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Esophagectomy
Carol C. Wu, MD
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Clinical Issues

          TERMINOLOGY

          • Definitions

            • Resection of primary esophageal neoplasm and locoregional lymph nodes
              • 2-field (mediastinal and upper abdominal) lymphadenectomy
                • Most commonly performed
              • Three-field (cervical, mediastinal, and upper abdominal) lymphadenectomy
                • Possible survival benefit for patients with squamous cell carcinoma
          • Types of Esophagectomy

            • Ivor-Lewis
              • Most common technique for resection of mid and lower esophageal neoplasms
                • Open surgery, minimally invasive or robotic procedures
              • Upper midline abdominal incision
                • Stomach mobilization; creation of gastric tube
                • Lymph node resection along celiac trunk, splenic, and common hepatic arteries
                • ± pyloromyotomy or pyloroplasty to prevent postvagotomy gastric outlet obstruction
              • Posterolateral right thoracotomy
                • Resection of esophagus and mediastinal lymph nodes
                • Gastric tube pulled into thorax through esophageal hiatus
                • Anastomosis in upper thorax
                  • Risk of mediastinitis with anastomotic leak
            • Transhiatal
              • Curative or palliative resection of esophageal malignancies or benign conditions; patients who cannot tolerate thoracotomy
              • Neck and abdominal incisions
                • Blind dissection of intrathoracic esophagus
                • Potentially less complete removal of intrathoracic lymph nodes
              • Anastomosis in left lower neck
                • Easier access of potential anastomotic leak
                • Removes risk of mediastinitis as result of leak
            • McKeown
              • Treatment of upper esophageal neoplasms
              • Similar to Ivor-Lewis with addition of cervical incision for lymph node dissection and lower cervical anastomosis
            • Other approaches, such as left thoracotomy, are less commonly performed
          • Conduit for Reconstruction

            • Stomach
              • Most common
              • Resection of gastric lesser curve and cardia, and closure with staple line to form gastric tube
              • Gastric conduit most commonly placed in prevertebral or paravertebral space
              • Less commonly in retrosternal space
            • Colon or jejunum used if stomach diseased or prior gastric conduit failed

          IMAGING

          • Radiographic Findings

            • Fluoroscopic Findings

              • CT Findings

                • Nuclear Medicine Findings

                  • Imaging Recommendations

                    DIFFERENTIAL DIAGNOSIS

                      CLINICAL ISSUES

                      • Natural History & Prognosis

                        • Indications for Esophagectomy

                          • Risk Factors for Immediate Pulmonary Complications

                            • Post-Esophagectomy Complications

                              Selected References

                              1. Benjamin G et al: Diaphragmatic hernia post-minimally invasive esophagectomy: a discussion and review of literature. Hernia. ePub, 2015
                              2. van Rossum PS et al: Calcification of arteries supplying the gastric tube: a new risk factor for anastomotic leakage after esophageal surgery. Radiology. 274(1):124-32, 2015
                              3. Christensen JD et al: Imaging of complications of thoracic and cardiovascular surgery. Radiol Clin North Am. 52(5):929-59, 2014
                              4. Sonavane S et al: Expected and unexpected imaging features after oesophageal cancer treatment. Clin Radiol. 69(8):e358-66, 2014
                              5. Devenney-Cakir B et al: Complications of esophageal surgery: role of imaging in diagnosis and treatments. Curr Probl Diagn Radiol. 40(1):15-28, 2011
                              6. Upponi S et al: Radiological detection of post-oesophagectomy anastomotic leak - a comparison between multidetector CT and fluoroscopy. Br J Radiol. 81(967):545-8, 2008
                              7. Kim TJ et al: Postoperative imaging of esophageal cancer: what chest radiologists need to know. Radiographics. 27(2):409-29, 2007
                              8. Upponi S et al: Imaging following surgery for oesophageal cancer. Clin Radiol. 62(8):724-31, 2007
                              9. Kim SH et al: Esophageal resection: indications, techniques, and radiologic assessment. Radiographics. 21(5):1119-37; discussion 1138-40, 2001
                              Related Anatomy
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                              Related Differential Diagnoses
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                              References
                              Tables

                              Tables

                              KEY FACTS

                              • Terminology

                                • Imaging

                                  • Top Differential Diagnoses

                                    • Clinical Issues

                                      TERMINOLOGY

                                      • Definitions

                                        • Resection of primary esophageal neoplasm and locoregional lymph nodes
                                          • 2-field (mediastinal and upper abdominal) lymphadenectomy
                                            • Most commonly performed
                                          • Three-field (cervical, mediastinal, and upper abdominal) lymphadenectomy
                                            • Possible survival benefit for patients with squamous cell carcinoma
                                      • Types of Esophagectomy

                                        • Ivor-Lewis
                                          • Most common technique for resection of mid and lower esophageal neoplasms
                                            • Open surgery, minimally invasive or robotic procedures
                                          • Upper midline abdominal incision
                                            • Stomach mobilization; creation of gastric tube
                                            • Lymph node resection along celiac trunk, splenic, and common hepatic arteries
                                            • ± pyloromyotomy or pyloroplasty to prevent postvagotomy gastric outlet obstruction
                                          • Posterolateral right thoracotomy
                                            • Resection of esophagus and mediastinal lymph nodes
                                            • Gastric tube pulled into thorax through esophageal hiatus
                                            • Anastomosis in upper thorax
                                              • Risk of mediastinitis with anastomotic leak
                                        • Transhiatal
                                          • Curative or palliative resection of esophageal malignancies or benign conditions; patients who cannot tolerate thoracotomy
                                          • Neck and abdominal incisions
                                            • Blind dissection of intrathoracic esophagus
                                            • Potentially less complete removal of intrathoracic lymph nodes
                                          • Anastomosis in left lower neck
                                            • Easier access of potential anastomotic leak
                                            • Removes risk of mediastinitis as result of leak
                                        • McKeown
                                          • Treatment of upper esophageal neoplasms
                                          • Similar to Ivor-Lewis with addition of cervical incision for lymph node dissection and lower cervical anastomosis
                                        • Other approaches, such as left thoracotomy, are less commonly performed
                                      • Conduit for Reconstruction

                                        • Stomach
                                          • Most common
                                          • Resection of gastric lesser curve and cardia, and closure with staple line to form gastric tube
                                          • Gastric conduit most commonly placed in prevertebral or paravertebral space
                                          • Less commonly in retrosternal space
                                        • Colon or jejunum used if stomach diseased or prior gastric conduit failed

                                      IMAGING

                                      • Radiographic Findings

                                        • Fluoroscopic Findings

                                          • CT Findings

                                            • Nuclear Medicine Findings

                                              • Imaging Recommendations

                                                DIFFERENTIAL DIAGNOSIS

                                                  CLINICAL ISSUES

                                                  • Natural History & Prognosis

                                                    • Indications for Esophagectomy

                                                      • Risk Factors for Immediate Pulmonary Complications

                                                        • Post-Esophagectomy Complications

                                                          Selected References

                                                          1. Benjamin G et al: Diaphragmatic hernia post-minimally invasive esophagectomy: a discussion and review of literature. Hernia. ePub, 2015
                                                          2. van Rossum PS et al: Calcification of arteries supplying the gastric tube: a new risk factor for anastomotic leakage after esophageal surgery. Radiology. 274(1):124-32, 2015
                                                          3. Christensen JD et al: Imaging of complications of thoracic and cardiovascular surgery. Radiol Clin North Am. 52(5):929-59, 2014
                                                          4. Sonavane S et al: Expected and unexpected imaging features after oesophageal cancer treatment. Clin Radiol. 69(8):e358-66, 2014
                                                          5. Devenney-Cakir B et al: Complications of esophageal surgery: role of imaging in diagnosis and treatments. Curr Probl Diagn Radiol. 40(1):15-28, 2011
                                                          6. Upponi S et al: Radiological detection of post-oesophagectomy anastomotic leak - a comparison between multidetector CT and fluoroscopy. Br J Radiol. 81(967):545-8, 2008
                                                          7. Kim TJ et al: Postoperative imaging of esophageal cancer: what chest radiologists need to know. Radiographics. 27(2):409-29, 2007
                                                          8. Upponi S et al: Imaging following surgery for oesophageal cancer. Clin Radiol. 62(8):724-31, 2007
                                                          9. Kim SH et al: Esophageal resection: indications, techniques, and radiologic assessment. Radiographics. 21(5):1119-37; discussion 1138-40, 2001