**5. Operative technique**

tissue edema, and compromised perfusion, an inadequate intravascular volume can predis-

In esophagectomy patients, an accurate fluid balance is essential to achieve adequate perfusion pressure and oxygen delivery to vital organs. The form of fluid replacement therapy, which is currently recommended, seems to be based on the principles of goal-directed therapy (GDT) with the aim to increase cardiac output in high-risk surgical patients. Various studies have found that GDT-based fluid administration improves intraoperative hemodynamic stability and reduces intensive care unit admissions, the incidence of complications, and mortality [38]. Some authors have suggested that restrictive fluid therapy is preferable to fluid overload because it leads to improved gastrointestinal recovery time, reduced overall morbidity [39], improved respiratory parameters, decreased incidence of postoperative pulmonary complications and shorter recovery periods [40]. On the other hand, fluid overload causes lung injury

Even with reduction in trauma access, MIE may still result in an important postoperative pain, and optimal multimodal analgesia is required. Effective analgesia accelerates extubation, recovery, and early mobilization. Despite the importance of regular postoperative sim-

Thoracic epidural analgesia (TEA) offers many benefits in esophagectomy, reducing respiratory complications, such us pneumonia [42–44] and postoperative pain. TEA has also been associated with decreased incidence of anastomotic leakage [37], possibly as a consequence of improving microcirculation in the gastric conduit [45]. Moreover, epidural analgesia also decreases the risk of prolonged ventilation or reintubation and improves some lung function parameters and blood oxygenation [46]. However, TEA also has some disadvantages: the incidence of failure may reach 12%, there are risks in the application technique, and it does not only promote urinary retention but also cause hypotension which makes necessary additional fluid administration [47–49]. Contraindications to an epidural access include sepsis or bacteraemia, infection at the insertion site, hypovolemia or shock, coagulopathy or thrombo-

Paravertebral blockade has recently been shown to provide analgesia comparable with TEA after thoracic step of esophagectomy. It is associated with less incidence of failed block and reduces hypotension and urinary retention when it is compared with TEA. Several recent reviews and meta-analyses defend its benefits [51–53], and it is a standard practice in some UK hospitals for minimally invasive esophagectomy. Local data also show shorter stays in the

MIE supposes many anesthetic challenges, some of them unique for this type of procedure and requires an accurate knowledge of the different surgical steps performed. Moreover, it is

pose to ischemia, end-organ dysfunction, and risk of anastomotic failure and leak.

and has negatively impact to intestinal anastomoses [41].

ple analgesia, a regional technique is essential.

cytopenia and increased intracranial pressure [50].

intensive therapy unit comparing with TEA.

**4.6. Conclusion**

40 Esophageal Abnormalities

**4.5. Thoracic epidural analgesia (TEA) versus paravertebral analgesia**

Minimally invasive esophageal resection for cancer involves a three-stage operation that includes a thoracosopy and laparoscopy, either with a cervical or intrathoracic anastomosis. It has been described as different combinations of laparotomy, thoracotomy, thoracoscopy, and laparoscopy approaches called hybrid techniques. These techniques have 1 step of the procedure completed via an open approach.

#### **5.1. Thoracoscopy phase**

The operation starts with thoracoscopic mobilization of the esophagus and thoracic lymphadenectomy. The thoracic phase can be performed through a lateral right thoracic approach by blocking the right tracheal bronchus, or in prone position without selecting any blocking.

In the first case, the patient is positioned in the left lateral decubitus position (LDP) and a right lung blocking is achieved employing a double-lumen tube. The surgeon stands on the left side of the patient and the assistant on the right. Three to four thoracoscopic ports are used in this approach and placed as follows:


When thoracoscopy is performed in a prone position (**Figure 1**), the mobilization of the esophagus takes place with a right prone posterior approach. Patients are intubated with a single-lumen endotracheal tube and the right lung remains partially collapsed because of the positive pressure of pneumothorax created and due to the gravity. The right upper limb is abducted 80–100°. The surgeon stands on the right side of the patient, the first assistant (camera) to the left of the surgeon, and the second assistant stands on the left side of the patient. Three ports are used and placed as follow:


**Figure 1.** Thoracic trocar position on the right chest for thoracoscopic esophagectomy.

Pneumothorax is created and the insufflation pressure must be maintained at 6–8 mmHg. A single retracting suture in the diaphragm could be used to provide downward traction allowing good exposure of the distal esophagus, although in most occasions this is not necessary.

After a general survey of the tumor area and pleura, the inferior pulmonary ligament and the mediastinal pleura over the esophagus are divided up to the level of the azygos vein (**Figure 2**), which is sectioned with an endoscopic vascular stapler. The proximal esophagus is exposed and dissected circumferentially up to the level of 1–2 cm above the carina, using 5-mm harmonic shears, from the pericardium, chest wall, descending thoracic aorta, and superior cava vein, including all surrounding lymph nodes (**Figure 3**), periesophageal tissue, and fat. A tape is used for retraction of the esophagus to facilitate the dissection around it. Any aortoesophageal vessel and any lymphatic branches must be clipped. The thoracic duct has to be protected. The vagal trunks are identified and divided.

The dissection should be performed near the esophagus to avoid trauma to the posterior membranous trachea and the recurrent laryngeal nerves, which is the most difficult step. Laterally, dissection is carried down to the left pleura and continues to the thoracic inlet. A careful lymph nodal clearance must be achieved in the supracarinal space. Mobilization of the distal esophagus poses no problem, and it is important to limit it in order to avoid difficulty in maintaining pneumoperitoneum during the abdominal phase.

After the placement of a chest tube, the right lung is allowed to expand fully (or inflated in left lateral decubitus approach). Some surgeons infiltrate intercostal spaces with local anesthetic. Trocars are removed, and ports are closed.

**Figure 2.** Division of the azygos vein using a stappler.

#### **5.2. Laparoscopy and cervical phase**

Pneumothorax is created and the insufflation pressure must be maintained at 6–8 mmHg. A single retracting suture in the diaphragm could be used to provide downward traction allowing good exposure of the distal esophagus, although in most occasions this is not necessary. After a general survey of the tumor area and pleura, the inferior pulmonary ligament and the mediastinal pleura over the esophagus are divided up to the level of the azygos vein (**Figure 2**), which is sectioned with an endoscopic vascular stapler. The proximal esophagus is exposed and dissected circumferentially up to the level of 1–2 cm above the carina, using 5-mm harmonic shears, from the pericardium, chest wall, descending thoracic aorta, and superior cava vein, including all surrounding lymph nodes (**Figure 3**), periesophageal tissue, and fat. A tape is used for retraction of the esophagus to facilitate the dissection around it. Any aortoesophageal vessel and any lymphatic branches must be clipped. The thoracic duct

The dissection should be performed near the esophagus to avoid trauma to the posterior membranous trachea and the recurrent laryngeal nerves, which is the most difficult step. Laterally, dissection is carried down to the left pleura and continues to the thoracic inlet. A careful lymph nodal clearance must be achieved in the supracarinal space. Mobilization of the distal esophagus poses no problem, and it is important to limit it in order to avoid difficulty

After the placement of a chest tube, the right lung is allowed to expand fully (or inflated in left lateral decubitus approach). Some surgeons infiltrate intercostal spaces with local anesthetic.

has to be protected. The vagal trunks are identified and divided.

**Figure 1.** Thoracic trocar position on the right chest for thoracoscopic esophagectomy.

42 Esophageal Abnormalities

in maintaining pneumoperitoneum during the abdominal phase.

Trocars are removed, and ports are closed.

The second stage starts turning the patient to a modified Lloyd-Davis position with reverse Trendelemburg and neck exposing the left cervical area. The surgeon remains between the legs of the patient. The first and second assistants stand to the right and to the left of the patient, respectively. Five abdominal ports are used for the dissection: 10-mm supraumbilical port for camera; 5 mm epigastric port for retraction of left lobe of the liver, 5–10 mm right midclavicular port for left-hand working; 5–10 mm left midclavicular port for right-hand working; and 5–10 mm left anterior axillary port for gastric retraction. It is advisable to use trocars of a diameter of 10 mm for the possibility of using staplers from any port.

**Figure 3.** Mediastinal periesophageal lymph node.

After placement of the ports, an abdominal general survey must be performed. The gastrohepatic omentum is divided; the right and left crura of the diaphragm are dissected to allow easy passage of the gastric tube through the hiatus (preventing later gastric outlet obstruction). Left gastric artery and vein are dissected and divided using an endoscopic stapler with vascular load and a careful lymph node clearance over the left gastric pedicle, celiac axis, common hepatic, and splenic artery must be achieved. The stomach is mobilized by dividing the short gastric vessels in the gastrocolic omentum, using ultrasonic coagulating shears taking care of preserving the right gastroepiploic arcade. The fundus is dissected from the superior pole of the spleen and the pancreaticogastric ligaments are divided. Authors do not recommend pyloroplasty since it has been widely demonstrated that this does not improve gastric emptying.

Then the gastric tube is constructed with the stapler by dividing the stomach starting at the lesser curve. The construction of the gastric tube may vary depending on the characteristics of the tumor (if the tumor is located in the gastroesophageal junction or it has gastric extension, it may be necessary to resect some of the proximal stomach and to make an intrathoracic anastomosis). It is preferably a gastric tube with 5–6 cm in diameter. Most of the groups place a feeding jejunostomy laparoscopically. Authors prefer to leave a nasojejunal feeding tube to avoid complications derived from a jejunostomy.

The phrenoesophageal membrane is dissected, and gastric conduit is pulled through posterior mediastinum and brought up to the neck. Torsion is avoided by ensuring that the greater curvature always lies toward the left crus.

The last stage consists of a careful dissection of the cervical esophagus. A 4–6 cm left skin crease cervical incision is made. The tape looped around the esophagus left during the thoracic dissection allows the surgeon to pull it out through the neck to facilitate the dissection. The esophagogastric specimen is pulled out of the neck incision and the esophagus is transected 2–3 cm distal to the upper esophageal sphincter. A very high anastomosis is performed between the cervical esophagus and gastric tube in an end-to-end manner using an End-toend anastomosis stapler (EEA sta-pler) or something similar. Some groups suture the gastric conduit to the prevertebral fascia. Neck wound is closed and a cervical drain could be placed. To prevent hiatal herniation, laparoscopic tacking sutures between the gastric tube and the diaphragm should be placed. If the anastomosis is performed intrathoracicaly, cervical stage is not performed.

Some groups pull out the specimen through a minilaparotomy incision incorporating camera port, and they construct the gastric tube in an extracorporeal way. This is recommended in cases of bulky tumors because it facilitates extraction of the specimen and allows to achieve a longer gastroplasty in case of performing the anastomosis in the neck.

One tube-drain is placed close to the hiatus. Trocars are removed, and ports are closed.

### **6. Minimally invasive surgery versus open approaches**

After placement of the ports, an abdominal general survey must be performed. The gastrohepatic omentum is divided; the right and left crura of the diaphragm are dissected to allow easy passage of the gastric tube through the hiatus (preventing later gastric outlet obstruction). Left gastric artery and vein are dissected and divided using an endoscopic stapler with vascular load and a careful lymph node clearance over the left gastric pedicle, celiac axis, common hepatic, and splenic artery must be achieved. The stomach is mobilized by dividing the short gastric vessels in the gastrocolic omentum, using ultrasonic coagulating shears taking care of preserving the right gastroepiploic arcade. The fundus is dissected from the superior pole of the spleen and the pancreaticogastric ligaments are divided. Authors do not recommend pyloroplasty since it has been widely demonstrated that this does not improve

Then the gastric tube is constructed with the stapler by dividing the stomach starting at the lesser curve. The construction of the gastric tube may vary depending on the characteristics of the tumor (if the tumor is located in the gastroesophageal junction or it has gastric extension, it may be necessary to resect some of the proximal stomach and to make an intrathoracic anastomosis). It is preferably a gastric tube with 5–6 cm in diameter. Most of the groups place a feeding jejunostomy laparoscopically. Authors prefer to leave a nasojejunal feeding tube to

The phrenoesophageal membrane is dissected, and gastric conduit is pulled through posterior mediastinum and brought up to the neck. Torsion is avoided by ensuring that the greater

The last stage consists of a careful dissection of the cervical esophagus. A 4–6 cm left skin crease cervical incision is made. The tape looped around the esophagus left during the thoracic

gastric emptying.

44 Esophageal Abnormalities

avoid complications derived from a jejunostomy.

curvature always lies toward the left crus.

**Figure 3.** Mediastinal periesophageal lymph node.

Minimally invasive esophagectomy emerges as an attempt to reduce the significant morbidity and mortality of classic open techniques and allows a faster recovery of the patient.

Different groups have reported their experience in implementation of minimally invasive surgery in esophageal cancer in order to assess the potential advantages and disadvantages. One of the largest series was published by Luketich et al. [9]. They showed their outcomes in 222 patients after MIE: 30-day operative mortality of 1.4%, median intensive care unit stay of 1 day (range 1–3), hospital stay of 7 days (range 3–75), lower incidence of pneumonia, and adult respiratory distress syndrome (ARDS) (7.6 and 5%, respectively); anastomotic leak rate of 11.7%; and excellent health-related quality of life (HRQL) scores at a mean follow-up of 19 months, showing that MIE is a safety procedure and have potential advantages over open approach. Palanivelu et al. [10] reported their experience in 130 patients who underwent MIE with prone thoracoscopy: median ICU stay of 1 day (range 1–32 days), median hospital stay of 8 days (range 4–68 days), postoperative morbidity of 20.76%, perioperative mortality of 1.54%, anastomotic leak rate of 2.31%, lower incidence of pneumonia, and ARDS (1.54 and 0.77%, respectively), minimum blood loss. Both series showed a stage-specific survival similar to an open approach.

These findings have been confirmed in a recent meta-analysis [13] of 57 studies containing 15,790 patients with resectable esophageal cancer. Less intraoperative blood loss, short hospital stay, reduction of the incidence of total and pulmonary complications (OR: 0.700, 95% CI 0.626–0.781 and OR: 0.527, 95% CI: 0.431–0.645, *p* < 0.05, respectively), and high operative time than Open esophagectomy were found. However, ICU stay, the number of harvested lymph nodes, and anastomotic leak had no significant differences.

As we have mentioned previously in this chapter, traditional open esophagectomy carries a significant risk of postoperative complications that involves a profound detrimental impact on patient's quality of life. Quality of life typically returns to baseline after 1 year [54]. Minimally invasive techniques avoid thoracoabdominal incisions and reduce the levels of tissue trauma. The recovery rate after minimally invasive esophagectomy seems to be faster than after open approach. Parameswaran et al. [11] assessed this question in a prospective longitudinal nonrandomized study in 62 patients, measuring health-related quality of life (HRQL) after MIE. Their study noticed that although patients reported marked deterioration in most aspects of HRQL 6 weeks after the operation, they started to recover by 3 months and returned to baseline levels by 6 months, except reflux and diarrhea.

There is concern about if oncologic outcomes are equivalent to that of the open approach. When minimally invasive surgery was introduced in the management of colorectal cancer, there was also a concern about safety and oncological quality of resections. However, several randomized prospective trials demonstrated that the laparoscopic approach was not only safe but also oncologically sound [12].

While the advantages over short-term postoperative outcomes have been widely published by different institutions, there is a lack on the available data about oncologic efficacy and survival after MIE compared with the open approach. Different groups have tried to demonstrate that the adequacy of surgical margins and lymphadenectomy can be maintained or even improved with a MIE approach [55]. Berger and colleagues [12] found in their retrospective review that there were no differences between the groups in the R0 resection rates and a significant increase in nodal harvest in the MIE group (median 20 versus 9; *p* < 0.0001). Because of the known impact of neoadjuvant treatments on lymph node yields, they also examined lymph node harvest by the presence or absence of neoadjuvant chemoradiation, and they did not find differences in both groups. However, patients in the open group had a more advanced stage disease, and most of them had received neoadjuvant treatments.

The same group published a later work, Palazzo et al. [56], that compares survival of patients undergoing MIE and open or hybrid esophagectomy (OHE) in a retrospective analysis. They found on Kaplan-Meyer univariate analysis, a significantly improved 5-year survival with MIE (MIE 64%, OHE 35%, *p* < 0.001) and after adjusting for potential confounding factors (lymph nodes harvested, neoadjuvant treatments, stage, etc.) in a multivariate analysis demonstrated that patients undergoing OHE had a significantly worse survival. They made the same selection bias as in their previous study.

Nevertheless, these results are based on nonrandomized small series with heterogeneous data and could be affected by patient selection bias (frequently MIE group include a higher number of patients who have early disease stages and thus, less patients who received neoadjuvant chemoradioteraphy). Advanced tumors and the use of neoadjuvant therapy have been considered to be contraindications to MIE by many surgeons and limited its use, especially in patients with advanced disease.

All these studies have culminated in TIME-trial published in *The Lancet* in 2012 by Biere et al. [15, 57]. It is the first randomized trial to investigate the potential advantages of minimally invasive esophagectomy. They undertook a multicenter, open-label, randomized controlled trial at five study centers in three different countries. They compared open with minimally invasive esophagectomy with a right thoracoscopy in the prone position in a total of 115 patients with resectable esophageal cancer, excluding cervical allocation. The results showed that significantly fewer patients had postoperatory pulmonary infections, shorter hospital stay, and less blood loss in the minimally invasive group than in the open group. No difference was found in ICU stay. Also, short-term postoperative quality of life measured by SF 36, EORTC C30, and esophageal-specific OES18 questionnaire were significantly better for patients in the minimally invasive group, and they had less pain according to the Visual Analogue Scale (VAS) pain score. However, pathological parameters of the resected specimen and 30-day and in-hospital mortality did not differ between groups. They concluded that patients undergoing the minimally invasive approach have short-term benefits in pulmonary infections, hospital stay, and quality of life outcomes with no compromise in the quality of the resected specimen.

patient's quality of life. Quality of life typically returns to baseline after 1 year [54]. Minimally invasive techniques avoid thoracoabdominal incisions and reduce the levels of tissue trauma. The recovery rate after minimally invasive esophagectomy seems to be faster than after open approach. Parameswaran et al. [11] assessed this question in a prospective longitudinal nonrandomized study in 62 patients, measuring health-related quality of life (HRQL) after MIE. Their study noticed that although patients reported marked deterioration in most aspects of HRQL 6 weeks after the operation, they started to recover by 3 months and returned to base-

There is concern about if oncologic outcomes are equivalent to that of the open approach. When minimally invasive surgery was introduced in the management of colorectal cancer, there was also a concern about safety and oncological quality of resections. However, several randomized prospective trials demonstrated that the laparoscopic approach was not only safe

While the advantages over short-term postoperative outcomes have been widely published by different institutions, there is a lack on the available data about oncologic efficacy and survival after MIE compared with the open approach. Different groups have tried to demonstrate that the adequacy of surgical margins and lymphadenectomy can be maintained or even improved with a MIE approach [55]. Berger and colleagues [12] found in their retrospective review that there were no differences between the groups in the R0 resection rates and a significant increase in nodal harvest in the MIE group (median 20 versus 9; *p* < 0.0001). Because of the known impact of neoadjuvant treatments on lymph node yields, they also examined lymph node harvest by the presence or absence of neoadjuvant chemoradiation, and they did not find differences in both groups. However, patients in the open group had a

more advanced stage disease, and most of them had received neoadjuvant treatments.

The same group published a later work, Palazzo et al. [56], that compares survival of patients undergoing MIE and open or hybrid esophagectomy (OHE) in a retrospective analysis. They found on Kaplan-Meyer univariate analysis, a significantly improved 5-year survival with MIE (MIE 64%, OHE 35%, *p* < 0.001) and after adjusting for potential confounding factors (lymph nodes harvested, neoadjuvant treatments, stage, etc.) in a multivariate analysis demonstrated that patients undergoing OHE had a significantly worse survival. They made the

Nevertheless, these results are based on nonrandomized small series with heterogeneous data and could be affected by patient selection bias (frequently MIE group include a higher number of patients who have early disease stages and thus, less patients who received neoadjuvant chemoradioteraphy). Advanced tumors and the use of neoadjuvant therapy have been considered to be contraindications to MIE by many surgeons and limited its use, especially in

All these studies have culminated in TIME-trial published in *The Lancet* in 2012 by Biere et al. [15, 57]. It is the first randomized trial to investigate the potential advantages of minimally invasive esophagectomy. They undertook a multicenter, open-label, randomized controlled trial at five study centers in three different countries. They compared open with minimally

line levels by 6 months, except reflux and diarrhea.

same selection bias as in their previous study.

patients with advanced disease.

but also oncologically sound [12].

46 Esophageal Abnormalities

More randomized clinical trials are needed in order to assess the long-term advantages of minimally invasive surgery.
