Ivor Lewis Oesophagectomy
This operation entails a combined laparotomy and right thoracotomy
What first, laparotomy or right thoracotomy ?
Post operative management
Mid 3rd tumours
Surgery in opposite hemithorax
Pre operative CXR
Note: What first, laparotomy or right thoracotomy ?
In small obviously resectable tumours the laparotomy is performed first, the stomach mobilised, and the laparotomy closed. The patient is then rolled onto their left side and the right thoracotomy part of the operation is performed.
In borderline resectable tumours the thoracotomy may be performed first to assess operability. The thoracotomy does not need to be formally closed, for the patient to be rolled onto their back for the laparotomy to be performed for the gastric mobilisation ( a large Tegaderm can be used for this). The patient is then rolled back onto their left side and the Tegaderm removed and the operation completed.
This procedure was proposed by Ivor Lewis in 1946. It consists of a laparotomy to mobilize the stomach as the conduit. Then, the esophagus is resected through a right thoracotomy incision and an intrathoracic esophagogastric anastomosis is performed.
The Ivor Lewis esophagectomy is chosen for patients that have tumors of esophageal cancer of the middle and lower third of the esophagus. The procedure is performed in two parts. First, in the abdominal portion which includes an exploration and mobilization of the neoesophagus; a gastric conduit. The second involves a right thoracotomy. In the very slender patient both fields may be included in the same operative preparation. We do not make this a common practice.
With the patient lying supinely, the abdomen is prepared in the usual sterile manner; surgical drapes are placed. A vertical upper midline incision is made. Peritoneum is examined for any evidence of metastasis and appropriate biopsies are taken. When intra abdominal metastasis are felt and present in patients, the patients are felt to be unresectable and no further surgery is performed. The laparotomy incision is closed.
The incision and exposure of the upper abdomen prior to mobilisation of the stomach and lower oesophagus
With no evidence of metastasis the greater omentum is incised approximately 2.5 cm away from its attachment to the right gastroepiploic vessels along the greater curvature of the stomach. This dissection is continued along the last gastroepiploic, ligating the short gastric vessels and detaching the greater curvature from the spleen. The lesser omentum is then incised, preserving, if possible, the right gastric artery as well. Any adhesions in the lesser sack are divided. The retroperitoneal attachments of the abdomen in its second and third portions are incised sharply. Once this is completed it should allow the pylorus to reach the esophageal hiatus. The periesophageal tissue and possibly the esophageal cruri may need to be resected along with the lower esophagus which is completely mobilized exposing the left gastric vessels. The left gastric vessels are then ligated taking the associated nodal tissue with it and avoiding any injury to the common hepatic or splenic arteries.
Because the vagas nerves in the cardia are being incised, there is possible postoperative gastric emptying delay. The result of which may increase the likelihood for anastomotic leak in the esophagogastrostomy. The pyloric drainage procedure is sometimes performed, either a pyloroplasty, pylorimotomy, or pylorimyectomy.Esophageal hiatus is enlarged by incising the central tendon anteriorly to the pericardium. This requires ligation of the left phrenic vessels. Once the laparotomy has been completed and wound closed, the patient is then positioned in the left lateral decubitus and a posterior lateral thoracotomy is performed.
The extent of dissection in the posterior mediastinum
Taking the oesophagus and its peri-oesophageal tissue off the pre-vertebral and peri-aortic fascia with the thoracic duct
Through the sixth intercostal space using a single lung ventilation, the inferior pulmonary ligament is transected. Prior dissection is identified and the soft drain is placed around the esophagus at this point. Further dissection is performed to a point approximately 10 cm above the level of the esophageal tumor.
This may require transection of the azygous vein. The esophagus is then transected at this point. The neoesophagus is then pulled up into the posterior mediastinum. The gastric transection is then performed approximately 5 cm away from the GE junction creating a gastric tube.
The gastric fundus is then sutured to the anterior longitudinal ligament with 2 to 3 silk sutures. An end-to-end anastomosis is then performed between the esophagus and the stomach, this can be stapled or hand sewn. Prior to completion of the anastomosis, a nasal gastric tube is past so that the tip of the tube lies just distal to the level of the pylorus. A basilar and an apical chest tube are placed at the end of the procedure. The area is thoroughly irrigated and the thoracotomy closed in the usual fashion
Preparing the conduit. The fundus and lesser curvature are resected in continuity with the diseased oesophagus
A hand sewn anastomosis
Performing the gun anastomosis. In this case the stomach has been transected and not linear stapled
To optimise results of surgery, post-operative management has to be meticulous and suitably targeted in appropriately staffed and equipped locations, usually the High Dependency Unit.
The vast majority of patients can be extubated immediately post-operatively and a chest radiograph carried out in the recovery room to confirm continued full lung expansion and appropriate placement of chest drains. Good epidural analgesia enables the patient to sit upright in bed and to move around, breathe deeply and co-operate fully with physiotherapy.
Fluid balance and oxygen saturations should be closely monitored and oxygen supplementation is mandatory. It is vital to maintain adequate nutrition during the early postoperative period as many of these patients have suffered significant weight loss and are malnourished. Total parenteral nutrition is the preferred choice in the majority of patients as significant problems have been encountered utilising jejunostomy feeding tubes.
Thrombosis prophylaxis is continued by thrombo-embolic deterrent stockings and subcutaneous heparin injections.
Should significant contamination have taken place during the course of dissection prophylactic antibiotics regimens are modified and antibiotics continued for 3-5 days.
It is essential to avoid intra-gastric stasis in the transposed stomach and regular naso-gastric suction is carried out in order to prevent respiratory complications secondary to aspiration. This is so important that the naso-gastric tube may be secured with a suture through the nasal septum or plastic loop around the nasal septum.
Attention to mouth care and pressure areas is vital. The patient is encouraged to move in bed and when epidural analgesia is weaned off (at approximately 48-72 hours) the patient is encouraged to mobilise out of bed.
Contrast swallow is performed on the 5th or 6th postoperative day to confirm the integrity of the anastomosis and patency of the upper gastro-intestinal tract without evidence of holdup. A successful examination is a prelude to removal of the naso-gastric tube and chest drains with check radiographs, thereafter. The patient should then be encouraged to eat and drink small quantities and mobilise fully.
Specific major complications in patients undergoing oesophagectomy include respiratory failure, anastomotic leakage and delayed gastric emptying.
Atelectasis and respiratory insufficiency
These are common after transthoracic oesophagectomy. Good analgesia, physiotherapy, appropriate hydration and early mobilisation are all essential to minimise respiratory complications.
This may occur in the early post-operative period (2-3 days) when it is deemed due to technical failure or later (3-7 days) when it is thought more likely to be due to ischaemic changes in the stomach, usually close to the suture line. This is associated with significant mortality and morbidity. Occasionally, small radiologically demonstrated leaks are seen at 7-10 days but these can be clinically insignificant or associated with little disturbance. These may be treated conservatively with confidence. Early leaks or gastric ischaemia may be associated with profound acidosis and respiratory distress. Such signs should alert the team to the possibilities of a leak or ischaemia and prompt early investigation, preferably by endoscopy, but contrast swallow may also be of help. Early leaks and ischaemia should be treated aggressively by re-exploration and appropriate resection, defunctioning or re-anastomosis where appropriate.
Delayed gastric emptying
This may occur if the stomach lies redundantly in the thorax. Occasionally, it is a consequence of an intact pylorus in a transposed stomach. This complication is best avoided by accurate positioning of the stomach within the chest and ensuring a widely patent pylorus at the time of surgery. Any doubts about patency should lead to the formation of a pyloroplasty. Treatment of delayed gastric emptying is directed at enhancing gastric emptying with Metoclopramide and/or pyloric balloon dilatation.