Transhiatal Esophagectomy - Procedure, Benefit, and Complications

Introduction

Transhiatal esophagectomy (THE) is a surgical procedure to remove a portion of the esophagus (a muscular tube connecting the mouth to the stomach). This surgery is typically performed in cases where the patient has been diagnosed with esophageal cancer, a malignant tumor that develops in the esophagus. The success rate of transhiatal esophagectomy varies depending on patient selection, disease stage, surgical technique, and postoperative care, but studies suggest a 5-year survival rate of approximately 30-50%. This article will discuss the basics of transhiatal esophagectomy, including the indications, technique, and potential complications.

What Are the Indications of Transhiatal Esophagectomy?

The following are some of the indications for transhiatal esophagectomy:

• Esophageal Cancer: Transhiatal esophagectomy may be recommended for patients with early-stage esophageal cancer who are unsuitable for less invasive treatment options, such as endoscopic resection or radiation therapy.

• Severe Reflux Disease: Transhiatal esophagectomy is advised for patients with severe gastroesophageal reflux disease (GERD) that have not responded to other treatments, such as medication or lifestyle changes.

• Barrett's Esophagus: Transhiatal esophagectomy is recommended for patients with Barrett's esophagus (a condition in which the cells lining the esophagus change and become abnormal).

• Other Conditions: Transhiatal esophagectomy is used to treat other conditions, such as strictures (narrowing of the esophagus), achalasia (a condition in which the esophagus cannot properly move food to the stomach), or trauma to the esophagus.

What Is the Preoperative Care in Transhiatal Esophagectomy?

The following are some common preoperative steps taken before transhiatal esophagectomy:

• The patient will undergo a thorough medical history and physical examination to identify potential health problems that may complicate the surgery.

• Imaging studies, such as CT (computed tomography) scans or endoscopy, may be performed to identify the extent of esophageal cancer and determine the best surgical approach.

• Blood tests will be taken to assess the patient's overall health and to check for any abnormalities that could impact the surgery.

• The patient's medications will be reviewed, and any blood-thinning medications may need to be temporarily discontinued before the surgery to reduce the risk of bleeding.

• The patient will receive a nutritional assessment to ensure adequate nutrition before and after the surgery. In some cases, the patient may require a feeding tube to provide nutrition during the recovery period.

• If the patient is a smoker, they may be advised to quit smoking prior to the surgery to reduce the risk of complications.

• The patient may be instructed to undergo bowel preparation to empty the bowels before the surgery.

• Patients with esophageal cancer may experience anxiety or depression related to their diagnosis. A mental health assessment may be conducted to identify any concerns and provide support and resources as needed.

What Is the Procedure of Transhiatal Esophagectomy?

Here is an overview of the steps involved in the transhiatal esophagectomy procedure:

• Anesthesia: The patient is given general anesthesia to ensure they are unconscious and do not feel any pain during the surgery.

• Incisions: The surgeon makes a vertical incision in the middle of the neck and another incision in the upper abdomen.

• Esophageal Dissection: The esophagus is dissected from the surrounding tissue and pulled out through the neck incision. The surgeon removes the esophagus part containing the tumor and nearby lymph nodes, if necessary.

• Stomach Mobilization: The surgeon then mobilizes the stomach by freeing it from its attachments to other organs.

• Creation of Esophagogastric Anastomosis: The surgeon pulls the stomach up through the chest and attaches it to the neck's remaining portion of the esophagus. This creates a new connection between the mouth and the stomach, allowing the patient to eat and swallow normally.

• Closure: The incisions in the neck and abdomen are then closed, and the patient is taken to the recovery room.

What Are the Postoperative Care After Transhiatal Esophagectomy?

The following are some common postoperative steps taken after transhiatal esophagectomy:

• The patient will receive pain medication to manage discomfort and pain following the surgery.

• The patient needs monitoring for vital signs, such as blood pressure, heart rate, and oxygen levels, to ensure stable recovery. The surgical site and incisions will be checked regularly for signs of infection.

• Initially, the patient will receive nutrition through an intravenous (IV) line or feeding tube. Over time, the patient will gradually advance to a regular diet as tolerated.

• The patient will be referred to a physical therapist who can provide exercises to help improve strength and mobility.

• The patient may need assistance to cough and clear their lungs to prevent infection and promote healing.

• The surgical incisions will be monitored closely for any signs of infection or bleeding. The wound dressing will be changed regularly, as needed.

• The patient will be given instructions for follow-up care, including appointments with the surgeon, oncologist, and other healthcare providers as needed.

What Are the Benefits of Transhiatal Esophagectomy?

Some potential benefits of transhiatal esophagectomy are as follows:

• Transhiatal esophagectomy may be a curative treatment option for patients with early-stage esophageal cancer, offering the potential for long-term survival.

• Transhiatal esophagectomy may improve the quality of life for patients with severe reflux disease or Barrett's esophagus by reducing or eliminating symptoms such as heartburn, difficulty swallowing, and chest pain.

• For patients with severe reflux disease or Barrett's esophagus, transhiatal esophagectomy may reduce the risk of complications associated with these conditions, such as esophageal bleeding or perforation.

• After the procedure, patients may have improved nutritional status and be able to tolerate a wider variety of foods.

• Transhiatal esophagectomy can remove the cancerous tissue and nearby lymph nodes, reducing the risk of cancer recurrence.

• While recovery from transhiatal esophagectomy is typically slow and requires significant time and effort, some patients may experience a faster recovery time than with other types of esophagectomy.

What Are the Complications of Transhiatal Esophagectomy?

Transhiatal esophagectomy (THE) is a major surgical procedure that carries significant risks and potential complications. While the surgery is intended to improve the patient's health and quality of life, the following complications may occur:

• Bleeding: Blood loss is a potential complication during or after surgery and may require transfusion.

• Infection: Infections may occur at the surgical site or in the chest, leading to fever, chills, and other symptoms.

• Leaks: Anastomotic leaks or other leaks can occur at the site where the remaining portion of the esophagus is connected to the stomach. This can lead to infections, abdominal pain, and other complications.

• Respiratory Problems: Patients may experience difficulty breathing or other respiratory complications after surgery.

• Difficulty Swallowing: Patients may have difficulty swallowing, especially in the first few weeks following the surgery.

• Dumping Syndrome: This can occur when food moves quickly from the stomach to reach the small intestine, causing nausea, vomiting, diarrhea, and other symptoms.

• Gastroesophageal Reflux Disease (GERD): In some cases, the surgery may result in the reflux of stomach contents into the esophagus.

• Nutritional Deficiencies: Patients may have difficulty absorbing nutrients from food, leading to malnutrition or other nutritional deficiencies.

• Lymphedema: Removal of lymph nodes in the chest can lead to lymphedema (excess fluid builds up in the tissues), causing swelling and discomfort.

• Death: As with any major surgery, there is a risk of death associated with transhiatal esophagectomy.

Conclusion

Transhiatal esophagectomy is a major surgical procedure that can benefit carefully selected patients. However, the surgery also carries significant risks and potential complications. Patients considering the procedure must discuss the risks and benefits with their medical team and carefully know their options to make an right decision based on their circumstances. With proper patient selection and postoperative care, patients can achieve good outcomes and improved quality of life after transhiatal esophagectomy.