Chapter 5. Transhiatal Esophagectomy

• Resectable esophageal carcinoma.
• Barrett esophagus with high-grade dysplasia.
• Carcinoma of the cardia or proximal stomach.
• Achalasia.
• Advanced disease (mega-esophagus).
• Failed esophagomyotomy.
• Benign (undilatable) stricture.
• Recurrent hiatal hernia or reflux esophagitis following multiple hiatal hernia repairs.

Absolute

• Biopsy-proven distant metastatic (stage IV) esophageal cancer.
• Tracheobronchial invasion by upper or mid-third tumors visualized on bronchoscopy.
• Aortic invasion demonstrated on MRI, CT scan, or endoscopic ultrasound (EUS).

Relative

• Cardiopulmonary comorbidities.
• Previous esophageal surgery causing excessive mediastinal adhesions.
• Previous radiation therapy (more than 6–12 months prior) causing mediastinal and esophageal radiation fibrosis.

• After induction of general anesthesia, flexible endoscopy is performed by the operating surgeon to verify the exact location of the mass or abnormality and to ensure that there is an adequate normal length of proximal esophagus above for construction of a cervical esophagogastric anastomosis.
• Following completion of endoscopy, a 16 French nasogastric tube is placed to evacuate air from the stomach.
• The patient should be supine with a folded blanket under the shoulders to provide adequate neck extension.
  • The head is turned to the right and supported on a padded head ring.
  • The skin of the neck, chest, and abdomen is prepared and draped from the angle of the mandible superiorly to the pubis inferiorly, and from both midaxillary lines anteriorly.
  • Both arms are padded and tucked at the patient's side following the placement of arterial and venous access lines.

• Immediate postoperative chest radiograph while the patient is in the operating room to exclude unrecognized pneumothorax or hemothorax.
• Extubation in the operating room and initiation of epidural anesthesia.
• Early use of an incentive spirometer within several hours of awakening from anesthesia.
• Early ambulation beginning on postoperative day (POD) 1.
• Ice chips by mouth (not to exceed 30 mL/h) for throat comfort until the nasogastric tube is removed on POD 3.
• Initiation of oral liquids on POD 4, with progressive daily advancement to full liquids, then mechanical soft (pureed) diet, and a soft diet by POD 7.
• Initiation of jejunostomy tube feedings on POD 3 and tapering as oral intake increases.
• Monitoring for resolution of ileus.
• Barium swallow examination on POD 7 to document integrity of the anastomosis, adequate gastric emptying through pylorus and hiatus, and absence of obstruction at the jejunostomy site.
• If oral intake is poor, nocturnal jejunostomy tube feeding supplementation can be used.
• If the patient is eating well and has no complications, the jejunostomy tube can be removed 4 weeks postoperatively during follow-up examination.

Intraoperative

• Pneumothorax.
• Hemothorax.
• Uncontrollable mediastinal bleeding (< 1%).
• Need for thoracostomy tubes due to entry into pleural cavity (75%).
• Iatrogenic splenectomy (3%).
• Membranous tracheal laceration (< 1%).
• Injury to the gastric or duodenal mucosa during pyloromyotomy (< 2%).

Early Postoperative

• Recurrent laryngeal nerve injury (< 1–2%) causing hoarseness and difficulty swallowing.
• Chylothorax (1%).
• Cardiac ...