McKeown esophagectomy

Patient Preparation

Preoperative Measures

• Nutritional Optimization: Feeding tube if needed; clear liquid diet pre-op.
• Comorbidity Management: Control of cardiac, pulmonary, renal disease, and diabetes.
• Smoking and Alcohol Cessation: Strongly encouraged preoperatively.
• Pulmonary Preparation: Breathing exercises, physiotherapy.
• Skin Preparation: Antiseptic showers (e.g., 4% CHG).
• Bowel Preparation: Sometimes ordered depending on surgeon’s preference.
• Medication Review: Discontinuation of anticoagulants or antiplatelets as necessary.
• Informed Consent: Explanation of surgery, hospital stay, risks, and recovery.
• Prophylactic Measures: Antibiotics, thrombosis prevention, urinary catheter insertion.

Patient Positioning

• Abdominal Phase: Supine or reverse Trendelenburg.
• Thoracic Phase: Left lateral decubitus or semi-prone, right chest exposed.
• Cervical Phase: Supine with head turned right, neck exposed for anastomosis.

Modified approaches may reduce repositioning by combining positions and minimizing disinfection.

Surgical Approach

Classical Open McKeown

1. Laparotomy: Stomach mobilization, abdominal lymphadenectomy, jejunostomy.
2. Right Thoracotomy: Esophageal mobilization, mediastinal lymphadenectomy.
3. Cervical Incision: Esophagus removal, cervical anastomosis.

Minimally Invasive (MIE)

• Laparoscopy: For abdominal phase.
• VATS or RATS: For thoracic phase.
• Cervical Incision: Still necessary for anastomosis.

MIE may use uniportal or multiportal access to reduce trauma and speed recovery.

Intraoperative Steps

I. Abdominal Phase

• Exploration and Staging: Rule out metastasis.
• Gastric Mobilization:
  • Preserve right gastroepiploic artery.
  • Divide short gastric and left gastric vessels.
• Kocher Maneuver: Mobilize duodenum for length.
• Pyloric Drainage (Optional): Pyloroplasty or pyloromyotomy.
• Gastric Conduit Formation: Tube (3–4 cm) fashioned with staplers.
• Lymphadenectomy: Around celiac, hepatic, splenic, and gastric arteries.
• Jejunostomy: For postoperative nutrition.
• Hiatal Dissection: Circumferential mobilization.

II. Thoracic Phase

• Lung Isolation: One-lung ventilation.
• Pleura Incision: From diaphragm to thoracic inlet.
• Esophageal Mobilization: Circumferential dissection with en bloc lymphatics.
• Azygos Vein Ligation: Improves access.
• Thoracic Duct Ligation: Reduces chyle leak risk.
• Lymphadenectomy: Paraesophageal, subcarinal, paratracheal, others.
• Conduit Passage: Coordination with abdominal/cervical teams.

III. Cervical Phase

• Neck Incision and Exposure: Anterior to sternocleidomastoid.
• Esophagus Identification: Careful nerve preservation.
• Conduit Delivery: Pulled gently through mediastinum to neck.
• Esophagectomy and Anastomosis: Gastric conduit joined to cervical esophagus.
• Drainage and Closure: Neck drain placed, wounds closed in layers.

Intraoperative Nerve Monitoring (IONM) may be used to protect the recurrent laryngeal nerves.

Possible Complications and Management

Early Complications

• Anastomotic Leak:
  • Cervical: Neck swelling, discharge, crepitus.
  • Management: Conservative care, antibiotics, drainage, stent if needed.
• Pulmonary Complications:
  • Pneumonia/Aspiration, Atelectasis, Pleural Effusion.
  • Management: Physiotherapy, antibiotics, drainage.
• Cardiac Arrhythmias:
  • Atrial Fibrillation.
  • Management: Medications, anticoagulation.
• Nerve Injury:
  • Recurrent laryngeal nerve palsy.
  • Management: Conservative, speech therapy, surgical if persistent.
• Chyle Leak:
  • Management: Dietary, TPN, surgical repair.
• Bleeding:
  • Management: May require reoperation.
• Wound Infection:
  • Management: Antibiotics, drainage.
• DVT/PE:
  • Management: Anticoagulants, mechanical prophylaxis.
• Delayed Gastric Emptying:
  • Management: Prokinetics, dietary changes.

Late Complications

• Anastomotic Stricture:
  • Management: Endoscopic dilation.
• Gastroesophageal (Bile) Reflux:
  • Management: PPIs, diet, bed elevation.
• Dumping Syndrome:
  • Management: Low-carb meals, frequent small meals.
• Malabsorption/Nutrient Deficiencies:
  • Management: Diet counseling, supplements.
• Diaphragmatic Hernia:
  • Management: Surgical repair.
• Dysphagia:
  • Management: Based on etiology (stricture, recurrence, motility).

Effective postoperative care and follow-up are essential for optimal recovery and monitoring.