Overview of Transhiatal Esophagectomy

In the 1980s, Dr. Orringer introduced a new surgical procedure to remove part of the esophagus, which is the tube that connects your throat to your stomach. This operation was developed as an alternative to the Ivor Lewis esophagectomy, a surgery that involves making three cuts – one in the neck, one in the chest, and one in the abdomen.

The main problem with the Ivor Lewis procedure was lung complications, mainly due to the cut made in the chest. Dr. Orringer believed these complications could be reduced by avoiding the chest cut altogether. The surgery he designed involved only two incisions, one in the abdomen and one in the neck. The stomach was then moved to connect with the esophagus in the neck. Any potential leak from the area where the stomach and esophagus were joined (the “anastomosis”) was far less dangerous than a similar leak inside the chest, which could occur with the Ivor Lewis surgery.

Nowadays, this surgery, known as transhiatal esophagectomy, is still used for patients who need to have part of their esophagus removed. However, there can be complications, and the operation requires a highly skilled surgeon and a well-trained team working together to give patients the best possible results.

Anatomy and Physiology of Transhiatal Esophagectomy

A transesophageal esophagectomy is a surgical procedure that requires a deep understanding of the structure and blood supply of the stomach, colon, chest, and neck. This operation mostly involves making gentle incisions without directly seeing where they’re being made, so a surgeon needs a good sense of touch and a great knowledge of human anatomy to be successful.

Before the surgery even starts, the surgeon needs to plan and decide on what part or ‘conduit’ they’ll choose as their first option. Typically, a tube created from the bigger curve on the stomach is used for a surgery known as transhiatal esophagectomy. This tube is moved to the neck area for a procedure known as cervical esophagogastric anastomosis. The tube is nourished by the right gastroepiploic artery, so it’s important to keep this artery safe while the others in the stomach are cut. This way, the tube can reach the neck area.

Sometimes, the tube from the stomach can’t be used, so the left side of the colon is used instead. The blood supply from the left colon is maintained by an artery called the left colic artery, while another artery, the middle colic, is cut. It’s essential to check the condition of the marginal artery of Drummond, which provides blood to this part of the colon, before cutting through the entire colon length.

There are vital organs in the chest within the surgeon’s reach during the procedure. The surgeon leverages the position of the esophagus to gently detatch all tissue connected to the esophagus, thereby releasing it to the highest part of the chest cavity. The surgeon is guided by structures like the spine and the membranes behind the windpipe and left bronchus. They must be careful not to harm critical blood vessels or the posterior part of trachea or bronchus.

The surgeon also creates an incision in front of the sternocleidomastoid muscle in the neck and dissects down to the esophagus by cutting through a muscle called the omohyoid. This allows them to access the esophagus while being careful not to damage any nerves there. The blood vessels and nerves in this area are crucial landmarks during this stage of the operation. The lower throat artery is also an important surgical marker that is divided eventually.

The primary goal of the operation is to remove the esophagus and restore the continuity of the intestines for eating. A tube made from the stomach or the colon is usually used to achieve this goal. After the procedure, patients are usually advised to stay upright after eating to prevent fluid or food from being inadvertently inhaled into the lungs (called aspiration), due to the conduits’ difficulty emptying quickly.

Why do People Need Transhiatal Esophagectomy

A tranhiatal esophagectomy is a type of surgery initially used to treat a condition known as achalasia, which leads to difficulty swallowing. Over time, this technique has also been helpful in treating patients with esophageal cancer and narrowings in the esophagus, called strictures.

Nowadays, while this surgery is still performed, it has been largely replaced with more modern procedures that include the use of robots or tiny cameras inserted in the chest (thoracoscopic assisted procedures). These more advanced techniques are less likely to cause lung-related complications and encourage faster recovery.

The newer procedures also provide a direct view of the chest area being operated on, lowering the risk of unintentional injury. Nonetheless, the traditional operation is still useful and can be performed for the treatment of achalasia, esophageal cancer, and strictures, as previously mentioned.

When a Person Should Avoid Transhiatal Esophagectomy

There are some situations where it may not be safe or possible to perform a transhiatal esophagectomy, a operation to remove part of the oesophagus, even if the patient needs it:

One reason might be the size of the tumour and how close it is to important areas in the chest. There is often no need for surgical treatment if the oesophagus has T1 Lesions – a very early stage of cancer that is usually small and hasn’t spread.

Inexperience of the surgeon with this specific technique could be a potential risk. It’s always safer if the surgeon performing the operation has good experience with it.

A prior treatment of the tumour is also a factor to consider. If the tumour has been treated with chemotherapy or radiation therapy before, it might complicate the procedure. Especially if radiation therapy was used because it can cause scarring, making a transhiatal approach difficult to perform.

Equipment used for Transhiatal Esophagectomy

The tools required for this surgical procedure are typically found in all operating rooms. For anesthesia, some doctors prefer to use a special breathing tube that allows each lung to be treated separately if necessary, along with two large intravenous lines (think of these as ‘super straws’ that allow fluid, medication, and nutrition to be delivered directly into your body) or a central line (a long, thin, flexible tube that’s put into a large vein in your chest). They also might use an arterial line, which is another type of IV that allows for constant monitoring of your blood pressure, and can also be used to draw blood.

A device to hold open the abdomen area, called a self-retaining retractor, is typically very helpful. The method used to separate the stomach or colon and tie off the blood vessels is up to the surgeon’s preference. The hiatus, a natural opening in your diaphragm, is gently widened to about the size of four fingers. Then the surgeon will carefully operate on the chest area, even though they can’t directly see all of it.

If a surgeon’s hand is a glove size seven or smaller, it’s usually better because larger hands could potentially hinder the heart’s ability to relax and fill with blood (diastole). It is important to have special clamps and stitches ready, and prepare for the possibility of severe bleeding or air leak. This readiness is critical in case of an emergency situation.

The joining of two separate sections of the body (anastomosis) can be either stapled or sewn together, again depending on the surgeon’s preference. It is standard to place a closed suction drain in the neck incision. This helps prevent fluid accumulation, promoting a smoother healing process. Some surgeons might also opt to insert a feeding tube into the small intestine (jejunal feeding tube) before closing up the abdominal incision. This can help provide nutrition whilst the body is healing.

Who is needed to perform Transhiatal Esophagectomy?

In the process of having a transhiatal esophagectomy (a surgery to remove part of your esophagus), there are several important medical professionals involved. Firstly, the anesthesiology team is there. This team includes an anesthesiologist and a nurse who specializes in anesthesia. They have the job of placing a special tube in your windpipe and keeping an eye on your vital signs (like your heart rate and blood pressure) during the surgery. They’re particularly important during the phase of the surgery that involves the chest, as changes in blood pressure and heart rhythms can happen.

You will also have a surgeon and their assistant during the operation, who take care of the part of the surgery involving the abdomen and chest. If needed, there is sometimes a second surgeon and assistant who can work on another part of the operation at the same time as the first team. This can make the operation quicker and mean less time being under anesthesia, which is better for you.

Once the surgery is over, you’ll be monitored in a special recovery area. Here, the medical team will continue to check for any signs of complications, such as irregular heart rhythms (arrhythmias) or low blood pressure (hypotension).

Preparing for Transhiatal Esophagectomy

Before a surgery, patients typically go through thorough check-ups. These ensure that the doctors correctly understand their medical condition and can plan for the operation. Tests could include body scans and endoscopies (which allows the doctors to look inside your body using a thin, flexible tube). If the patient has cancer, it’s even more crucial to get detailed information on the illness before the surgery. Doctors may use a particularly useful procedure called an endoscopic ultrasound which uses sound waves to create detailed images of the inside of your body.

Patients should also undergo heart and lung tests to check if they are strong enough for the surgery and its possible after-effects. Often, patients may need to be ready to breathe with a single lung during the procedure and there might be a potential risk for open chest surgery if required. It’s a good idea for patients to walk or exercise regularly and stop smoking at least 3 to 4 weeks before the surgery. If there are any abnormalities in blood test results, doctors will try to correct these before the operation. Doctors also make sure that patients are well-fed and might even provide special nutritious supplements.

On the day before surgery, patients are typically asked to clean out their bowels. This is done just in case the doctors need to use a piece of the colon (large intestine) during the surgery. Patients may also go through some breathing exercises and drink lots of water to keep hydrated. Inside the operation room, the medical team usually places two large tubes in the patient’s veins or a central tube to allow quick access to the bloodstream. The patient will also receive an “arterial line,” which provides data on blood pressure and oxygen levels.

Next, they’ll put the patient to sleep using a special kind of anesthesia that offers separate ventilation for each lung. Doctors generally take precautions to prevent any food or drink from entering the lungs (aspiration) during the process. The patient is positioned lying face-up, with their neck turned to the right for easy access. Also, doctors place a “Foley catheter” (a thin, sterile tube) to drain urine from the bladder during surgery, along with a nasogastric tube to drain the stomach contents if needed. Devices to improve blood circulation in the legs are usually also in place. The operation typically begins with looking at the abdominal area and then moves on to the cervical (neck) area if needed.

How is Transhiatal Esophagectomy performed

Firstly, anesthesia is administered to the patient and necessary catheters and tubes are put into place. The patient is then laid flat on their back with their head turned to the right. The areas of the body that need to be clean and free from bacteria for the surgery are from the neck all the way down to the abdomen. The surgeon will then make a large cut either in the center or the shape of a “V” on the upper abdomen. The purpose of the surgery dictates whether the surgeon will look for traces of cancer spread.

With an emphasis on preserving healthy organs and tissues, the colon is shifted away from the stomach. Careful focus is done on ensuring the preservation of the right gastroepiploic artery, a blood vessel that is essential for the ‘conduit’ or passage that will be used in the surgery. The surgeon identifies and isolates the important blood vessels along the edges of the stomach. The lower part of the esophagus and stomach are then separated from the tissues around them.

The bottom part of the stomach is carefully moved so that it can reach the hiatus that is the opening in the diaphragm through which the esophagus runs. The surgeon takes care to ensure that all the tissues that may contain illness, especially cancer nodes or nodules, are removed. The hiatus, the hole in the diaphragm through which the esophagus passes, is enlarged so it can accommodate the surgeon’s movement during surgery.

The surgeon then detaches the back surface of the esophagus from the spine, and the front surface from the pericardium, a sac that surrounds the heart. To do this, the surgeon has to seal, or tear minute blood vessels that supply the esophagus from the main artery, the aorta. This might cause little bleeding that stops after a while. The esophagus is carefully separated from its surrounding structures.

During this procedure, the patient’s blood pressure and heart rhythm is carefully monitored. In case of sudden falls in blood pressure or irregular heartbeats the surgeon stops to let the heart recover. For further steps, the surgeon may require another team to assist from the neck, or he may continue alone. A cut on the neck in front of a major neck muscle (sternocleidomastoid muscle) exposes the upper part of the esophagus. Here, nerves that control voice (recurrent laryngeal nerves) and a major lymph duct (thoracic duct) are carefully preserved.

The surgeon then attaches a drain to the lower part of the esophagus and feeds it into the abdomen. They then create a tube from the stomach stapling across from one side to the other. This stomach tube with the diseased segment are removed together. The drain attached previously is then connected to this stomach tube. The surgeon then carefully pulls this stomach tube up from the abdomen into the chest and up to the neck. The stomach is then attached to the remaining part of the esophagus in the neck by stitching or staples as preferred by the surgeon. Then, to reduce stress on this newly created connection, the stomach is fixed to a layer on the back of the neck.

The surgeon places a drain near this joint that can help evacuate any fluids or pus if an infection occurs. The neck cut is then stitched up layer by layer. The surgeon then re-examines the abdomen to judge the need for a feeding tube to be inserted in the small intestine (jejunum). A decision is also made regarding whether an additional procedure to facilitate stomach emptying (pyloromyotomy or pyloroplasty) is required. If the surgeon feels it necessary, either of the two procedures are done. In a classical transhiatal esophagectomy, a minor opening is made in pylorus, the lower part of the stomach about 2cm in size and a feeding tube (jejunostomy) is also placed. Finally, the abdomen is then closed.

Possible Complications of Transhiatal Esophagectomy

During a surgery, serious complications can happen like heavy bleeding from a large vein, known as the azygos vein. If this happens, the bleeding has to be immediately controlled. Less severe bleeding will generally stop on its own with time. Additional complications can include a significant air leak from a tear in the trachea (the windpipe) or bronchus (the main passageway into the lungs). This can make it difficult to help the patient breathe during the surgery. To manage this, the doctor will move the breathing tube past the tear and fix the hole. If the newly created passage for food and air (the “conduit”) isn’t working because its blood supply is affected, the surgeon might need to use another organ like the colon to create a new conduit.

There’s also a risk of injuries to the recurrent laryngeal nerves, which control your vocal cords. If this occurs, there’s often a need for a specialist in ear, nose, and throat diseases (an otolaryngologist) to help and possibly a need for a tracheostomy, which is a procedure to create a breathing hole directly in the neck.

After surgery, complications can include standard complications like bleeding and infection, the formation of protrusions (hernias), pain, fever, etc. Unique complications can be pneumonia, irregular heartbeats (cardiac arrhythmias), obstruction of blood vessels by a blood clot (deep vein thrombosis and pulmonary embolus), as well as urinary tract infections and superficial wound infections. Minor leaks from where the conduit was sewn (anastomosis) to the neck can often be managed by draining or packing the wound – most of these heal on their own. However, if the leak is in the chest area, it can be life-threatening and may need immediate surgical exploration.

Other complications may include abscesses – pockets of pus – forming deep within the body. A CT scan, a specialized form of X-ray, might be required to diagnose this. These will need careful treatment, usually with the fitting of a drain to get the pus out, and antibiotics given through a vein. Another common problem can be delayed emptying of the stomach or the new conduit, which can be better managed by the patient eating smaller frequent meals while sitting upright.

To make sure there are no leaks or other problems, all patients should have a contrast study, a type of X-ray, between three to seven days after the surgery. If there is a problem, the treatment might include widening the conduit with an endoscope, a specialized instrument for look inside the body, and sometimes a stent, a device used to keep the passage open.

What Else Should I Know About Transhiatal Esophagectomy?

Tranhiatal esophagectomy is a surgical procedure often performed by specialists to remove part of the esophagus. This process is evolving, with newer and less invasive methods being employed, resulting in a safer and more precise operation.

These days, surgeons are using techniques involving robots and small cameras (thoracoscopic techniques) to perform the complicated thoracic component of the operation. This procedure helps them see what they are doing more clearly, resulting in a more accurate dissection compared to the older methods. This approach also allows them to remove lymph nodes – small glands that are part of the immune system – more effectively.

It’s important to note that even if the status of these lymph nodes doesn’t affect patient outcomes directly, more and more doctors prefer using these minimally invasive approaches for patient safety and comfort. Another advantage of this procedure is the use of a cervical anastomosis, a method to connect the remaining parts of the esophagus, which results in fewer complications if a leak occurs.

New technologies also enable the abdominal part of the operation to be done robotically or laparoscopically (using a thin tube with a camera), further reducing the risks associated with this complex surgery. Enhanced recovery protocols, specifically designed to help patients recover more quickly after esophagectomy, are also in place.

Frequently asked questions

1. What are the potential complications and risks associated with a transhiatal esophagectomy? 2. How experienced are you in performing this specific surgical technique? 3. How will my esophagus be reconstructed after the removal? Will a tube made from the stomach or colon be used? 4. What can I expect in terms of recovery and post-operative care? 5. Are there any alternative procedures or treatments that I should consider?

A transhiatal esophagectomy is a surgical procedure that involves removing the esophagus and reconnecting the intestines for eating. The surgeon will typically use a tube made from the stomach to achieve this. After the procedure, patients are advised to stay upright after eating to prevent aspiration.

You may need a Transhiatal Esophagectomy if you have a tumor in the esophagus that is not in the early stages and is located close to important areas in the chest. Additionally, it is important for the surgeon performing the operation to have experience with this specific technique. If you have previously undergone treatment for the tumor, such as chemotherapy or radiation therapy, it may also affect the feasibility of a Transhiatal Esophagectomy.

One should not get a transhiatal esophagectomy if the tumor is large and close to important areas in the chest, if the surgeon is inexperienced with this specific technique, or if the tumor has been previously treated with chemotherapy or radiation therapy, which can complicate the procedure.

The recovery time for Transhiatal Esophagectomy is not explicitly mentioned in the provided text.

To prepare for a Transhiatal Esophagectomy, the patient should undergo thorough check-ups, including body scans and endoscopies, to understand their medical condition. Heart and lung tests should be done to ensure the patient is strong enough for the surgery. Patients should also walk or exercise regularly, stop smoking, and correct any abnormalities in blood test results. The day before surgery, patients should clean out their bowels, do breathing exercises, and stay hydrated.

The complications of Transhiatal Esophagectomy include heavy bleeding from the azygos vein, air leak from a tear in the trachea or bronchus, issues with the newly created passage for food and air, injuries to the recurrent laryngeal nerves, standard complications like bleeding and infection, formation of hernias, pneumonia, cardiac arrhythmias, deep vein thrombosis and pulmonary embolus, urinary tract infections, superficial wound infections, leaks from the conduit, abscesses forming deep within the body, delayed emptying of the stomach or the new conduit, and potential problems that may require further treatment such as contrast studies, endoscopy, and stent placement.

The symptoms that would require Transhiatal Esophagectomy include difficulty swallowing (achalasia), esophageal cancer, and narrowings in the esophagus (strictures).

There is no specific information provided in the given text about the safety of Transhiatal Esophagectomy in pregnancy. It is recommended to consult with a healthcare professional for a comprehensive evaluation and personalized advice regarding the safety and risks of any surgical procedure during pregnancy.

Join our newsletter

Stay up to date with the latest news and promotions!

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

We care about your data in our privacy policy.