T J Crofts
Upper GI Unit, Royal Infirmary of Edinburgh. Lauriston Place, Edinburgh EH3 9YW
J.R.Coll.Surg.Edinb., 45,October 2000, 296-303

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Introduction

Assessment and staging

Patient preparation

Pre-operative preparation

Surgical intentions

The procedure

Post-operative management

Complications

References

"The early case means less sepsis, less malnutrition and easier and quicker operations. Early diagnosis should thus be rewarded by reasonable operative mortality, good relief of symptoms and at any rate a fair number of five year cures. It is disappointing that, for the moment, the outlook is not brighter. For no field in surgery presented more dangers and difficulties; in none was the challenge taken up with more persistent endeavour in the face of repeated failures." (1)

For those surgeons familiar with the unique challenges presented by surgery for oesophageal tumours the words of Ivor-Lewis would appear as valid today as they were when first written over 50 years ago, " There is little doubt that the successful outcome of radical curative surgery for oesophageal carcinoma remains one of the great challenges of surgical practice".

To achieve satisfactory results necessitates optimisation of the patient's preoperative physical and emotional preparation, a high degree of surgical skill and teamwork involving close co-ordination of the nursing, surgical, anaesthetic and physiotherapeutic modalities of treatment.

If the oesophageal tumour is diagnosed at an appropriately early stage in a suitably fit patient it is appropriate to seek to resect the oesophageal tumour with its adjacent areas of possible spread (submucosal and lymphatic) in an effort to cure the patient. At the very least, a prolonged disease free interval with a good quality of life should result.

In order that the appropriate level of surgical treatment should be directed at the appropriate patients, meticulous preoperative preparation and staging is essential.

It is only when a tumour is amenable to surgical resection in a fit patient capable of withstanding a major resection that surgery should be considered.

Full staging of the tumour should occur after the histological diagnosis has been made. Staging includes a barium swallow and endoscopy. This allows the length of the tumour to be estimated and may give valuable information with regard to distortion of the axis or lumen of the oesophagus, important if alternative palliative therapies are to be utilised, e.g. laser ablation or stenting. The possibility of submucosal satellite nodules, rigidity and mobility of the tumour may also be assessed by endoscopy.

Computerised tomography (CT) scanning is important to assess the status of the retroperitoneal and mediastinal lymph nodes, peri-aortic infiltration, the relationship of the tumour to the pericardium and the possible presence of hepatic metastases. CT scanning may indicate the length of the tumour and its relationship to the trachea, although any suggestion of infiltration is confirmed by bronchoscopy.

Endoscopic ultrasound is essential for the accurate assessment of the T stage and may indicate involvement of peri-oesophageal lymph nodes.

Laparoscopic assessment of the liver and diaphragmatic hiatus, both by direct vision and by laparoscopic ultrasound, is of considerable help in some cases of carcinoma of the lower third of the oesophagus. This is especially the case where the coeliac axis nodes are affected. Increasingly more reliance is being placed on endoscopic and laparoscopic ultrasound to assess resectability. Endoscopic ultrasound can reliably T stage (80-90% accuracy) and N stage (60-80% accuracy) oesophageal tumours. Similarly, laparoscopy has an accuracy of in excess of 90% when detecting liver or peritoneal metastases.

The majority of patients considered for oesophageal resection are elderly (average age in Scotland 70 years), malnourished, and have a degree of cardiopulmonary compromise. Many have been smokers and have chronic obstructive airways disease.

It is mandatory that any patient being considered for oesophageal resection should have adequate levels of hydration and nutrition and satisfactory cardiopulmonary function and mobility, as these are essential prerequisites to withstanding oesophageal resectional surgery.

Surgery should not be contemplated in any patient in whom a disease free survival time of less than 12 months is anticipated.

It should always be remembered that there is a multiplicity of alternative therapies, strategies and interventions offering humane palliation, with substantially less physical and emotional disturbance to the patient, than radical surgery.

Having staged the patient and fully discussed the treatment options available and the relative dangers of the treatment options as well as the likely prognosis related to the stage of the disease, a decision is made with regards to surgical intervention.

It is essential that the patient, having made the decision to undergo surgical treatment, fully understands the nature of the surgery and the likely progress that they will make in the postoperative period. It is essential that the patient is familiar with all members of the anaesthetic, nursing and surgical team. It is important that the patient is taken to the areas of the hospital where they will be nursed in the postoperative period. Familiarisation is necessary in maintaining a degree of emotional security in what can be an extremely demanding time. Due regard must be paid to the mental health and welfare of these patients.

Careful attention must be paid to ensure adequate levels of nutrition in the peri-operative period, as well as satisfactory levels of hydration. Physiotherapy must be instituted in all patients and instructions given with regards to maximising respiratory efficacy in the peri-operative period. Any anaemia should be corrected pre-operatively and patient mobility fully assessed. Detailed profiles of cardiopulmonary function needs to be obtained and exercise testing carried out where there is any doubt as to the fitness of the patient to withstand surgery. Routine investigations include full blood count, urea and electrolytes, liver function tests, respiratory function tests, blood gas analysis, electrocardiograph, chest radiograph, stress testing and echocardiogram, where indicated. Four units of blood are cross-matched.

Having optimised the patient's surroundings and their physical condition in preparation for major resectional surgery the surgeon should have a clear-cut idea, based on his knowledge of the tumour and the patient, as to his/her surgical intentions.

If the oesophageal tumour is diagnosed at an appropriately early stage in a suitably fit patient the aim of surgery is to resect the oesophageal tumour with its adjacent areas of possible spread (submucosal and lymphatic) in an effort to cure the patient, or, at the very least, confer the possibility of a prolonged disease free interval with a good quality of life. Surgery, therefore, of T4 lesions or lesions with distant metastases is contraindicated.

Patients with T3 N1 disease may be considered for radical resection but only in those who are fit and of an appropriate age.

For those patients subjected to resection the surgical intention should be extirpation of the whole thoracic oesophagus and its associated immediate lymphatic drainage. For tumours of the middle and lower third this must include the lesser curvature lymph nodes adjacent to the stomach, as well as coeliac axis nodes. Cardiac and upper and lower para-oesophageal nodes should also be removed. The nodes at the tracheal bifurcation should be considered for resection but if these are involved by tumour then it is highly likely that other nodes associated with the oesophagus are involved and the possibility of surgical cure is remote.

It is a common failing to ignore the coeliac axis and lesser curvature nodes which are frequently (greater than 60%) involved in tumours of the lower third of the oesophagus. Should coeliac axis nodes be involved then surgical cure is impossible and such nodes should be regarded as indicative of distant metastases and associated with a poor prognosis. The finding of involved coeliac axis nodes should preclude surgical resection.

The thoracic duct in close proximity to the lower third of the oesophagus should also be resected in continuity with the oesophagus and tied off where it penetrates the diaphragm to enter the posterior mediastinum.

At all times, however, it should be remembered that the vast majority of these patients would succumb to their disease within the three years following their surgery. The surgeon, therefore, should be prepared at any time to modify his/her decisions with regard to surgical resection should the findings at surgery be at variance with preoperative staging, as there is a multiplicity of alternative therapies, strategies and interventions offering humane palliation.

The anaesthetic technique has to be of the highest standard and the anaesthetic procedure is often a significant clinical challenge. Single lung ventilation is mandatory in order to obtain proper visualisation and radical resection of the area concerned. Epidural analgesia is essential to obtain satisfactory levels of analgesia post-operatively, thereby, facilitating physiotherapy and enhancing respiratory function. The level of epidural anaesthesia should be to T5-6. Arterial and central venous pressure lines are inserted and the patient is catheterised.

Special equipment offering additional help in oesophageal surgery includes a vacuum bean bag for positioning the patient during thoracotomy, bipolar scissors (Powerstar) and the Omnitract special retraction device which enables wide rib retraction and excellent access through the thoracotomy wound.

The surgical approach of Ivor-Lewis oesophagectomy is a two stage surgical procedure- abdominal operation followed by a right thoracotomy and oesophageal resection. The intention of the abdominal dissection is

(1) to assess any possibility of sub-diaphragmatic spread that has been previously overlooked by preoperative staging,

(2) to mobilise the stomach on its vascular pedicles so that it can be transposed as an oesophageal replacement into the chest,

(3) to resect associated lymphatic spread from the para-oesophageal and cardiac nodes, as well as the lesser curvature nodes, which are not infrequently associated with lower third oesophageal tumours.

The abdomen is entered through a subcostal muscle-cutting (diathermy) incision, based approximately 3-4 cms distal to the costal margin in the shape of a rooftop (Figure 1).

This incision allows forceful costal margin retraction using Balfour retractor blades held under tension by tapes attached to poles which are secured to the head end of the operating table at the level of the patient's shoulders. The correct application of these retractors allows the lifting of the anterior costal margin forwards and upwards tending to make the diaphragmatic dome shallower and bring downwards the oesophageal hiatus. This facilitates dissection around the hiatus. The inferior margin of this wound is reflected downwards and the apex of the inferior wound is then sewn to the anterior abdominal wall allowing the display of the stomach and upper abdominal organs with a minimum of further retraction from the assistants.

A thorough laparotomy is carried out ensuring that there is no evidence of distal spread in the rectovesical pouch or in the mesentery of the bowel. The whole of the abdominal cavity is meticulously inspected and palpated for evidence of further intra-abdominal disease. The para-aortic and coeliac axis nodes should be palpated at this stage and if there is suspicion of tumour involvement the nodes are sent for frozen section. If involved with tumour there should be a re-evaluation of the place of resectional surgery. Having confirmed at laparotomy favourable indications for proceeding to resect, the stomach is mobilised.

Mobilisation of the stomach makes use of the gastro-epiploic arcades running parallel with the greater and lesser curvatures and originating from the left and right gastric and gastroduodenal arteries. These gastro-epiploic arcades are carefully preserved in order that stomach viability is not compromised.

Initially, a pack is placed behind the spleen bringing it forwards and lessening the tension between the stomach and the spleen where mobilisation of the gastro-splenic ligament takes place. Access is gained to the lesser sac outside the gastro-epiploic arcade at a convenient point where the peritoneal layers are suitably transparent. Having gained the lesser sac the greater curvature is mobilised and any significant vessels ligated and divided. Progress is made laterally towards the gastrosplenic ligament and at this point it is appropriate to mobilise the splenic flexure of the colon in order that greater mobility and easier dissection in the gastrosplenic ligament can take place. The short gastric vessels in the gastrosplenic ligament are divided as far laterally as possible to allow any collateral circulation between them to be maintained, thereby, enhancing the circulation to the gastric fundus. Dissecting the gastrocolic omentum towards the duodenum the stomach is lifted forwards to allow the various peritoneal layers to be dissected more easily. It is at this point, inferior to the first part of the duodenum and anterior to the head of the pancreas, the right gastro-epiploic artery origin is dissected and is vulnerable to injury. Thereafter, the duodenum is generously 'Kocherised' and any loose adhesions between the duodenum and gallbladder fundus are divided at this point. A small pack is placed behind the duodenum to displace it forwards.

Attention is now turned to the lesser omentum and, with the left hand tenting the stomach forwards, loose adhesions across the lesser sac posteriorly can be drawn taut and divided. These are generally avascular. Thereafter, the fingers of the left hand can tent forwards the lesser omentum and divide it carefully close to the under-surface of the left lobe of the liver up to the oesophageal hiatus. At this point, the stomach is lifted forwards and tented over the costal margin by the assistant. This displays a wedge of tissue connecting the lesser curvature to the posterior abdominal wall. Palpation will confirm the pulsation of the left gastric vessels arising from the coeliac axis at this level. Careful dissection will allow the vein and artery to be displayed individually and tied off with 2/0 Vicryl. Loose adherent tissue superior to this aspect is composed of fat with a few small vessels within it which requires lifting forwards to display the crura of the diaphragm, seen as two muscular columns of tissue passing upwards to arch over the anterior aspect of the oesophagus. Gentle pressure posteriorly between these two pillars allows access to the posterior mediastinum where loose areolar tissue can be broken down with gentle finger and pledget dissection. It is useful to feel gently through the hiatus to attempt to palpate the oesophageal tumour and gain an assessment of its mobility. Any significant adherence experienced should alert the operator to the possibility of a T4 lesion and prompt reevaluation of further surgery. Similarly, any lymph node enlargement related to the coeliac axis should be critically assessed and sent for frozen section. Coeliac axis nodes involved with tumour should be regarded as distant metastatic disease and, therefore, preclude radical resection.

Having developed the plane behind the crura and lifted the oesophagus with the associated pre-aortic fascia to gain access to the posterior mediastinum, the muscular pillars of the crura can be hooked with the fingers laterally using the left hand and divided by diathermy scissors. In this way, a cuff of crus can be dissected with the oesophagus en bloc and may be of significance if a lower than expected oesophageal tumour is found, as the hiatus can be infiltrated directly at this point. Having divided the pillars of the crura of the diaphragm, the fringe of diaphragm at the hiatus is taken anterior to the hiatus, taking great care not to disrupt the prominent diaphragmatic vein that runs anterior to the oesophagus within the diaphragm at this point. This can be readily controlled with transfixion sutures. Having divided the diaphragmatic hiatus circumferentially at this point, access is gained to the fibro-fatty and lymphatic tissue separating the oesophagus from the pericardium. It is appropriate to reflect this fibro-fatty and lymphatic tissue using gauze or pledget dissection. In this way associated peri-oesophageal lymphatics and fat can be swept off the pericardium. The oesophagus can then be further mobilised under direct vision by the utilisation of a malleable copper retractor insinuated carefully through the enlarged diaphragmatic hiatus. This will enable the pre-aortic fascia to be further dissected and any oesophageal branches from the aorta to be ligaclipped and divided, thereby, further enhancing mobilisation. During this procedure it is not unusual for the left pleural cavity to be opened and part of the left pleura, adjacent to the left lateral oesophagus to be taken en bloc with the dissection.

With this technique the lower third of the oesophagus can be easily mobilised and dissected clear of surrounding structures. It should be stressed that dissection through the hiatus at this point does not compromise the radicality of the procedure and will contribute significantly to the ease of the thoracic dissection. Utilising this approach it is possible to clear the peri-aortic fascia and dissect along the aorta to the level of the tracheal bifurcation. Having mobilised the lower oesophagus and peri-oesophageal tissue in this manner a final assessment is made with regard to the complete mobilisation of the stomach.

At this point it should be possible for the pylorus to be placed at the hiatus and the stomach should be freely mobile on the right and left gastro-epiploic vessels. It should be completely free posteriorly having attached to its lesser curvature lymph nodes and lymphatic tissue as well as the left gastric artery which has been transected close to its origin from the coeliac axis. All this tissue will be resected from the stomach after it has been transposed into the chest. Having ensured that the hiatus is of a satisfactory size to accommodate the stomach and that haemostasis is satisfactory, packs are removed from behind the spleen and the duodenum. Consideration may also be given to the insertion of a feeding jejunostomy tube (prior to closure) in a nutritionally compromised patient. The abdomen is closed in layers using 0 PDS on a blunt needle with staples to skin. Pyloroplasty is not carried out and only occasionally are two drains inserted into the abdomen if there has been excessive oozing from the dissection or there has been minor splenic trauma.

At this stage the condition of the patient is further assessed with regard to cardiovascular status and the manner in which he or she has withstood the first part of the operation. The patient is then prepared for the thoracic component of the dissection. The patient is turned on to the left side and positioned in the left lateral position so that the lower thorax rests over the break in the table which can then be inclined in its lower half in order to open up the chest and spread the ribs more effectively. The uppermost right arm is flexed at the shoulder joint in the sagittal plane to 90 degrees as is the elbow joint on the right side and is laid in an armrest and adequately secured with appropriate insulation. Attention should be paid to all pressure areas and the posture of the patient is paramount and maintained more effectively by a vacuum bean bag. The patient's spine should be parallel with the edge of the table and the plane of the patient's back should be at 90 degrees to the table. A pillow is placed between the legs to prevent pressure on the knees. The lowermost arm is flexed at the elbow and adequately protected from compression.

The thoracic incision extends from a point midway between the spinous process of the third thoracic vertebra and the medial border of the scapula and extends in a curvi-linear fashion inferiorly to skirt by 3-4cms the inferior tip of the scapula on the right side and then passes forward to terminate approximately 3-4cms below the right nipple. This will allow an extensive exposure of the thoracic contents. The skin wound is deepened through the muscle layers of latissimus dorsi anteriorly and trapezius posteriorly and then through the serratus anterior muscle, dividing it approximately 3 CMS below the tip of the scapula. Thereafter, the areolar tissue underneath the scapula is divided by a combination of sharp and blunt dissection and the second rib palpated and the ribs counted down from that level to ascertain which is the most appropriate point of entry into the chest, usually the fourth intercostal space. The periosteum of the fifth rib is incised by diathermy along its superior border and with diathermy dissection immediately adjacent to the bone the intercostal muscles superior to the fifth rib are incised. Having divided the intercostal muscle, entry is gained through the pleura immediately above the fifth rib and the pleura incised along the whole length of the wound, taking care anteriorly not to injure the internal mammary artery. Having opened the chest and collapsed the lung on the right side the posterior one-inch of the fifth rib just beyond the tubercle is excised after elevating the periosteum. This allows satisfactory retraction of the rib cage, usually without compromising the integrity of the other ribs and also allows a satisfactory subsequent closure.

Having gained access to the chest cavity the Omnitract retractor is then fitted and can be applied from either side of the patient. With suitable placement of the paddles and blades, retraction of the scapula as well as satisfactory costal retraction can be achieved, ensuring wide exposure to the posterior mediastinum. The paddles and blades are usually placed after draping gauze swabs to protect the edges of the wound. The lung, which is now collapsed, is retracted forward to display the posterior mediastinum which at this stage will have a degree of bruising surrounding the oesophagus which has been caused by dissection from below. The azygos vein will be seen clearly passing from the posterior to the anterior aspect. The azygos vein is formed as a result of a confluence of the two hemi-azygos veins superiorly and inferiorly. The azygos vein should be carefully divided and, if long, the central portion of the azygos vein can be taken en bloc with the oesophagus having tied off its proximal and distal ends securely. The lower lobe of the lung is then retracted and the pulmonary ligament divided up to the level of the pulmonary vein. Having freed the inferior portion of the medial aspect of the lower lobe of the lung attention is then turned to the groove that has been established just medial to the inferior hemi-azygos vein. This leads the operator into a trough filled with fibro-fatty and lymphatic tissue which extends deep into the posterior mediastinum. Posteriorly, this tissue is reflected along the whole length of the oesophagus, off the pre-vertebral fascia. Stripping this tissue medially the operator comes into contact with the peri-aortic fascia which can then be cleaned off the aorta and swept forwards to be taken with the oesophagus which lies slightly anterior to the aorta at this point (Figure 2).

Further segmental vessels may be encountered at this point and can be ligaclipped and divided. Meticulous haemostasis is necessary during this portion of the dissection as in the depths of the chest significant pooling of blood can lead to compromised dissection and clearance. Having mobilised the posterior aspects of the oesophagus with its surrounding lymphatics and fatty tissue, the wedge of tissue adjacent to the oesophagus will at this point contain the thoracic duct. This wedge of tissue, therefore, has to be tied off as it penetrates behind the diaphragm adjacent to the aorta. The thoracic duct is then taken en bloc with the rest of the oesophagus and its surrounding tissues. (Figure 3)

Having mobilised the whole of the oesophagus within the chest and dissected anteriorly the oesophagus from the lower pulmonary vein and the right main bronchus, the dissection is carried superiorly to take the oesophagus off the membranous part of the trachea which is, at this point, just above where the azygos vein passes forwards to the superior vena cava, and is vulnerable to injury. Having mobilised the oesophagus to a suitable level in the upper reaches of the right hemi-thorax and, after establishing satisfactory clearance from the main tumour, a suitable point is chosen for transection of the oesophagus and two stay sutures inserted initially of 2/0 PDS. At the point of transection, dissection of the oesophagus should not proceed too far proximally so that vascularity of the oesophagus is not compromised. Thereafter, the oesophagus is transected and a Foley catheter inserted into the cut end of the oesophagus and the balloon gently inflated with approximately 8mls of saline so that the oesophageal lumen can be gently distended.

Attention is then transferred to the hiatus where with gentle manipulation the stomach is delivered through the hiatus into the chest making sure that it does not undergo any form of rotation during this procedure. This has to be done with the utmost gentleness so as not to disrupt any of the vasculature on the greater and lesser curvatures. Having brought the stomach in its entirety into the chest and established proper orientation it is transformed into a satisfactory conduit by excising the lesser curvature of the stomach with its associated lymphatic drainage and the dissected lymphatic tissue associated with the left gastric artery. This is most easily done using a linear stapling device which can be insinuated across the fundus of the stomach to run parallel with the upper part of the lesser curvature and a second stapling device to continue the transection of the stomach to a point on the lesser curvature just above the incisura (Figure 4).

In this way, the oesophageal specimen becomes completely isolated and can be removed from the chest cavity. A gastric conduit is then established and requires anastomosis to the stump of the thoracic oesophagus in the upper chest. Alternatively, the upper stomach can be transected and left open for the insertion of the anastomotic gun and subsequently sutured or stapled (Figure 5).

If stapled, the central part of the staple line in the gastric tube is then cut away over a 2cm length to accommodate a 25mm EEA Autosuture gun with a tilting anvil head. The anvil head should be detached from the gun prior to insertion. The thoracic remnant of the oesophagus now has to be prepared for receiving the anvil head. This is done by inserting as many as five stay sutures through the muscle and mucosa of the cut oesophageal end so that satisfactory gentle traction can be placed upon the oesophagus. The Foley catheter is removed and, thereafter, a 2/0 purse-string Prolene suture is inserted loosely around the cut end of the oesophagus. The anvil head is then inserted and the purse-string tied snugly around the shaft of the anvil head. The remainder of the gun is now inserted with its pointed shaft fully retracted into the stomach tube. A suitable placement of the gun within the stomach tube has to be chosen. This must be away from any previously inserted staple lines and away from the greater curvature vessels. The level at which the gun is to penetrate the gastric tube has to ensure that when the anastomosis has been performed it will be without tension. This is essential. Having inserted and chosen a suitable place on the posterior aspect of the stomach tube the gun is made to penetrate the posterior wall and the pointed shaft of the gun detached so that it may be connected with the anvil which is resting in the thoracic oesophagus. The gun is then fired in the customary manner and the doughnuts inspected to ensure their integrity and completeness of anastomosis. The anastomosis should be palpated digitally from within the stomach after removal of the gun and inspected exteriorly by gentle retraction on the gastric tube. Once this has been done, the naso-gastric tube is passed across the anastomosis, through the stomach tube and into the duodenum. The opening in the stomach along its reformed lesser curvature is sutured with 3/0 PDS and the whole of the stomach staple line inverted with a continuous 3/0 PDS suture.

Other members of our team prefer hand anastomotic techniques. This is performed using 3/0 oiled Vicryl to ensure smooth suture insertion. The anastomosis consists of interrupted all-layer sutures and is relatively easy to perform if constructed in the manner described below.

Anteriorly, sutures with needles remaining attached are placed in the anterior oesophageal wall; good bites of tissue are taken to encompass all layers of the wall. These sutures are passed outer to inner and are then clipped - needles attached. These sutures help to hold the anterior oesophageal wall out of the way whilst the posterior sutures are positioned across the oesophagus and stomach walls. Placement of these sutures is facilitated by careful insertion of stay sutures through the oesophagus and stomach laterally. Having completed the posterior wall anastomosis, the anterior placed sutures inserted previously into the oesophageal margin are reclaimed and inserted through the anterior gastric wall to complete the anastomosis. In this way, accurate placement of sutures is enhanced and a very reliable anastomosis obtained.

Two chest drains are placed through the lower lateral chest wall issuing between the eighth and ninth intercostal spaces. The anterior chest drain is passed towards the apex of the pleura close by, but not in contact with the anastomosis and the lower drain is brought out to drain the lower recesses of the chest. These are secured in place with strong silk sutures and a purse-string suture inserted around the area of insertion of the chest drain for skin closure after removal of the chest drain. It is important to gauge the position of the chest drain accurately, allowing for chest closure. Haemostasis is checked and the viability of the stomach confirmed. The chest retractors are then gently removed and the table levelled out and unbroken so that the intercostal wound can be brought together and sutures inserted around the ribs to approximate the ribs and the wounds closed in layers. Ribs are approximated using a rib approximator and No.1 Vicryl sutures and 2/0 Vicryl is used to close all muscle layers in turn. Prior to closure of the muscle layers the re-expansion of the right lung is confirmed. Thereafter, the drains are connected to underwater seals and the wound closed in layers with 2/0 Vicryl with staples to skin.

To optimise results of surgery, postoperative management has to be meticulous and suitably targeted in appropriately staffed and equipped locations, usually the High Dependency Unit.

The vast majority of patients can be extubated immediately post-operatively and a chest radiograph carried out in the recovery room to confirm continued full lung expansion and appropriate placement of chest drains. Good epidural analgesia enables the patient to sit upright in bed and to move around, breathe deeply and co-operate fully with physiotherapy.

Fluid balance and oxygen saturations should be closely monitored and oxygen supplementation is mandatory. It is vital to maintain adequate nutrition during the early postoperative period as many of these patients have suffered significant weight loss and are malnourished. Total parenteral nutrition is the preferred choice in the majority of patients as significant problems have been encountered utilising jejunostomy feeding tubes.

Thrombosis prophylaxis is continued by thrombo-embolic deterrent stockings and subcutaneous heparin injections.

Should significant contamination have taken place during the course of dissection prophylactic antibiotics regimens are modified and antibiotics continued for 3-5 days.

It is essential to avoid intra-gastric stasis in the transposed stomach and regular naso-gastric suction is carried out in order to prevent respiratory complications secondary to aspiration. This is so important that the naso-gastric tube may be secured with a suture through the nasal septum or plastic loop around the nasal septum.

Attention to mouth care and pressure areas is vital. The patient is encouraged to move in bed and when epidural analgesia is weaned off (at approximately 48-72 hours) the patient is encouraged to mobilise out of bed.

Contrast swallow is performed on the 5th or 6th postoperative day to confirm the integrity of the anastomosis and patency of the upper gastro-intestinal tract without evidence of holdup. A successful examination is a prelude to removal of the naso-gastric tube and chest drains with check radiographs, thereafter. The patient should then be encouraged to eat and drink small quantities and mobilise fully.

Specific major complications in patients undergoing oesophagectomy include respiratory failure, anastomotic leakage and delayed gastric emptying.

These are common after transthoracic oesophagectomy. Good analgesia, physiotherapy, appropriate hydration and early mobilisation are all essential to minimise respiratory complications.

This may occur in the early postoperative period (2-3 days) when it is deemed due to technical failure or later (3-7 days) when it is thought more likely to be due to ischaemic changes in the stomach, usually close to the suture line. This is associated with significant mortality and morbidity. Occasionally, small radiologically demonstrated leaks are seen at 7-10 days but these can be clinically insignificant or associated with little disturbance. These may be treated conservatively with confidence. Early leaks or gastric ischaemia may be associated with profound acidosis and respiratory distress. Such signs should alert the team to the possibilities of a leak or ischaemia and prompt early investigation, preferably by endoscopy, but contrast swallow may also be of help. Early leaks and ischaemia should be treated aggressively by re-exploration and appropriate resection, defunctioning or re-anastomosis where appropriate.

This may occur if the stomach lies redundantly in the thorax. Occasionally, it is a consequence of an intact pylorus in a transposed stomach. This complication is best avoided by accurate positioning of the stomach within the chest and ensuring a widely patent pylorus at the time of surgery. Any doubts about patency should lead to the formation of a pyloroplasty. Treatment of delayed gastric emptying is directed at enhancing gastric emptying with Metoclopramide and/or pyloric balloon dilatation.

Review of all oesophageal resections described in 59 reports in the world literature over the period 1980-88 by Muller et al (1990), suggests that anastomotic leakage continues to be a major problem.⁽²⁾ Intrathoracic anastomotic leak rate was 11 ± 6% and, when it occurred, was associated with a high mortality (69 ± 16%).

Muller also noted a much lower mortality 11± 7% for curative intent resections, compared with palliative intent resections (19 ± 8%).

The Scottish Audit of Gastro-oesophageal Cancer (in preparation) which studied all cases of gastro-oesophageal cancer occurring within Scotland, between 1997 and 1999, suggests a postoperative leak rate of 10% for all oesophageal resections and a postoperative 30 day mortality of 11.3%.

These findings echo once again the wise words of Ivor Lewis half a century ago.⁽¹⁾

To Eve Hood, my medical secretary, for endless corrections. To my surgical oncological mentors of 20 years’ standing, Mr Andrew Logan, Mr James Dalrymple (South AFrica) and Professor Arthur Li (Hong Kong). Particular thanks to Mr Mike Griffin and Mr Daya Karat (Newcastle) for introducing us to the OMNI-TRACT and technique for rib resection. Finally, thanks to my most generous colleague, Simon Paterson-Brown, for his encouragement, advice and support.

Ivor-Lewis oesophagectomy for middle and lower third oesophageal lesions

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