Esophageal Cancer Surgery

Kenneth Blank, MD
Last Modified: November 1, 2001

Dear OncoLink "Ask the Experts,"
What are the options for esophageal cancer surgery?  
Thank you,

Kenneth Blank, MD, OncoLink Editorial Assistant, responds:

Many surgical approaches exist for extirpation of esophageal cancer. The four most common are listed below, and differ in the location of the incisions and placement of the anastamosis.

  1. Transthoracic or Ivor Lewis Esophagectomy (named after British surgeon Dr. Ivor Lewis who described this procedure in 1940s): Right thoracotomy and laparotomy. The anastamosis lies in the chest.

  2. Total Thoracic Esophagectomy: Same as Ivor Lewis with a neck incision. The anastamosis lies in the neck.

  3. Transhiatal Esophagectomy: The esophagus is bluntly dissected from above through a neck incision and below through a laparotomy. There is no thoracotomy. The anastamosis lies in the neck.

  4. Thoracoabdominal Esophagectomy: One incision extending from the left thorax into the abdomen. The anastamosis lies in the chest.
  • Laparotomy: incision in the abdomen
  • Thoracotomy: incision in the chest
  • Anastamosis: the esophagus is removed and the two free ends of bowel are linked together—this linkage is called the anastamosis.
The procedure used is largely dependent on the tumor location and surgeon's preference. Tumors in the mid and upper esophagus, for example, are only accessible through a right thoracotomy (Ivor Lewis) or Transhiatal procedure, because the great vessels block the surgical approach from the left. The relative pros and cons of each procedure have been heavily debated in the surgical literature. The transhiatal esophagectomy spares the patient a thoracotomy and is therefore much better tolerated, without the high risk of pulmonary complications encountered when the chest is entered. Another benefit to the transhiatal esophagectomy is that the anastamosis is placed in the neck, thereby avoiding the potential fatal complication of mediastinitis should it leak. On the other hand, some argue that the transhiatal esophagectomy does not offer adequate exposure of the mediastinum and requires a blunt tumor dissection that may not obtain adequate margin on the tumor. No randomized trial has compared one procedure to the other.