Residency · Residency · Cardiothoracic Surgery

Esophagectomy: Ivor Lewis, McKeown, and Transhiatal Approaches

Overview

Esophagectomy is the surgical cornerstone for resectable esophageal cancer. Multiple approaches exist, each with distinct advantages, disadvantages, and complication profiles. The choice of approach depends on tumor location, surgeon experience, and patient factors. Minimally invasive esophagectomy (MIE) is increasingly standard, with equivalent or superior perioperative outcomes. Anastomotic leak remains the most feared complication regardless of approach.

Ivor Lewis Esophagectomy (Transthoracic)

Technique

The Ivor Lewis esophagectomy is a two-phase operation combining a laparotomy (or laparoscopy) with a right thoracotomy (or thoracoscopy). The abdominal phase involves gastric conduit creation by mobilizing the stomach along the greater curvature while preserving the right gastroepiploic artery, dividing the left gastric artery and short gastric vessels, performing a pyloroplasty or pyloromyotomy (to prevent gastric outlet obstruction from vagal denervation), performing a Kocher maneuver for duodenal mobilization, creating a 4-5 cm wide gastric tube using sequential stapler firings along the lesser curvature, and placing a feeding jejunostomy. The thoracic phase involves a right posterolateral thoracotomy (or VATS/robotic approach) through the 4th-5th intercostal space, mobilization of the esophagus from the posterior mediastinum, systematic mediastinal lymph node dissection, division of the esophagus above the level of the tumor with adequate proximal margin, delivery of the gastric conduit into the chest, and creation of the esophagogastric anastomosis in the upper chest.

Anastomotic Technique

Several techniques are available for the esophagogastric anastomosis. Circular stapled (EEA) involves placing the anvil in the esophageal stump and bringing the stapler through the gastric conduit. Linear stapled (side-to-side) uses an overlap technique creating a functional end-to-end anastomosis. Hand-sewn anastomosis uses single or double layer interrupted sutures. Reinforcement with omentum, intercostal muscle, or pleural flap reduces leak risk.

Advantages

The Ivor Lewis approach provides good exposure for mediastinal lymphadenectomy. The intrathoracic anastomosis in the upper chest avoids a cervical incision, and the recurrent laryngeal nerve injury rate is lower compared to the McKeown approach. It is the most commonly performed approach worldwide for distal and GEJ tumors.

Disadvantages

An intrathoracic anastomotic leak can be catastrophic, producing mediastinitis, empyema, and sepsis. The approach cannot reach very proximal (upper thoracic) tumors. A right thoracotomy (or thoracoscopic equivalent) is required.

<image>Ivor Lewis esophagectomy steps showing abdominal gastric conduit creation, right thoracotomy approach, and intrathoracic esophagogastric anastomosis</image>

McKeown Esophagectomy (Three-Field)

Technique

The McKeown esophagectomy is a three-phase operation. The thoracic phase (performed first) uses a right thoracotomy for esophageal mobilization and mediastinal lymphadenectomy. The abdominal phase involves gastric conduit creation (same as Ivor Lewis). The cervical phase uses a left cervical incision anterior to the sternocleidomastoid to mobilize the cervical esophagus, deliver the gastric conduit through the posterior mediastinum to the neck, and create a cervical esophagogastric anastomosis (hand-sewn or stapled).

Advantages

A cervical anastomotic leak is more manageable than an intrathoracic leak because it drains externally with a lower sepsis risk. The approach achieves the longest esophageal margin and is suitable for mid and upper esophageal tumors. It allows three-field lymphadenectomy (cervical, thoracic, abdominal).

Disadvantages

The recurrent laryngeal nerve injury rate is higher (5-10%). The cervical anastomotic leak rate is higher (10-25%) compared to intrathoracic (5-15%). The stricture rate at the cervical anastomosis is higher. Three operative fields increase operative time and complexity. There is a risk of conduit redundancy in the posterior mediastinum.

Transhiatal Esophagectomy (THE)

Technique

The transhiatal esophagectomy is a two-phase operation with no thoracotomy. The abdominal phase involves gastric conduit creation and mobilization of the distal and mid-esophagus through the hiatus by blunt dissection. The cervical phase mobilizes and divides the cervical esophagus, with blunt and finger dissection meeting the abdominal approach. The esophagus is delivered out of the neck, and the gastric conduit is pulled through to the cervical incision for a cervical esophagogastric anastomosis.

Advantages

The transhiatal approach avoids thoracotomy, resulting in a lower respiratory complication rate. It has a shorter operative time, is better tolerated by patients with limited pulmonary reserve, and the cervical leak management is easier than intrathoracic.

Disadvantages

Blind mediastinal dissection carries a risk of bleeding (azygos vein, bronchial arteries, thoracic duct). Mediastinal lymphadenectomy is limited because systematic dissection cannot be performed without thoracic visualization. There is a risk of tracheal or bronchial injury with blunt dissection. Cervical anastomotic leak and stricture rates are higher. This approach is not appropriate for locally advanced tumors adherent to mediastinal structures.

<image>Comparison of the three esophagectomy approaches (Ivor Lewis, McKeown, transhiatal) showing incision locations, anastomosis level, and lymph node dissection extent</image>

Esophagectomy Approaches Comparison

Minimally Invasive Esophagectomy (MIE)

Approaches

Hybrid MIE combines a laparoscopic abdominal phase with an open thoracotomy (or vice versa). Totally MIE (Ivor Lewis) uses laparoscopic plus thoracoscopic techniques. Totally MIE (McKeown) uses thoracoscopic plus laparoscopic plus cervical approaches. Robotic-assisted MIE uses the da Vinci system for thoracic and/or abdominal phases.

Evidence

The TIME trial compared totally MIE versus open esophagectomy and showed less blood loss, fewer pulmonary complications, and shorter ICU stay with MIE, with equivalent oncologic outcomes (lymph node harvest, margin status) and no difference in anastomotic leak rate. The ROBOT trial compared robotic MIE versus open esophagectomy and demonstrated lower overall complications, less pain, and faster recovery with the robotic approach, with equivalent oncologic outcomes but higher cost.

Advantages of MIE

The most consistently demonstrated benefit is reduced pulmonary complications. MIE also provides less postoperative pain, shorter hospital stay, equivalent lymph node harvest and R0 resection rates, and faster return to adjuvant therapy.

Learning Curve

There is a significant learning curve of 30-50 cases for proficiency in MIE, with higher complication rates during the learning phase. Introduction should occur with mentorship and proctoring.

Conduit Creation and Management

Gastric Conduit

The standard conduit is a 4-5 cm wide tubularized stomach with blood supply from the right gastroepiploic artery (primary) and right gastric artery. Twisting or kinking must be avoided during delivery to the chest or neck. Conduit ischemia, especially at the tip, is the primary risk factor for anastomotic leak. ICG fluorescence angiography is an emerging tool to assess conduit perfusion intraoperatively, identifying ischemic areas before anastomosis and potentially reducing anastomotic leak rates.

Alternative Conduits

Colon interposition is used when the stomach is unavailable (prior gastrectomy, caustic injury). The left colon based on the ascending branch of the left colic artery is most commonly used, though the right colon based on the middle colic artery is an alternative. Isoperistaltic placement is preferred. Jejunal interposition — free or pedicled — is used primarily for short cervical defects. Free jejunal transfer requires microvascular anastomosis and has limited reach for long-segment reconstruction.

Complications

Anastomotic Leak

This is the most serious surgical complication, with an overall incidence of 5-20%. Intrathoracic leak (Ivor Lewis) carries mortality of 20-50% if uncontrolled; management includes NPO status, drainage (CT-guided or surgical), covered esophageal stent, endoscopic vacuum therapy, and reoperation for large uncontrolled leaks. Cervical leak (McKeown, THE) is generally less morbid; the cervical incision is opened for drainage and wound packing, and most heal with conservative management.

Conduit Necrosis

Conduit necrosis is a devastating complication requiring emergent takedown. Risk factors include conduit creation technique, tension, torsion, and compromised blood supply. ICG fluorescence may reduce the incidence by guiding conduit length.

Anastomotic Stricture

Stricture occurs in 10-30% (higher with cervical anastomosis) and is managed with serial endoscopic dilations. Most respond to 2-3 dilation sessions.

Recurrent Laryngeal Nerve Injury

The risk is 5-10% with cervical dissection (McKeown, THE), manifesting as hoarseness and aspiration risk. It is usually neuropraxia with recovery in weeks to months.

Chylothorax

Thoracic duct injury during mediastinal dissection causes chylothorax in 1-4% of cases. Low-output chylothorax is managed conservatively (MCT diet, octreotide, TPN), while high-output chylothorax (greater than 1 L per day) requires thoracic duct ligation.

Pulmonary Complications

Pneumonia, atelectasis, and ARDS are the leading causes of morbidity and mortality. Aspiration risk is increased by impaired swallowing and delayed conduit emptying. Prevention includes early mobilization, pulmonary toilet, and head-of-bed elevation.

Delayed Gastric Emptying

Vagal denervation leads to pyloric dysfunction. Pyloroplasty or pyloromyotomy at the time of esophagectomy is debated. Botulinum toxin injection into the pylorus is an alternative. Management includes prokinetics (erythromycin, metoclopramide) and endoscopic pyloric dilation.

<image>ICG fluorescence angiography of the gastric conduit during MIE showing the demarcation between well-perfused tissue and the ischemic tip used to guide anastomosis placement</image>

Enhanced Recovery After Surgery (ERAS) for Esophagectomy

Standardized ERAS protocols reduce morbidity and length of stay. Key elements include preoperative carbohydrate loading, minimizing IV fluid administration, thoracic epidural or paravertebral blocks for pain control, early extubation (same day or postoperative day 1), early mobilization (postoperative day 0-1), early enteral nutrition via jejunostomy (postoperative day 1), protocol-based chest tube management, and a swallow study or contrast esophagram before oral intake (postoperative day 5-7).

Clinical Pearls

Ivor Lewis is the most versatile and commonly performed approach for distal and mid-esophageal tumors. Transhiatal esophagectomy sacrifices lymph node dissection for the benefit of avoiding thoracotomy — this trade-off should be considered carefully in curative-intent patients. An intrathoracic anastomotic leak can be lethal, and a high index of suspicion is warranted with any tachycardia, fever, or pleural effusion in the early postoperative period. ICG fluorescence assessment of conduit perfusion is becoming standard practice and may reduce leak rates. Minimally invasive esophagectomy is now the preferred approach at experienced centers, with consistently demonstrated benefits in pulmonary complications. A cervical anastomotic leak, while more common, is far more forgiving than an intrathoracic leak. A feeding jejunostomy should always be performed because nutritional support is critical for recovery after esophagectomy.

References

• Luketich JD et al. "Outcomes after minimally invasive esophagectomy." Ann Surg. 2012.
• Biere SS et al. "Minimally invasive versus open oesophagectomy for patients with oesophageal cancer (TIME)." Lancet. 2012.
• van der Sluis PC et al. "Robot-assisted minimally invasive thoracolaparoscopic esophagectomy versus open transthoracic esophagectomy (ROBOT)." Ann Surg. 2019.
• Orringer MB et al. "Transhiatal esophagectomy: clinical experience and refinements." Ann Surg. 1999.
• Low DE et al. "International consensus on standardization of data collection for complications associated with esophagectomy (ECCG)." Ann Surg. 2015.

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