monitoring to detect complications early
Judicious use of feeding tubes for prolonged nutritional support if needed.
Prognosis
Factors Affecting Prognosis:
Stage of the tumor at diagnosis is the most significant prognostic factor
Histological type, tumor grade, nodal involvement, and presence of distant metastases all influence survival
The patient's overall health status and comorbidities play a role
The ability to achieve a complete oncologic resection (R0) is crucial for long-term survival.
Outcomes:
For early-stage esophageal cancer, esophagectomy offers the best chance for cure, with 5-year survival rates potentially exceeding 50-70% for stage I disease
However, for locally advanced or metastatic disease, the prognosis is poor
For benign conditions, successful esophagectomy can significantly improve quality of life by resolving dysphagia and aspiration
Morbidity and mortality rates vary between institutions and surgeons, but generally range from 5-15% mortality and higher morbidity.
Key Points
Exam Focus:
Indications for transhiatal esophagectomy vs
other approaches (e.g., Ivor Lewis)
Management of anastomotic leaks and recurrent laryngeal nerve injury
Nutritional support strategies post-esophagectomy
Staging of esophageal cancer
Oncologic principles of resection (R0 resection)
Contraindications for transhiatal esophagectomy.
Clinical Pearls:
Always identify and protect the recurrent laryngeal nerves during mediastinal dissection
Ensure adequate length and blood supply of the gastric conduit
Perform tension-free anastomosis
Close monitoring for early signs of anastomotic leak
Early ambulation and respiratory physiotherapy are vital
Consider feeding jejunostomy for prolonged nutritional support.
Common Mistakes:
Inadequate oncologic staging leading to inappropriate surgical decision-making
Failure to identify or protect recurrent laryngeal nerves
Incomplete mediastinal lymphadenectomy
Performing a tension-filled anastomosis
Delayed recognition and management of anastomotic leaks
Insufficient postoperative nutritional support.