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Innovative and Contemporary Interventional Therapies for Esophageal Diseases

Strollo, Diane C. MD, FACR*; Chan, Ernest G. MD; Jaimes Vanegas, Natalia MD; Ocak, Iclal MD§; Joubert, Kyla MD; Villa Sanchez, Manuel MD

doi: 10.1097/RTI.0000000000000423
Symposium: Imaging of Innovative and Contemporary Thoracic Interventions: State-of-the-Art
Free
SDC

Esophageal surgery has become quite specialized, and both dedicated diagnostic and refined surgical techniques are required to deliver state-of-the-art care. The field has evolved to include endoscopic mucosal resection and radiofrequency ablation for early-stage esophageal cancer and minimally invasive esophagectomy with the reconstruction of a gastric conduit for carefully selected patients with esophageal cancer or those with “end-stage” esophagus from benign diseases. Reoperative esophageal surgery after esophagectomy deserves special mention given that these patients, with improved survival, are presenting years after esophagectomy with functional and anatomic disorders that sometimes require surgical intervention. Different diagnostic modalities are essential for assessing patients and planning surgical treatment. Recognizing early and late postoperative complications on imaging may expedite and improve patient outcomes. Finally, endoscopic management of achalasia with peroral endoscopic myotomy and the use of the LINX device for gastroesophageal reflux disease are highly effective and minimally invasive treatments that may reduce complications, costs, and length of hospital stay.

*Department of Cardiothoracic Surgery, University of Pittsburgh

Departments of Cardiothoracic Surgery

§Radiology, University of Pittsburgh Medical Center, Pittsburgh

Department of Cardiothoracic Surgery, Vanegas Thoracic Surgical Consultants, Fox Chapel, PA

The authors declare no conflicts of interest.

Correspondence to: Diane C. Strollo, MD, FACR, Department of Cardiothoracic Surgery, University of Pittsburgh, 200 Lothrop Street, Pittsburgh, PA 15213 (e-mail: strollodc2@upmc.edu).

Both benign and malignant esophageal diseases may require surgical intervention. Esophageal surgery has become quite specialized, and both refined surgical and dedicated diagnostic techniques are required to deliver state-of-the-art care. From the standard and well-established surgical techniques of esophagectomy, fundoplication, and myotomy, the field has evolved to include endoscopic management of achalasia, use of LINX device for gastroesophageal reflux disease (GERD), and radiofrequency ablation (RFA) and endoscopic mucosal resection (EMR) for early-stage esophageal cancer. Reoperative esophageal surgery after esophagectomy deserves special mention given that these patients, with improved survival, are presenting years after esophagectomy with functional and anatomic disorders that sometimes require surgical treatment. Different diagnostic modalities are essential for assessing patients and planning surgical treatment. Recognizing early and late postoperative complications on imaging may expedite and improve patient outcomes.

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NORMAL ESOPHAGEAL ANATOMY AND FUNCTION

Anatomy

The esophagus transports liquids and food from the pharynx into the stomach and also allows gastrointestinal contents to egress the stomach during episodes of belching, reflux, and vomiting.1 The esophagus starts in the midline of the neck at the cricoid cartilage (C6), extends ~35 cm to the esophagogastric junction (EGJ), and consists of 3 segments.2,3 The cervical esophagus is 4 to 5 cm long and is composed of striated muscle. The thoracic esophagus courses from the sternal notch to the diaphragm, is divided into proximal, mid, and distal segments, and transitions from striated muscle proximally to predominantly smooth muscle distally. The abdominal esophagus is about 1 cm long, passes through the right diaphragmatic crus, extends from the diaphragm to the gastric cardia, and is covered with peritoneum.1

The esophagus has 2 gentle curves. It traverses slightly to the left of the midline in the neck and upper mediastinum, veers to the right to descend in the midline of the mediastinum, and then courses slightly to the left to enter the abdomen at the diaphragmatic hiatus. Hence, the best surgical approach to the cervical esophagus is via the left side of the neck, to the midesophagus is from the right hemithorax, and to the lower esophagus is from the left hemithorax.

The esophageal wall is composed of 4 layers: mucosa, submucosa, muscular, and adventitia.3,4 The esophageal mucosa is lined with nonkeratinizing stratified squamous epithelium. The Z-line is a visible interface, just proximal to the EGJ that demarks the transition between the esophageal squamous and gastric columnar mucosa. The submucosa contains connective tissue, mucous glands, and extensive lymphatic and vascular networks.1 The muscular layer provides motor function and consists of inner and outer layers. In the abdominal esophagus, the inner circular muscle fibers thicken and become more semicircumferential and interconnected to form the intrinsic component of the lower esophageal sphincter (LES).1 The adventitia is an external layer of connective tissue that covers the esophagus and loosely attaches it to adjacent structures.1 An absence of serosa and mesentery likely facilitates the early dissemination of esophageal cancer.2

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Vascular Supply and Lymphatics

The esophagus receives a rich segmental vascular supply from the inferior thyroid arteries, branches from the aorta, and the left gastric and inferior phrenic arteries.2,3 Esophageal veins arise from the periesophageal venous plexus and drain in a segmental manner that parallels the arterial supply.2,3 Of note, the abdominal esophagus, and some venous collaterals from the midesophagus, drain into the left gastric vein, which is a tributary of the portal venous system. Thus, esophageal malignancies may easily seed the liver.2

The esophagus has an elaborate interconnecting longitudinal network of lymphatic channels and lymph nodes that drain into paraesophageal and regional cervical, mediastinal, gastric, and celiac axis lymph nodes and ultimately into the thoracic duct.2–4 Of note, bidirectional esophageal lymphatic flow and numerous lymphatic connections may facilitate early tumor dissemination beyond regional lymph nodes and result in skip or jump metastases to other portions of the esophagus or distant lymph nodes.1–3,5 The thoracic duct transports 1 to 2 L of chyle each day and ascends in the chest, in close proximity to the esophagus, to drain into the left brachiocephalic vein in the lower neck.6,7 Hence, the duct may be easily injured during esophageal surgery.

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Innervation

The esophagus and stomach are innervated by the autonomic nervous system.1,2 The parasympathetic nervous system, via the vagus nerve (cranial nerve X) and its recurrent laryngeal branches, increases glandular and peristaltic activity and predominantly innervates the upper and LES.1,2 The sympathetic nervous system, from the cervical and thoracic sympathetic chain (spinal segments T1-T10), causes vasoconstriction, sphincter contraction, and relaxation of the esophageal muscular wall.1,2 Unavoidable interruption of the nervous supply related to various procedures may impair the function of the esophagus, stomach, conduit, and small bowel.

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Esophageal Function

The esophagus is composed of motor, mixed, and smooth muscles that contract and relax in a coordinated manner to propel a food or liquid bolus through the esophagus and EGJ into the stomach.2 The upper and lower esophageal “sphincters” are 2 high-pressure functional zones located at the upper and lower ends of the esophagus.1 The upper esophageal sphincter (UES) is a musculocartilaginous structure that is situated between the pharynx and cervical esophagus and functions in tandem with the epiglottis to prevent aspiration.1,2 During swallowing, the UES relaxes so that a bolus may enter the esophagus, while the epiglottis swings down to cover the laryngeal vestibule.1,2 The UES remains closed between episodes of swallowing, to prevent air from entering the esophagus.2 The LES is located at the EGJ and is composed of intrinsic and extrinsic components. The intrinsic component consists of thickened inner circular muscle fibers. The extrinsic component is formed by the right diaphragmatic crus, which encircles the terminal esophagus and increases pressure in the LES related to inspiration. The LES maintains tonic muscular contraction (resting pressure of 15 to 25 mm Hg), which functions to prevent acidic gastric contents from entering the distal esophagus.2,8 The LES naturally relaxes during swallowing, which decreases pressure and allows the bolus to enter the stomach, and then resumes its normal contractile state.2,8

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ESOPHAGEAL CANCER

Introduction

Esophageal cancer is one of the most common malignancies worldwide and is highly lethal, with a reported 5-year survival rate of <10%.9–11 Squamous cell carcinoma (SCC) and adenocarcinoma represent >95% of esophageal malignant neoplasms, and up to 80% of affected patients present with incurable, locally advanced unresectable or metastatic disease, regardless of histology.10,11 For most of these patients, the goal is palliative treatment.12 Recent advances in neoadjuvant chemotherapy (CTX), radiotherapy (XRT), and combined chemoradiotherapy have enhanced local control, increased rates of surgical resection, and improved disease-free survival.3,10 The goal of surgery in carefully selected patients with localized disease is to completely resect and cure the primary tumor.3

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Histopathology and Tumor Location

SCC and adenocarcinoma differ in terms of pathogenesis, epidemiology, tumor biology, staging, and prognosis.10,11,13 Tissue sampling before neoadjuvant therapy or endoscopic resection is imperative to determine histopathologic cell type and grade.11,14 After induction therapy, obliterative changes may impair tumor characterization.

SCC is almost always due to tobacco and/or alcohol use and begins as epithelial dysplasia and progresses stepwise to carcinoma in situ and then invasive carcinoma. Most SCCs arise in the mid or upper third of the esophagus, and may directly invade the central airway and manifest as an esophageal-airway fistula.11 SCC tends to first recur with locoregional metastases.10,11

Adenocarcinoma is almost always the sequela of chronic mucosal inflammation from long-term GERD, arising from foci of normal squamous mucosa in the lower esophagus that have been replaced with metaplastic intestinal columnar cells (Barrett esophagus) of any length of involvement.11,15 Barrett esophagus can be recognized on endoscopy and requires biopsy confirmation. Barrett esophagus may progress to low-grade then high-grade dysplasia, intramucosal adenocarcinoma and then adenocarcinoma.11 Up to 10% of patients with GERD suffer from Barrett esophagus. An overall 40% of patients who undergo esophagectomy for high-grade dysplasia have occult cancer.16 Adenocarcinoma typically occurs in the distal esophagus and EGJ and commonly recurs with distant metastases.10,11

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Staging of Esophageal Cancer

See text, Supplemental Digital Content 1 (http://links.lww.com/JTI/A141),17,18 which reviews the seventh edition (2010) of the American Joint Committee on Cancer (AJCC) of TNM staging of esophageal cancer. (Table 1, Seventh edition AJCC/UICC staging categories for esophageal cancer.)19 A detailed review of esophageal cancer staging is beyond the scope of this manuscript. The current eighth edition revision (2017) of the AJCC/Union for International Cancer Control (UICC) Staging of Cancers of the Esophagus and EGJ provides separate classifications for clinical (cTNM), pathologic (pTNM), and postneoadjuvant (ypTNM)-stage groups.14 The eighth edition further clarifies specifics of tumor location.14 The tumor epicenter and length of the cancer are determined from upper and lower border measurements on endoscopic ultrasound (EUS) or computed tomography (CT).19 For treatment planning, it is critical to report the superior border for cancers of the upper esophagus, the lower border for cancers of the lower thoracic esophagus and EGJ, and the resectability of the radial (axial) tumor margins.19 When the epicenter of an adenocarcinoma is confined within 2 cm into the gastric cardia, it is staged as esophageal cancer, whereas those with greater inferior extension are staged as gastric cancers.19 Nonetheless, patients with adenocarcinoma of the distal esophagus, EGJ, and/or gastric cardia typically undergo the same preoperative neoadjuvant therapy and are then assessed for suitability of surgical resection.12

TABLE 1

TABLE 1

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Diagnostic and Staging Modalities

Barium esophagram examines esophageal function and may identify mucosal abnormalities, strictures, and obstruction. These may be confirmed with esophagogastroduodenoscopy (EGD) and may be managed with intraluminal tumor laser ablation, balloon dilation, or stent placement, when appropriate. EUS is the imaging modality of choice for evaluation of tumor staging, as it can accurately depict the layers of the esophageal wall and depth of tumor invasion and can evaluate regional lymph nodes.19–21 EUS with fine-needle aspiration is the preferred method for locoregional staging of paraesophageal and some mediastinal lymph nodes and may even assess abdominal lymph nodes around the celiac axis.20 More invasive lymph node sampling via thoracoscopy, laparoscopy, or mediastinoscopy may be needed.19 Bronchoscopy should be performed on all patients to assess for synchronous cancer or airway invasion from a proximal esophageal cancer.

Initial staging CT of the chest and abdomen, with intravenous and oral contrast, may accurately depict mural thickening, focal nodularity, polypoidal lesions, and local tumor invasion.10,20 CT angiography of the abdomen and pelvis may be needed to assess the vascularity of potential conduits. Whole-body positron emission tomography (PET)-CT with fluorodeoxyglucose (FDG) is more sensitive than contrast-enhanced CT or EUS for the detection of distant metastases.10 Whole-body PET-CT imaging is the gold standard in restaging patients with locally advanced disease after initial induction therapy.10 Suspicious PET findings should be confirmed with a biopsy before excluding a patient from surgical consideration.10 Diagnostic laparoscopy is typically recommended to exclude peritoneal metastases in patients with potentially resectable clinical T2-T4 adenocarcinomas of the distal esophagus and EGJ.10

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Necessity for Surgery

Minimally Invasive Resection

Complete resection of the primary cancer, with satisfactory tumor-free margins, is essential to obtain a cure. In a subset of patients who have well-delineated Barrett esophagus or high-grade dysplasia, or in select patients with T1a esophageal cancer (confined to the mucosa), EMR and RFA are FDA-approved endoscopic potentially curative alternatives to esophagectomy, with low morbidity and mortality.22–24 However, patients with T1a have a 7% risk of regional nodal metastases; thus, the residual tumor may remain untreated.16 With EMR, a solution is injected into the submucosa under the target lesion, and the specimen, including both mucosa and submucosa, is sucked into a cap on the end of the endoscope and resected with a snare. With RFA, an electrode mounted on an endoscope delivers heat energy to directly eradicate the targeted lesion. Surgical risks for EMR and RFA include bleeding, perforation, and stricture formation.19,23,24

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Esophagectomy Alone

Esophagectomy (and optimum lymphadenectomy) alone, without neoadjuvant therapy, may be recommended for patients with early stage T1N0 and T2N0 esophageal and EGJ cancer, regardless of histology.3,13,24 In addition, those with Barrett esophagus with nodular, long-segment, or multifocal involvement or high-grade dysplasia, are unlikely to have node metastases and may also benefit from esophagectomy alone.3,13,24

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Combined Modality Therapy and Consideration for Esophagectomy

For patients with T3N0, T4N0, or clinically node-positive thoracic esophageal cancer, combined modality therapy may be recommended, rather than esophagectomy alone.3,13,19 Most of these patients may be treated with neoadjuvant CTX, combined with XRT in select patients with bulky tumor or tumoral invasion of the diaphragmatic crus or the aorta, followed by esophagectomy.13

Neoadjuvant CTX may decrease tumor size and locoregional involvement and “sterilize” microscopic metastases.3,9,13 Preoperative XRT may reduce the size of marginally resectable tumors and treat local tumor extension, without adversely affecting surgical resection or surgical morbidity.9 Postoperative XRT may be used to control gross residual locoregional tumor and eradicate the residual microscopic disease.9,13 Following neoadjuvant therapy, esophagectomy should be considered for all surgically eligible patients with adenocarcinoma and for patients with SCC who have had an incomplete endoscopic response to chemoradiotherapy.13 Patients with SCC have higher rates of complete response following neoadjuvant therapy, and nonoperative management is then an option.13 Definitive chemoradiotherapy is a reasonable approach for patients who are not surgical candidates.12,13

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ESOPHAGECTOMY FOR ESOPHAGEAL CANCER

Introduction

Esophagectomy constitutes the most radical procedure with regard to the treatment of esophageal pathologies and may be the only viable therapeutic option for some benign and malignant diseases. Esophageal cancer is always surgically approached through the abdomen, with additional access through the chest and/or neck.3 The selected approach is predicated on tumor location, histology, and stage; previous interventions (surgeries, CTX, and/or XRT); anticipated type of conduit; and surgeon preference.3 Surgical approaches include right thoracic with intrathoracic anastomosis (Ivor Lewis), right thoracic with neck anastomosis (McKeown), and left thoracoabdominal (Sweet approach) and transhiatal esophagectomies and may be performed with minimally invasive technique or open laparotomy and muscle-sparing thoracotomy. The conduits used for reconstruction include the stomach (preferred due to robust blood supply), colon, and jejunum. The reconnection route may be posterior right mediastinum (along the course of the esophagus) or retrosternal. This discussion covers surgery for thoracic esophageal lesions. Resection and reconstruction of cervical esophageal neoplasms are the domain of head and neck surgery.

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Esophagectomy: Surgical Approaches

See text, Supplemental Digital Content 2 (http://links.lww.com/JTI/A142),25–33 which reviews the historical perspective of esophageal surgery.

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Transhiatal Esophagectomy

Transhiatal esophagectomy is performed through abdominal and cervical incisions, with the conduit, preferentially the stomach, tunneled through the thorax, and the anastomosis is performed in the neck.3 This approach avoids a thoracotomy and an intrathoracic anastomosis. Other benefits include en bloc esophagectomy of distal esophageal and EGJ tumors, the ability to maximize the proximal resection margin, better management of an anastomotic leak in the neck, should one occur, decreased symptoms of reflux, and fewer pulmonary complications.34,35 Limitations include the less than optimal ability to perform adequate 2-field lymphadectomy of the abdomen and chest.

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“Two-hole” Ivor Lewis Esophagectomy

“Two-hole” Ivor Lewis esophagectomy utilizes abdominal and right thoracotomy incisions, and the stomach is tailored into a gastric tube (conduit) to replace the esophagus, with a single anastomosis, typically in the upper chest at or above the level of the azygous vein3,36,37 (Fig. 1). The Ivor Lewis esophagectomy permits en bloc resection of mid and distal esophageal and EGJ tumors, facilitates completion of a 2-field lymphadenectomy, and allows direct view of nearly the entire length of the conduit from the anastomosis to the diaphragm.39 This may be the preferred approach in patients with previous surgery or XRT of the neck. However, it may not be the ideal procedure for cancers of the upper thoracic or midesophagus with proximal extension, as it may be difficult to obtain adequate tissue margins. Complications include anastomotic leak within the thorax, which may be devastating due to the risk of mediastinitis and sepsis. Because the proximal esophagus is not resected, skip metastases to the remnant esophagus and cervical lymph nodes, if present, will not be resected.3

FIGURE 1

FIGURE 1

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“Three-hole” McKeown Esophagectomy

“Three-hole” McKeown esophagectomy includes a right thoracotomy and abdominal and cervical incisions. The stomach is used as the conduit, and a single anastomosis is performed in the neck, which decreases morbidity by circumventing an intrathoracic leak3 (Fig. 2). The left clavicular head and first rib may be resected to facilitate access. This approach allows en bloc resection of the mid and distal esophageal and EGJ tumors as well as three-field lymphadenectomy. The neck anastomosis also allows a more proximal resection margin of the esophagus, which is particularly important for proximal thoracic tumors and diffuse esophageal diseases such as achalasia.40,41 The cervical anastomosis will likely be outside of radiation ports if postoperative XRT is needed.3 Complications include recurrent laryngeal nerve injury during neck dissection, high rate of anastomotic leak due to the greater possibility of tension and ischemia at the cervical anastomosis, and chyle leak in the neck.38,41,42

FIGURE 2

FIGURE 2

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The Left Thoracoabdominal Approach

The left thoracoabdominal approach has largely been supplanted by other techniques, but remains relevant today for wide exposure of the cancer field, for the ability to perform extensive locoregional lymphadenectomy, as a reoperative approach for benign or malignant esophageal disorders or complicated perforations, and for ease of reconstruction.43–46 It requires a left thoracoabdominal and diaphragmatic radial incision (and repair) and provides great exposure of the mediastinum from the EGJ to the aortic arch. The stomach is typically used as the conduit, and the anastomosis may be performed in the chest or neck. The approach also allows Roux-en-Y reconstruction of the conduit to the jejuneum. Contraindications include prior left thoracotomy or diaphragmatic dysfunction. The diaphragm incision may increase respiratory morbidity, and dissection behind the aortic arch may injure the aorta.

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Minimally Invasive Esophagectomy (MIE)

MIE was initially described by Cuschieri, DePaula, and their colleagues and represents one of the most recent developments in the natural evolution of esophageal surgery.47,48 Although it requires advanced and complex laparoscopic and thoracoscopic skills, MIE has been adopted by the thoracic surgical community because it is a safe and oncologic equivalent alternative to open surgery and may be used for the Ivor Lewis, McKeown, and tranhiatal approaches.3 With MIE, patients experience less pain and an expedited recovery.49,50 In addition, gastrectomy and Roux-en-Y reconstruction can be performed as minimally invasive surgeries when needed.51,52

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Surgical Techniques for Ivor Lewis and McKeown Esophagectomy

Abdominal Portion

The procedure begins with EGD to accurately define tumor location and any proximal extent of Barrett esophagus.50 The abdomen is insufflated with carbon dioxide (CO2) and closely inspected for occult metastases. The proper position of the gastric conduit starts with careful mobilization and stretching of the stomach, taking care to minimize torsion and preserve the right gastroepiploic vascular arcade of the greater curvature. If the tumor bed has been radiated, a well-vascularized omental flap is mobilized to be used to buttress the intrathoracic anastomosis. An extensive lymph node dissection is performed along the celiac axis and left gastric vessels. A pyloroplasty is performed to reduce the risk of gastric outlet obstruction.3 To replicate normal anatomy, a narrow 3 to 5 cm-diameter gastric conduit is created from the greater curvature, with a small subdiaphragmatic gastric antral reservoir. To accomplish this, several staple loads are fired parallel to the lesser curve of the stomach to the tip of the fundus. The conduit is now separated from the specimen (the lesser curve of the stomach and the esophagus) and is tacked with a single suture to the esophageal specimen to maintain proper orientation. The surgeon uses a marking stitch, just above the new gastric reservoir, to help gauge the amount of conduit that is introduced into the chest and to minimize redundancy, unless more length is needed for the anastomosis. The size of the hiatus is carefully calibrated to the that of the conduit, as a mismatch may be a precursor for a paraconduit hernia or conduit obstruction or redundancy.39 A feeding jejunostomy tube (j-tube) is placed laparoscopically, and the jejunum is tacked to the left midabdominal wall. Gastric branches of the vagal nerves are unavoidably sacrificed, which will impair conduit emptying after esophagectomy.

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Thoracic Portion

A total of 5 surgical ports are placed, and the right hemithorax is insufflated with CO2.50 The posterior mediastinal pleura is incised, and the esophagus is directly visualized and mobilized from the hiatus to the azygous vein. A radical thoracic lymphadenectomy is performed, to include all lymph nodes from level 9 (inferior pulmonary ligament), level 8 (paraesophageal), and level 7 (subcarinal). The esophagus is then transected above the azygous vein, and the specimen is pulled into the chest, with the conduit attached. The specimen is then removed. The conduit is carefully introduced into the right posterior hemithorax/mediastinum, and, to prevent spiraling, it is oriented so that the anterior surface of the conduit faces anteriorly and so that the conduit staple line, along the right side of the conduit, faces the right lateral aspect of the chest (Fig. 3). The high thoracic anastomosis may be performed end-to-end or end-to-side and may be buttressed with an omental flap to improve perfusion3 (Fig. 4). The McKeown anastomosis is performed end-to-end in the left neck, and, postoperatively, it may straighten out and descend into the upper mediastinum (Fig. 5). At this time, the size of the hiatal opening relative to the conduit is reassessed and may be adjusted. The conduit may be anchored to the right crus to prevent herniation of the conduit reservoir. The thoracic duct is not routinely ligated.

FIGURE 3

FIGURE 3

FIGURE 4

FIGURE 4

FIGURE 5

FIGURE 5

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Postoperative Imaging

The standard lines and tubes include a 28 Fr chest tube, with the tip positioned in the posterior right apex. A Jackson Pratt (JP) drain is placed posterior to the anastomosis, drains via the right chest wall, and is gradually pulled back to prevent it from serving as a nidus for dehiscence. A nasogastric tube is advanced 40 cm into the conduit. For the McKeown approach, a cervical drain is placed in the left neck, and the wound is loosely closed with staples. A left pleural pigtail catheter may be placed for pneumothorax or pleural effusion. The lung bases may have small atelectasis and effusions. Mediastinal surgical clips track along the esophagectomy site. Clustered surgical staples in the lower right chest wall reflect the thoracoscopic incisions, which may be potential sites of persistent air leak, pleurocutaneous fistula, or subsequent lung herniation.

Chylothorax typically occurs within several days of the thoracic duct injury and may have devastating consequences.6,7 Chylous effusion is an inert exudative lymphocytic effusion and typically has a milky color, an elevated triglyceride count, and chylomicrons. On CT, chylothorax typically manifests as a unilateral “simple” pleural effusion of water attenuation, without pleural thickening, and may rapidly enlarge when untreated.

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Postoperative Complications Following Ivor Lewis and McKeown Esophagectomy

Perioperative and Early Postoperative Complications

Early complications include respiratory complications, hemorrhage, pleural effusion to include chylothorax, pneumothorax, injury of the recurrent laryngeal nerve or airway, and pulmonary embolism.38,53–55 Injury of the thoracic duct from a left neck incision may also result in chyle leak.6,7 Most conduit leaks occur at the anastomosis but may occur at any of the resection sites.38 In a series of 533 patients undergoing Ivor Lewis MIE, 23 (4%) developed an anastomotic leak that required surgical intervention, and 9 (2%) developed conduit necrosis.56 Affected patients may present with unexplained tachycardia, respiratory failure, or leukocytosis, and endoscopy should be performed early to search for anastomotic leak and conduit ischemia.57 An anastomotic leak on postoperative day 3 typically reflects anastomotic dehiscence and may manifest on CT as extraluminal gas or fluid collection near the anastomosis or conduit suture line58 (Fig. 6). A leak at days 3 to 7 may reflect ischemia of the conduit, usually at the suture line, possibly due to compromise of the gastric blood supply or torsion of the conduit.58,59 A leak may result in a mediastinal abscess, conduit stricture, or fistula from the conduit to the airway, mediastinum, or aorta (Fig. 7). A leak may manifest on esophagram as an extraluminal collection of contrast.38 Endoscopy is the most sensitive method to evaluate conduit viability and should be performed early. CT has low sensitivity for the detection of ischemia but may reveal gas in the soft tissues of the neck or mediastinum, or may present as a perianastomotic or mediastinal fluid collection.60 Small leaks and mild cases of ischemia, with good JP drainage and no associated sepsis, may be treated conservatively.57,58 Larger thoracic collections should be drained via pigtail catheter or chest tube placement. In the setting of sepsis and extensive intrathoracic collections, surgical intervention may be needed. Full-thickness conduit necrosis is a disastrous, potentially lethal complication and requires débridement, emergent conduit take-down into the abdomen, or conduit resection, cervical esophagostomy, and enteral feeding tube placement, with the eventual long-term goal of conduit reconstruction57,58 (Fig. 8).

FIGURE 6

FIGURE 6

FIGURE 7

FIGURE 7

FIGURE 8

FIGURE 8

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Late Complications

Delayed complications include anastomotic strictures, long-term conduit dysfunction, obstruction of the conduit at the diaphragmatic hiatus or of the proximal small bowel, torsion of the conduit, and conduit and paraconduit hernias. In addition, intestinal mobility disorder (dumping syndrome), bile reflux esophagitis due to loss of the LES, postoperative thoracic pain syndrome, and tumor recurrence may also occur.39,61

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Anastomotic Strictures

The incidence of anastomotic strictures after esophagectomy ranges from 10% to 56% and may occur early or late in the clinical course.58,62 The majority (83%) of anastomotic strictures that occur in the first year are benign and typically respond well to early dilation.63 Affected patients may experience symptoms of obstruction such as aspiration and dysphagia. On esophagram, a stricture manifests as focal luminal narrowing at the anastomosis (Fig. 9). On CT, the esophagus proximal to the anastomosis may be dilated and contain an air-fluid level (Fig. 10). While the incidence of benign anastomotic strictures is relatively high, current management is highly effective and includes chronic proton-pump inhibitor therapy and early endoscopic dilations.64 Risks of dilation include perforation and potential fistula formation (Fig. 11). In contrast, almost all strictures that occur after 1 year are malignant, may not respond to dilation, and may need placement of a stent63 (Fig. 12).

FIGURE 9

FIGURE 9

FIGURE 10

FIGURE 10

FIGURE 11

FIGURE 11

FIGURE 12

FIGURE 12

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Conduit Dysfunction

The long-term durability of a gastric conduit is inherently compromised because it is denervated, lacks peristaltic activity, and relies solely on gravity for emptying. Hence, any process that changes conduit position, size, or shape or impinges on the distal aspect of the conduit, over time, may severely impair emptying, increase luminal pressure, promote conduit dilation and redundancy, and cause food to back up.39 Affected patients typically present with dysphagia, odynophagia, recurrent aspiration pneumonias, reflux, and other obstructive symptoms. A barium swallow may evaluate conduit size, shape, and position and its ability to empty. CT may assess conduit torsion or obstruction, conduit and paraconduit hernias, and tumor recurrence. An upper endoscopy may characterize the conduit caliber, shape, and obstructive features, including tumor recurrence.

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Obstruction of the Functional Hiatus or Proximal Small Bowel

Obstruction of the functional hiatus or proximal small bowel at the pylorus or at the j-tube site may impair conduit function. Kent et al39 reported that of 21 patients undergoing conduit revision, 54% had mechanical obstruction from a narrowed hiatus or pyloric obstruction, and 23% had a redundant conduit. A small hiatal orifice, relative to the size of the conduit, may compress the conduit and impair emptying (Fig. 13). A small hiatal orifice and pyloric obstruction both respond well to endoscopic dilatation. In refractory cases, surgical revision of the hiatus or pyloroplasty or pyloromyotomy may be needed. Obstruction at the site of the previous j-tube, due to adhesions or angulated loops of bowel, may require lysis of adhesions.

FIGURE 13

FIGURE 13

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Torsion

Torsion may occur when the conduit is rotated, as it is pulled into the chest and may result in outflow obstruction. Patients may be profoundly symptomatic. On CT of a normally positioned conduit, the lesser curve staple line should course along the 9 o’clock position of the conduit from below the diaphragm to the anastomosis. Any rotation of the staple line beyond 90 degrees is considered torsion, and torsion rarely exceeds 120 degrees’ rotation.39 In the series by Kent et al,39 3 of 43 esophagectomy patients (14%) with redundant conduit had torsion. Torsion may manifest as a corkscrew configuration of gastric folds on endoscopy, esophagram, and CT (Figs. 14, 15).

FIGURE 14

FIGURE 14

FIGURE 15

FIGURE 15

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Herniation of the Conduit Gastric Reservoir and/or Paraconduit Hernias

Herniation of the conduit gastric reservoir and/or paraconduit hernias occurs in ~4% of patients after esophagectomy, with a mean time to diagnosis of 32 months.39 The subphrenic reservoir may herniate into the chest secondary to a large diaphragmatic defect or when sutures securing the conduit to the diaphragm are disrupted (Figs. 16, 17). Over 90% of paraconduit hernias, typically involving the colon, omentum, and occasionally the small bowel, occur through the hiatus to the left of the conduit, extend into the left hemithorax, and impinge on the conduit39 (Fig. 18). The herniated bowel may cross to the right of the midline, anterior or posterior to the conduit.39 (See Fig., Supplemental Digital Content 3, http://links.lww.com/JTI/A143, which illustrates a left paraconduit hernia that contains small bowel and crosses into the right hemithorax.) (See Fig., Supplemental Digital Content 4, http://links.lww.com/JTI/A144, which depicts a left paraconduit hernia that contains colon, herniates to the right of the midline, and obstructs the conduit.) Conduit and paraconduit hernias may ultimately narrow the hiatus and result in a large, dilated, redundant, sometimes sigmoid-shaped conduit that further impedes emptying and may contain a gas-fluid level. A shelf may form within the redundant conduit, creating an area where food may accumulate, which further obstructs the lumen (Fig. 15). (See Fig., Supplemental Digital Content 5, http://links.lww.com/JTI/A145, which shows a dilated conduit that is obstructed with a shelf.) Herniated contents may strangulate and perforate.

FIGURE 16

FIGURE 16

FIGURE 17

FIGURE 17

FIGURE 18

FIGURE 18

All patients with a paraconduit hernia, even when asymptomatic, should undergo repair to reduce the hernia and resuture the conduit to the diaphragm. Reduction of herniated/redundant conduits may be achieved laparoscopically; small diaphragmatic defects may be closed primarily with sutures, while large defects may require mesh, preferentially absorbable, as a nonabsorbable mesh has the potential to erode into the conduit.39 When additional mobilization of the thoracic portion of the conduit is needed, a combined laparoscopic-thoracoscopic approach may be used. After hernia repair, ~30% of affected patients will develop a second or third paraconduit hernia, also to the left of the conduit, and these must be repaired.39

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Surgical Revision of the Conduit

After nonsurgical management has failed, postesophagectomy patients with conduit complications and unremitting, unbearable symptoms may be considered for conduit revision.39 The average time from esophagectomy to conduit revision has been reported at 3.8 years.61 The goal of surgery is to restore a straight, narrow, nonredundant conduit, with a small subdiaphragmatic reservoir. The anatomic changes of the conduit will dictate the surgical revision. Conduit length typically is not a factor in revisional surgery, as conduits are usually redundant and dilated. Most conduits can be corrected with reduction, retubularization, and/or revision of the anastomosis. Regardless of the exact revision, the vascular arcade to the conduit must be preserved. Herniated abdominal contents may be reduced laparoscopically, and diaphragmatic defects may be closed primarily or with mesh. A combined laparoscopic-thoracoscopic approach is typically used when the anastomosis needs to be revised or when the thoracic portion of the conduit needs to be mobilized.

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Treatment of Tumor Recurrence

After esophagectomy, the overall 5-year survival rate remains a dismal 25%, predominantly due to tumor recurrence after a disease-free period.65 It has been reported that within 2 to 3 years after esophagectomy, more than half of esophageal cancer patients have local tumor recurrence or metastases.65 In one study of 27 consecutive patients, the tumor recurred at the anastomosis in 23 (85%), esophageal remnant in 3 (11%), and conduit in 1 (4%) of the patients.66 Close follow-up should be performed during this time frame to detect early tumor recurrence.65 Fifty percent of the patients with recurrence manifest with symptoms, even while undergoing routine surveillance imaging, while 45% of recurrences are detected during surveillance CT.67 Treatment of recurrent esophageal cancer after primary therapy typically includes palliative CTX-XRT to reduce tumor burden and improve survival.68,69 However, in a small group of highly selected patients estimated at 4%, salvage esophagectomy may be useful in a final attempt to improve survival.68,69

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ACHALASIA

Introduction

Achalasia is an uncommon debilitating idiopathic neurodegenerative disorder due to progressive loss of ganglion cells in the myenteric plexus of the esophageal wall.70,71 It is characterized by failure of relaxation of the LES, absent or ineffective peristalsis in the lower esophagus, EGJ outlet obstruction, and increased intraluminal pressure.71 Patients typically present with the insidious onset of progressive dysphagia, first to solid food followed by liquids, chest pain, and regurgitation of undigested food.70,72,73 Idiopathic achalasia must be differentiated from esophageal cancer, mechanical obstruction, and a variety of other inflammatory or connective tissue diseases.72,74 Affected patients have a small increased risk of developing esophageal cancer, typically SCC.70,72,75

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Traditional Surgical Approaches for Achalasia

The goal of treatment is to palliate symptoms by decreasing LES resting pressure and improving esophageal emptying.75–77 Patients may initially choose the least invasive option, such as endoscopic injection of botulinum toxin (Botox) to decrease LES smooth muscle tone and pressure, before proceeding to mechanical disruption of the LES muscle fibers with endoscopic pneumatic dilation or surgical myotomy.71,76 Heller myotomy, usually combined with partial fundoplication to prevent reflux, has become the gold standard and most reliable treatment choice for achalasia.71,74,75 With Heller myotomy, the esophageal circular and longitudinal muscle fibers of the LES are surgically divided, via open or laparoscopic approach, without disrupting the mucosal lining. Finally, after a long protracted clinical course and multiple esophageal procedures, some patients with debilitating symptoms may elect to have an MIE.77

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Peroral Endoscopic Myotomy (POEM)

POEM is a newer, purely endoscopic alternative to Heller myotomy and is a safe and effective (>90%) approach to treat carefully selected patients with symptomatic primary achalasia or diffuse esophageal spasm.72,78,79 More than 5000 POEM procedures had been performed worldwide by 2016.80 POEM uses a submucosal tunneling technique to access the muscular layer of the esophagus.71,77 Compared with the laparoscopic Heller myotomy, POEM provides comparable relief of symptoms and improved opening of the LES, with fewer postoperative complications and a shorter hospital stay.77,81 POEM is a complex procedure and requires a substantial learning curve.80 The rate of serious adverse events is reported as <5%, but longer-term studies are needed.73,80,81

Relative contraindications to POEM include severe erosive esophagitis, bleeding disorders, and prior therapies that may compromise esophageal integrity, such as XRT, EMR, or RFA.71 Patients at the extremes of age or with end-stage megaesophagus should be approached with caution.71 POEM may be performed safely in patients with achalasia previously treated with Botox injection, balloon dilation, or surgical myotomy.71,77

For preoperative planning of a POEM, an esophagram, manometry to measure esophageal muscular function, EGD, and, in some instances, EUS are critical to exclude malignancy and to confirm the correct diagnosis.72,74,75,80,82,83 With the POEM technique, a flexible endoscope is placed perorally into the esophagus (Fig. 19). A small mucosal incision (mucostomy) is performed 10 to 12 cm proximal to the EGJ, and a submucosal tissue plane is created by using gentle CO2 insufflation and blunt dissection. Using the endoscope, a submucosal tunnel is created and extends 2 to 3 cm beyond the EGJ into the stomach, taking care to avoid mucosal perforation.80 The circular smooth muscle fibers are then divided while preserving the longitudinal muscle layer. The mucosal incision and any mucosal perforation are then completely closed with hemostatic clips.80 When the closure is not deemed adequate, a covered esophageal stent may be placed.71 The hemostatic clips gradually slough into the bowel.81

FIGURE 19

FIGURE 19

Postoperative imaging includes a chest radiograph and esophagram. Hemostatic clips are typically positioned over the lower esophagus at the mucostomy site and may be retained for several weeks81 (Fig. 20). The most common adverse effects are related to CO2 insufflation.80 Pneumomediastinum, pneumoperitoneum, retroperitoneal gas, and gastric pneumatosis are common and expected postoperative changes related to CO2 tracking along tissue planes and escaping through rents in the esophageal wall73,80,81 (Fig. 21). However, when patients experience pain or other atypical symptoms, esophageal or gastric perforation should be excluded.71

FIGURE 20

FIGURE 20

FIGURE 21

FIGURE 21

An esophagram is typically performed 24 hours after the procedure, and the esophagus and stomach are evaluated for intramural dissection or extraluminal leak.81 Intramural dissection has been reported in 30% of POEM and is likely due to a persistent defect at the mucostomy site. Contrast may collect in the submucosal tunnel, which manifests as a thin opaque stripe that parallels the mucosa and typically resolves within several weeks without intervention (Fig. 22). Esophageal leak, with extraluminal contrast, occurs in <1% of POEM cases.80 Management depends on the extent of injury and includes observation, endoscopic repair with hemostatic clips, or placement of a covered stent. CT may be of value in patients with atypical symptoms or suspected leak not confirmed on eosphagram.

FIGURE 22

FIGURE 22

Esophageal distension and dysmotility may be decreased, and emptying may be improved as early as the first postoperative day.71,81 Perioperative complications include delayed mucostomy closure (0.8%), delayed bleeding (0.2%), and hydrothorax (0.5%) and pneumothorax (1.5%) requiring intervention.71,80 Potential long-term complications include recurrent narrowing of the EGJ, reflux that may require an antireflux procedure, and esophageal cancer.71,80

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GERD: LINX IMPLANTATION

Introduction

GERD is one of the most common chronic gastrointestinal diseases in the United States.84 The LINX Reflux Management System (Torax Medical, St. Paul, MN) is an innovative minimally invasive approach to treat carefully selected patients with early uncomplicated GERD.85 The FDA approved the device in 2012. Patients should have objective evidence of GERD, including abnormal pH testing and symptoms that are refractory to maximum medical therapy.85 The laparoscopic Nissen fundoplication has been the traditional surgical gold standard for refractory GERD, but, postoperatively, patients may have difficulty belching and suffer from gastric bloating.86,87 The LINX implantation is an alternative less invasive laparoscopic procedure that does not alter gastric anatomy, typically preserves the ability to belch and vomit, and may be easily reversed. Symptomatic GERD is improved in most patients following LINX placement, and almost 90% of patients no longer need proton-pump inhibitor therapy at 3 to 5 years after implantation.85,88–90

The LINX device consists of a series 10 to 18 interlinked titanium beads with permanent magnetic cores. The device can be individually sized and forms a flexible and expandable annular ring that helps to keep a weak LES closed.85 Each bead can move independently on the sliding titanium wire “links,” but the beads cannot separate completely.84 The magnetic attraction of the beads is stronger than the intragastric pressure, which allows the beads to pull together to help prevent reflux. During swallowing or belching, as the esophagus distends and pressure increases, the magnetic bond is weak enough to allow the beads to spread apart, followed by immediate closure after esophageal pressure decreases84 (Fig. 23).

FIGURE 23

FIGURE 23

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Contraindications

There are 2 versions of the LINX device, and both are considered magnetic resonance imaging (MRI) Conditional. The new version was FDA approved in 2015 and is MRI Conditional for static magnetic fields up to 1.5 T.84 The version implanted before May 2015 is MRI Conditional for static fields up to 0.7 T.84,88 Higher-than-recommended field strengths may permanently interfere with the strength and function of the device, rendering it ineffective, and may potentially cause serious injury to the patient. In instances when an MRI must be performed, the LINX device may be safely removed laparoscopically. The safety and efficacy of the LINX device have not been evaluated in patients with electrical implants such as pacemakers, defibrillators, or other abdominal metallic implants, prior esophageal or gastric surgery, esophageal motility disorders, anatomic abnormalities of the esophagus, varices, pregnancy, and morbid obesity, and those younger than 21 years of age.84,88 A feeding tube with a metallic component should not be placed in a patient the LINX device.

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Surgical Technique

The LINX device is laparoscopically implanted around the abdominal esophagus and is sized according to the diameter of the esophagus.84 The EGJ is dissected circumferentially to expose the outer (longitudinal) muscle layer of the esophagus. The device is placed around the level of the LES, and the ends are secured with a locking clasp. The device may erode into surrounding tissues or migrate when it is not sized appropriately.88 When a sliding hiatal hernia >3 cm is present, the hernia should be surgically reduced to <3 cm, and the diaphragmatic crura may be approximated with sutures.85 There have been no reported deaths, and the intraoperative and perioperative complication rate is 0.1%.84 Long-term results and comparative trials are needed to ensure efficacy and safety.85

Postoperative imaging typically includes a chest radiograph and esophagram (Fig. 24). The device should be seen in the profile below the diaphragm approximately at a 45-degree angle to the horizontal plane. As the beads may move independently, they may not be evenly spaced on imaging studies.84 Contrast should pass easily into the stomach on the esophagram. If the device is too tight, residual contrast may hold up in the esophagus for up to 10 minutes, and the barium tablet may get lodged at the device. (See Figs., Supplemental Digital Content 6, http://links.lww.com/JTI/A146, which illustrate 3 patients with LINX complications). Chest radiography and endoscopy performed at 1 and 2 years after implantation have shown no evidence of device migration or erosion.84

FIGURE 24

FIGURE 24

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Postoperative Complications

The most common side effects after LINX implantation are dysphagia, pain, and gastric bloating. Dysphagia may occur in the first few weeks after surgery but typically resolves to as low as 10% at 1 year and 4% at 3 years.91 Dysphagia may be treated with endoscopic dilation of the EGJ, which ranges from 6% to 12% of patients.84 When dysphagia is persistent, the device may be removed via endoscopy or laparoscopy and has been reported at a rate of 3% to 6%.84 Erosion of the device into the esophageal lumen, typically when the size of the device is too small, is rare and may be treated with the removal of the device.84,88 These patients are then able to undergo subsequent fundoplication.92

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CONCLUSIONS

The surgical approach to the esophagus can be challenging, as the esophagus is intimately associated with vital structures in the neck, chest, and abdomen. Patients with benign disorders of GERD and achalasia or with premalignant or early-stage esophageal cancer may now be treated with minimally invasive or endoscopic techniques such LINX device, POEM, and EMR or RFA, respectively. Patients with localized esophageal cancer or end-stage esophagus from achalasia or those with multiple failed antireflux procedures may need an esophagectomy, with the creation of a conduit. Providers need to understand the surgical approach (abdominal incision with thoracic and/or cervical access), the conduit used (most commonly stomach), and location of the anastomosis (upper thorax or neck).

Concerning esophageal cancer, it is important to understand the typical patterns of tumor spread, the recently updated staging classification, and patterns of tumor recurrence, 45% of which are detected on surveillance imaging. Following esophagectomy, the conduit should be carefully evaluated for debilitating or potentially life-threatening disorders. The imaging checklist should include (1) conduit size, orientation, and integrity of the anastomosis; (2) size of the diaphragmatic hiatus or the presence of a diaphragmatic defect, especially to the left of the conduit; and (3) herniation of the conduit reservoir, paraconduit hernia, or any other encroachment on the hiatus.

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Keywords:

esophageal cancer; esophagectomy; achalasia; peroral endoscopic myotomy; gastroesophageal reflux disease; LINX device

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