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Transhiatal Esophagectomy FAQ

Transhiatal Esophagectomy (THE)

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What is it? - understanding terminology

The esophagus (swallowing passage) is an 11" long tube of muscle that conducts food from the back of the throat to the stomach. The esophagus is located in the back part of the chest just in front of the spine. It passes through the diaphragm, the flat muscle that separates the chest cavity from the abdominal cavity. The opening in the diaphragm through which the esophagus passes on its way to joining the stomach is called the diaphragmatic hiatus.

The medical term for "removal" is "- ectomy", eg., appendectomy means to remove the appendix, tonsillectomy means to remove the tonsils, and esophagectomy means to remove the esophagus. An esophagectomy may be required for a number of conditions that interfere with the comfortable passage of solid food and liquids into the stomach. These include cancer, strictures (or scarring) due to a variety of causes (GERD, lye ingestion, prior perforation, etc), unsuccessful prior esophageal surgery, and advanced esophageal muscle (motility) disorders such as achalasia and scleroderma.

One way to remove the esophagus involves making an incision between the ribs, entering the chest (thorax), and freeing the esophagus from attachments which hold it in place. This is called a "transthoracic esophagectomy" (TTE) - an esophagectomy performed through the chest.


Historical standard chest and abdominal incisions used in the past to remove tumors of the esophagus. (A) Either one continuous incision from the chest onto the abdomen or separate chest and abdominal incisions are used. (B) Portion of esophagus to be removed is shown in the colored area. (C) Completed esophageal replacement using the stomach connected to the esophagus high in the chest. The pylorus (muscle at the outlet of the stomach) has been cut to insure that the stomach empties adequately after the operation. (From Orringer MB. Chapter 20 Tumors, injuries, and miscellaneous conditions of the esophagus in Greenfield LJ, Mulholland MW, Oldham KT, et al, eds. Surgery Scientific Principles and Practice, 3rd Edition, Lippincott Williams & Wilkins, Philadelphia, 2001, pg 706 with permission, modified from Ellis FH Jr. Treatment of carcinoma of the esophagus and cardia. Mayo Clin Proc 1960;35:653, with permission)

Typically, after the lower esophagus is removed in this way, the surgeon opens the abdomen (belly) at the same operation, loosens the stomach from the attachments which hold it in place, pulls the now freed upper end of the stomach through the hiatus and into the chest, and connects (anastomoses) the remaining esophagus to the stomach in the chest. This connection inside the chest between the remaining esophagus and stomach is called an intrathoracic esophagogastric anastomosis.

An alternative operation, developed and refined at the University of Michigan since 1976, is a transhiatal esophagectomy (THE), removing the esophagus through the diaphragmatic hiatus without opening the chest. In this operation, an upper abdominal incision (from the bottom of the breast bone to the belly button) is made. The surgeon then frees up the esophagus by working upward through the diaphragmatic hiatus. With the addition of a 2" incision on the left side of the neck, the surgeon completes the freeing up of the esophagus, removes it, and moves the stomach upward through the hiatus and into the chest until its upper end appears in the neck wound. The remaining esophagus is connected to the stomach in the neck. This connection in the neck between the remaining esophagus and the stomach is called a cervical esophagogastric anastomosis (CEGA).


(A) Transhiatal removal of the esophagus being performed through an abdominal incision and a neck incision without the need to open the chest. (B) Side view showing the surgeon's hand proceeding upward into the chest through the abdomen as an instrument with a sponge at the end of it is used to dissect the esophagus from above. (From Orringer MB. Chapter 20 Tumors, injuries, and miscellaneous conditions of the esophagus in Greenfield LJ, Mulholland MW, Oldham KT, et al, Eds, Surgery Scientific Principles and Practice, 3rd Edition, Lippincott Williams & Wilkins, Philadelphia, 2001, pg 707 with permission, modified from Orringer MB, Sloan H. Esophagectomy without thoracotomy. J Thorac Cardiovasc Surg 1978;76:643, with permission.)

What are the advantages of THE?

The two leading causes of death in the first few days after a TTE are 1) lung complications (especially pneumonia) associated with a large operation that requires opening both the chest and the belly. The pain of these combined incisions may make it difficult for the patient to take a deep breath early after the operation, and this allows pneumonia to set in; and 2) severe infection in the chest (mediastinitis) resulting from a "leak" where the esophagus has been attached to the stomach. After a THE, because the patient has not had the chest opened, there is less pain early after surgery, the patient can move about better as a result, and lung complications are less. Furthermore, if after a THE a leak at the connection between the esophagus and stomach in the neck (anastomotic leak) should occur in the first 10 critical days until healing is complete, this is managed by removing the skin stitches, letting the infection drain out, and packing the wound with gauze until the leak heals itself, which it usually does. An anastomotic leak in the neck, because it drains outward, versus a leak inside in the chest were the esophagus and stomach have been attached, does not carry nearly the same risk for complications of infection. Because a THE is a "smaller" operation than a TTE, our patients generally tolerate the operation well, do not require treatment in an intensive care unit after surgery, and are up and walking the day after operation. They are typically discharged one week after the operation eating a soft diet.

Final position of the stomach that has been moved up through the chest and connected to the remaining short segment of the esophagus in the neck. (From Orringer MB. Chapter 20 Tumors, injuries, and miscellaneous conditions of the esophagus in Greenfield LJ, Mulholland MW, Oldham KT, et al, Eds, Surgery Scientific Principles and Practice, 3rd Edition, Lippincott Williams & Wilkins, Philadelphia, 2001, pg 709 with permission, modified from Orringer MB, Sloan H. Esophagectomy without thoracotomy. J Thorac Cardiovasc Surg 1978;76:643, with permission.)


What are the complications of THE?

Eighty percent of University of Michigan patients undergoing a THE have no postoperative complications. The complications of THE may be divided into those which may occur during the operation (intraoperative complications), those which may occur early after surgery during recovery in the hospital (early postoperative complications), and those which may occur "late", well after discharge from the hospital. Having now performed more than 1,700 THEs, the largest reported experience with this operation in the world, the University of Michigan Thoracic Surgery Service has carefully cataloged the complications of this operation:

Intraoperative
No.
Percent
Pleural Entry
831
77
Splenectomy
34
3
Tracheal Tear
4
<1
Hemorrhage
6
<1
Death
3
<1
Postoperative
No.
Percent
Anastomotic Leak
146
13
Hoarseness
  - Transient
  - Permanent
74
(50)
(24)
7
(6.8)
(3.2)
Wound Infection/Dehiscence
29
3
Chylothorax
18
2
Atelectasis (pneumonia)
17
2
Mediastinal Bleeding
5
<1
Pyloromyotomy Leak
1
<1

With University of Michigan Thoracic surgeons performing 100-125 THEs annually, and an organized support staff assisting in caring for our patients, the complication rate after this operation is gratifyingly low in the majority undergoing a THE.

What is the quality of life after a THE?

The thought of having one's esophagus "ripped out" and replaced with the stomach, pulled upward through the chest and connected to the "back of the throat" is understandably terrifying to many! However, with more than 1,700 patients having undergone this operation at the University of Michigan Medical Center - the patients ranging from 14 years to 94 years of age and in every walk of life - there has been ample opportunity to evaluate "life after a THE".

The object of the operation is to restore comfortable swallowing, and so how the stomach functions as a replacement for the esophagus ("functional result") is very important. After a THE and CEGA, 48% of patients have an excellent result (they have absolutely no difficulty eating or adverse effects from the operation), and 31% describe very mild symptoms which require no treatment (for example, food may periodically "stick" slightly in the neck, or the patient may have occasional cramps or diarrhea after eating). Therefore, nearly 80% of patients describe either an excellent or good functional result after THE. Approximately 18% of patients have a "fair" result and describe symptoms which require some sort of treatment (eg., sticking of food that requires an occasional stretch (dilatation) of the esophagus, or the need to take medication such as Lomotil to control diarrhea after eating). We have rated 3% of our patients as having a "poor" result, needing regular treatment such as ongoing dilatations or regular medication to control diarrhea and cramps.

A major focus of our refinements of THE has been reduction in the incidence of an anastomotic leak after the operation. Because 50% of patients who experience an anastomotic leak develop a later anastomotic stricture (which requires ongoing dilatations), reduction of the leak rate has been a major goal of ours. Approximately four years ago, we developed a new method for connecting the esophagus and stomach in the neck using a stapling device. This new "side-to-side stapled cervical esophagogastric anastomosis" has reduced our leak rate following THE to the 3-4% range. As a result, our patients swallow more comfortably after the operation than in the past, and the need for subsequent dilatations has been markedly reduced.

Many patients are concerned that regurgitation ("backwash" of stomach contents) may be a major problem after a THE and bringing the end of the stomach up into the neck. Fortunately, while regurgitation may occur, especially if the patient lays flat soon after eating, this is generally not a significant problem for the majority of patients undergoing the operation. If the patient does not eat for a few hours before laying down at night, so that the stomach is empty, regurgitation is uncommon. If it does occur, sleeping with the head of the bed elevated at night usually controls the problem.

In general, the quality of life after THE is quite good. Approximately 1/3 of patients gain weight after the operation, 1/3 remain at the same weight as at the time of operation, and 1/3 lose some weight. Patients are able to return to full employment and eat socially with their family and friends.