What Is Transhiatal Esophagectomy?
Transhiatal esophagectomy (THE) is a complex and intricate surgical procedure introduced to treat various esophageal conditions, most commonly esophageal cancer. This surgery involves the removal of a portion of the entire esophagus, along with nearby lymph nodes, and the reconstruction of the digestive tract to restore continuity. It was developed mainly for patients undergoing a laparotomy (a surgical incision into the abdominal cavity) and thoracotomy (a surgical incision into the chest), as well as for poor outcomes for patients associated with leakage of luminal contents from a surgical joint in the chest and associated high mortality. The transhiatal approach, when compared to the transthoracic approach, minimizes chest incisions, making it the best alternative option for certain patients.
What Are the Indications and Contraindications for Transhiatal Esophagectomy?
Indications:
Transhiatal esophagectomy was first indicated for achalasia patients; gradually, it was used for esophageal cancers and benign esophageal diseases.
Esophageal Cancer - This is the most common indication for transhiatal esophagectomy. Transhiatal esophagectomy is generally considered in cases of locally advanced tumors or cancers involving the gastroesophageal junction. In this surgical approach, cancerous tissue along with the affected lymph nodes is removed to offer a curative approach.
Benign Esophageal Diseases - In certain benign esophageal conditions, such as severe Barrett's esophagus with high-grade dysplasia, refractory strictures, or corrosive injury to the esophagus, transhiatal esophagectomy may be indicated.
Achalasia - Transhiatal esophagectomy was first indicated for achalasia patients, which is a motility disorder characterized by impaired esophageal peristalsis and the lower esophageal sphincter due to relaxation failure.
Reflux Disease - Gastroesophageal reflux disease (GERD) that does not respond to medical treatment may be treated with transhiatal esophagectomy. This is mainly relevant when complications such as Barrett's esophagus or strictures are present.
Contraindications:Transhiatal esophagectomy is contraindicated in patients with the following conditions:
Advanced Carcinomas - Transhiatal esophagectomy is contraindicated in carcinoma of the upper and middle third of the esophagus with tracheobronchial tree invasion when heart or great vessels are found on endosonography, computed tomography (CT), or bronchoscopy. Also, in stage IV cancers with liver metastasis, pleural effusion (accumulation of fluid in between the pleural cavity), or malignant ascites (accumulation of fluid in the peritoneal cavity).
Mediastinal Fibrosis - A condition where the esophagus adheres to the adjacent mediastinal structures, which usually occurs after previous surgery or radiation therapy, leading to mediastinal fibrosis. This condition can be identified with palpation and if the surgeon feels that it is unsafe to perform transhiatal esophagectomy, it can be completely avoided.
Comorbidities - Transhiatal esophagectomy is contraindicated for patients who have other health conditions like cardiac or pulmonary issues.
Inexperienced Person - A surgeon's inexperience with this surgical technique is also a relative contraindication.
How Is Transhiatal Esophagectomy Performed?
The surgery is performed under general anesthesia.
The patient is placed in the supine position with the neck extended and rotated slightly to the opposite side, which helps to expose and access the upper abdomen and neck.
The abdomen is explored either with a chevron incision or a midline incision.
If any abnormality is present, that is addressed. Lymph nodes in the abdominal region are carefully dissected and removed to ensure thorough cancer staging. The colon is moved away from the stomach. The distal esophagus and stomach are mobilized from the surrounding tissues.
The surgeon separates the lower esophagus from the diaphragm during hiatal dissection to make adequate clearance and help in reconstruction.
Then, the esophagus is mobilized from its surrounding structures, like the trachea, bronchi, and heart.
This is done to create enough mobility for the esophagus to be pulled into the neck during the later stages of the surgery.
The upper part of the esophagus is exposed by creating a neck incision. Through this incision, the mobilized esophagus is carefully pulled to allow for the removal of the affected portion.
The diseased portion of the esophagus, like the tumor, along with some surrounding healthy tissue, is resected. The extent of resecting the surrounding healthy tissues depends on the specific pathology and staging of the cancer.
After esophageal resection, the next step is the reconstruction of the digestive tract. Depending on factors like patient anatomy, surgeon preference, and the extent of esophageal resection, a reconstruction method may be chosen and employed, like gastric pull-up or colonic interposition.
After successful reconstruction of the digestive tract, the incisions are closed, and drains may be placed to remove excess fluids from the surgical site.
During postoperative care, patients are closely monitored for any complications, such as pulmonary issues, anastomotic leaks, and infections.
Rehabilitation and nutritional support are often essential components of the postoperative care plan.
After transhiatal esophagectomy, long-term follow-up is crucial to check for disease recurrence and assess the patient's overall health.
Adjuvant therapies, such as chemotherapy and radiation, may be recommended depending on the staging of the cancer.
What Are the Complications of Performing a Transhiatal Esophagectomy?
Bleeding from large vessels like the azygous vein is a life-threatening intraoperative complication It requires chest and mediastinum packing with an immediate thoracotomy to control the bleeding vessel. Minor bleeding is not so serious and generally stops with time or packing.
Massive air leaks from the hole in the posterior membranous trachea or bronchus cause difficulty ventilating the patient. This complication should be addressed immediately, and the endotracheal tube should be advanced past the tear, and the hole should be repaired using a thoracotomy incision.
A recurrent laryngeal nerve injury can also cause complications.
Postoperative complications may include infection, bleeding, hernias, pain, fevers, etc., which are similar to other operations.
Leaks from the cervical anastomosis are a minor complication, as most cervical leaks heal spontaneously. They can be treated by opening the cervical wound and draining or packing the wound.
Pneumonia, cardiac arrhythmias, deep vein thrombosis, urinary tract infections, superficial wound infections, and pulmonary embolism are other complications.
Anastomotic strictures are a longer-term complication that is common after leaks from the initial surgery. These can be managed with endoscopic dilation and, occasionally, stenting.
Conclusion:
Transhiatal esophagectomy is a complex surgical procedure that plays an important role in the treatment of various esophageal disorders, particularly esophageal cancer. This is a complex surgical technique requiring careful patient selection; otherwise, a sufficient outcome may not be obtained. Recent advancements in perioperative care have contributed to improved outcomes and reduced complications. Despite the challenges associated with this surgery, transhiatal esophagectomy continues to be a valuable option for patients requiring extensive esophageal resection and reconstruction.
