The Ivor Lewis Esophagectomy

Preparation

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Diagnostic Workup

• Endoscopy with biopsy and EUS
• CT chest/abdomen/pelvis
• PET-CT
• Barium swallow
• Bronchoscopy (for mid/upper tumors)

Surgical Fitness Evaluation

• Pulmonary function tests (PFTs)
• Cardiac evaluation (ECG, echo, stress testing)
• Nutritional optimization
• Anesthesia and dental consults

Prehabilitation

• Smoking and alcohol cessation
• Physical and respiratory therapy

Multidisciplinary Planning

• MDT meeting with oncologists, surgeons, and radiologists
• Plan for neoadjuvant therapy if indicated

Preoperative Protocols

• Clear liquids 24–48 hours pre-op
• Fasting from midnight
• Chlorhexidine showers
• Antibiotic prophylaxis
• Thromboprophylaxis
• Epidural placement for pain control

Patient Positioning

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Phase 1: Abdominal (Laparotomy or Laparoscopy)

• Supine position
• Arms tucked or extended
• Reverse Trendelenburg for exposure
• Padding for pressure points
• Double-lumen tube placed pre-op if thoracic phase planned

Phase 2: Thoracic (Right Thoracotomy or Thoracoscopy)

• Left lateral decubitus position
• Right chest uppermost
• Table flexed to widen intercostal spaces
• Axillary roll under left chest
• Single-lung ventilation confirmed

Minimally Invasive Variations

• Laparoscopy: Supine or modified lithotomy
• Thoracoscopy: Left lateral decubitus or prone
• Robotic assistance may be used

Surgical Approach

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Abdominal Phase

• Goal: Mobilize stomach, create conduit, abdominal lymphadenectomy

Open Approach

• Upper midline or chevron incision
• Explore abdomen for metastases

Laparoscopic Approach

• Multiple small upper abdominal ports
• Pneumoperitoneum created

Key Steps

• Divide gastrocolic ligament, preserve right gastroepiploic artery
• Ligate left gastric artery and vein
• Kocher maneuver if needed
• Mobilize esophagus at hiatus
• Staple and form gastric conduit
• Optional pyloroplasty or botulinum toxin injection
• Feeding jejunostomy placed

Thoracic Phase

• Goal: Mobilize thoracic esophagus, resect tumor, intrathoracic anastomosis

Open Thoracotomy

• Posterolateral incision in 4th–6th intercostal space
• Right lung collapsed

Thoracoscopy (VATS)

• Multiple right chest ports
• Camera and instruments inserted

Key Steps

• Mobilize esophagus and divide azygos vein
• Thoracic lymphadenectomy
• Pull up gastric conduit
• Transect proximal esophagus
• Resect specimen en bloc
• Intrathoracic esophagogastric anastomosis (stapled or hand-sewn)
• Chest tube insertion and closure

Lymphadenectomy

• Abdominal nodes: celiac, left gastric, hepatic, splenic
• Thoracic nodes: paraesophageal, subcarinal, paratracheal
• Typically two-field dissection

Intraoperative Steps

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Abdominal Phase

The Ivor Lewis esophagectomy begins with the abdominal phase, performed via laparotomy or laparoscopy following general anesthesia and appropriate patient positioning.

• Incision and Exploration:
  • Access to the peritoneal cavity via midline or laparoscopic incisions.
  • Systematic inspection to exclude peritoneal or hepatic metastases.
• Gastric Mobilization:
  • Division of the gastrocolic ligament and short gastric vessels.
  • Preservation of the right gastroepiploic artery as the main blood supply to the gastric conduit.
  • Ligation and division of the left gastric artery and vein.
  • Entry into the lesser sac and division of the phrenoesophageal and gastrohepatic ligaments.
  • Dissection of the right crus of the diaphragm.
• Hiatal Dissection and Esophageal Mobilization:
  • Widening of the esophageal hiatus.
  • Circumferential mobilization of the distal esophagus up to the pericardium.
• Gastric Tube Creation:
  • Fashioning of a narrow (4–5 cm) gastric conduit along the greater curvature using linear staplers.
  • Optimization of vascularity and reduction of complications like delayed gastric emptying.
• Lymphadenectomy:
  • Dissection of abdominal lymph nodes along the left gastric, celiac, and common hepatic arteries.
  • Extent tailored to oncologic staging and tumor location.
• Optional Pyloric Drainage:
  • Pyloromyotomy or pyloroplasty may be performed to facilitate gastric emptying.
  • Less commonly performed in minimally invasive procedures.
• Feeding Jejunostomy:
  • Placement of a jejunostomy tube for postoperative enteral nutrition, especially in high-risk patients.
• Closure and Repositioning:
  • Abdominal incisions are closed.
  • Patient is repositioned for the thoracic phase.

Thoracic Phase

Following completion of the abdominal phase, the patient is placed in the left lateral decubitus position for a right thoracotomy or thoracoscopy.

• Thoracic Access and Port Placement:
  • For minimally invasive surgery, several thoracoscopic ports are placed in the right chest.
  • Includes a camera port and multiple working ports.
• Division of the Inferior Pulmonary Ligament:
  • Ligament is divided up to the inferior pulmonary vein.
  • Station 9 lymph nodes resected.
• Mediastinal Dissection and Lymphadenectomy:
  • Mediastinal pleura incised anteriorly and posteriorly.
  • Thoracic esophagus mobilized from the diaphragm to the azygous vein.
  • Lymph node stations 7 (subcarinal), 8 (paraesophageal), 9 (pulmonary ligament), and 10 (hilar) dissected.
• Division of the Azygous Vein:
  • Azygous vein divided using a vascular stapler to allow access to the upper thoracic esophagus.
• Esophageal Transection and Specimen Removal:
  • Proximal esophagus transected above the tumor to ensure clear margins.
  • Specimen including esophagus and attached gastric conduit removed.
• Gastric Conduit Delivery:
  • Prepared gastric conduit is pulled into the thoracic cavity.
• Intrathoracic Esophagogastric Anastomosis:
  • Anastomosis performed with a circular stapler in the upper/mid thorax.
  • Leak test may be performed to ensure anastomotic integrity.
• Omental Flap Placement:
  • Optional wrapping of the anastomosis with a pedicled omental flap to reinforce the site and reduce risk of leakage.
• Chest Tube Placement and Lung Reinflation:
  • One or more chest tubes placed.
  • Lung reinflated under direct vision.
• Closure:
  • Incisions closed.
  • Patient transferred to ICU for postoperative monitoring.

Key Technical and Oncologic Considerations

• Aim for R0 resection with negative proximal, distal, and radial margins.
• Perform adequate two-field lymphadenectomy (abdominal and mediastinal).
• Minimally invasive and robotic techniques are increasingly favored for their reduced morbidity.
• Bronchoscopy is standard preoperatively for mid/upper esophageal tumors to rule out airway invasion.
• Preventive measures include perioperative pulmonary optimization and early mobilization.

Possible Complications and Management

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Anastomotic Leak

• Incidence: 5–15%
• Signs: Fever, dyspnea, pleural effusion, sepsis
• Diagnosis: Contrast study, CT, endoscopy
• Management:
  • Minor: NPO, antibiotics, jejunal feeding, endoscopic stent
  • Major: Reoperation, drainage, esophagostomy if needed

Pulmonary Complications

• Types: Pneumonia, atelectasis, ARDS, pleural effusion
• Prevention: Physiotherapy, mobilization, pain control
• Treatment: Antibiotics, chest drainage, ventilation support

Cardiovascular Complications

• Common: Atrial fibrillation, MI, DVT, PE
• Management: Rate/rhythm control, anticoagulation, cardiac care

Gastric Conduit Necrosis

• Cause: Ischemia
• Signs: Sepsis, blackened conduit
• Management: Emergency reoperation, conduit removal, delayed reconstruction

Chyle Leak

• Cause: Thoracic duct injury
• Signs: Milky chest output
• Treatment:
  • Conservative: NPO, MCT diet, TPN, octreotide
  • Surgical: Thoracic duct ligation

Recurrent Laryngeal Nerve Injury

• Signs: Hoarseness, aspiration
• Management: Voice therapy, medialization

Bleeding

• Intra- or postoperative
• Management: Transfusion, reoperation if needed

Other Complications

• Wound infection
• Delayed gastric emptying
• Anastomotic stricture
• Reflux esophagitis
• Dumping syndrome
• Nutritional deficiencies

Mortality

• Rate: 2–5% in high-volume centers
• Causes: Anastomotic leak, ARDS, MI, sepsis

Principles of Management

• Early detection
• Prompt imaging and labs
• Source control
• Supportive therapy
• Multidisciplinary approach