1119 Esophageal Resection: Indications, Tech- niques, … · EDUCATION EXHIBIT 1119 Esophageal Resection: Indications, Tech-niques, and Radiologic Assessment1 LEARNING OBJECTIVES

EDUCATION EXHIBIT 1119

Esophageal Resection:Indications, Tech-niques, and RadiologicAssessment1

LEARNINGOBJECTIVESFOR TEST 2After reading thisarticle and takingthe test, the reader

will be able to:

� Discuss varioussurgical techniquesfor benign and malig-nant esophageal le-sions.

� List the indicationsfor each surgicaltechnique.

� Discuss the ana-tomic changes andcomplications thatmay accompanyesophageal surgery.

Seong Hyun Kim, MD ● Kyung Soo Lee, MD ● Young Mog Shim, MDKwhanmien Kim, MD ● Po Song Yang, MD ● Tae Sung Kim, MD

Various surgical procedures are performed for benign and malignantesophageal lesions. These procedures include transthoracic esophagealresection through a right or left thoracotomy and transhiatal bluntesophageal resection (esophagectomy) without thoracotomy. Thewhole stomach, colon, gastric tube, jejunum, and free revascularizedgrafts may be used as substitutes for the resected esophagus. Bypassprocedures including substernal stomach bypass surgery and subster-nal or subcutaneous colon bypass surgery are performed for tracheo-esophageal fistula, previous esophagectomy without reconstruction, orobstruction due to lye ingestion. The mortality rate for esophageal re-section depends on the stage of the tumor, the patient’s condition, andthe surgeon’s skill and is quite low when the procedure is performed bya highly skilled surgeon. The most frequent sources of morbidity re-lated to esophageal surgery include pneumothorax, pleural effusion,pneumonia, and respiratory failure. Mediastinitis and sepsis due to dis-ruption at an anastomosis site cause serious postoperative morbidityand mortality; therefore, thoracic anastomotic leaks require aggressivesurgical treatment. Familiarity with these surgical options, the resultantanatomic changes associated with each option, and the expected find-ings at postoperative imaging is essential for evaluating the effective-ness of surgical procedures and for the early detection and manage-ment of surgery-related complications.

Index terms: Esophagus, CT, 71.1211 ● Esophagus, diseases ● Esophagus, neoplasms, 71.31, 71.32 ● Esophagus, surgery, 71.451, 71.458 ● Gastroin-testinal tract, 70.92

RadioGraphics 2001; 21:1119–1140

1From the Departments of Radiology (S.H.K., K.S.L., P.S.Y., T.S.K.) and Thoracic Surgery (Y.M.S., K.K.), Samsung Medical Center, Sungkyun-kwan University School of Medicine, 50 Ilwon-Dong, Kangnam-Ku, Seoul 135-710, Korea. Recipient of a Certificate of Merit award for an educationexhibit at the 2000 RSNA scientific assembly. Received February 27, 2001; revision requested April 4 and received April 19; accepted April 23. Ad-dress correspondence to K.S.L. (e-mail: [email protected]).

©RSNA, 2001

CME FEATURESee accompanying

test at http://www.rsna.org

/education/rg_cme.html

See the commentary by Aquino.

IntroductionVarious surgical procedures are used in esopha-geal resection. The surgical option is chosen onthe basis of the benign or malignant condition ofthe lesion, the extent of the lesion, and the pres-ence of complications (Table 1) (2,3,18).

The morbidity and mortality rates for esopha-gectomy are significant, and sometimes the asso-ciated risks are high enough to prohibit surgery.However, meticulous surgical techniques and im-proved postoperative care have reduced the com-plications and death rates associated with this sur-gical procedure (19). Because of lack of familiar-ity with the diversity of surgical procedures, thenormal postoperative radiographic findings, andthe most common potential complications, radi-ologists may encounter difficulties in postopera-tive radiologic interpretation.

In this article, we discuss and illustrate the in-dications for and results of various techniques of

esophageal surgery. In addition, we demonstratethe imaging manifestations of postoperative ana-tomic changes and complications associated witheach surgical option in various esophageal dis-eases.

Esophageal Resection

Transthoracic Esophagec-tomy through a Right ThoracotomyIn transthoracic esophagectomy through a rightthoracotomy (Fig 1), the thoracic cavity is usuallyentered through the fifth intercostal space. Withthis approach, the aortic arch does not limit ac-cess to the esophagus. The stomach is mobilizedthrough an abdominal incision or through theesophageal hiatus without such an incision. Mostoften, a high intrathoracic anastomosis is created(Fig 1c), although a cervical esophagogastricanastomosis may also be created (Figs 1d, 2).

Ivor Lewis esophagectomy (separate lapa-rotomy and right thoracotomy incisions) is the

Table 1Indications, Surgical Mortality Rates, and Complication Rates for Various Types of Esophagectomy

Procedure IndicationsSurgical Mortality

Rate Complication Rate

Transthoracic esophagectomythrough a right thoracot-omy

Carcinoma involving the upper two-thirds of the esophagus, high-grade dysplasia in Barrett esopha-gus, destruction of the lower two-thirds of the esophagus by causticingestion, complications of refluxesophagitis failed with other refluxprocedures

16 (range, 5–27)* Overall, 45%; anastomoticleak, up to 14%; respira-tory complication, up to38%†

Transhiatal esophagectomywithout thoracotomy

Curative or palliative resection ofthoracic-cervicothoracic esopha-geal carcinoma, removal of tho-racic esophagus after pharyngec-tomy or pharyngolaryngectomyfor esophageal carcinoma, esoph-ageal stricture, neuromotor dys-function (achalasia, spasm, sclero-derma), recurrent gastroesopha-geal reflux, perforation, causticinjury

11 (range, 3–19)* Overall, 62%; anastomoticleak, up to 26%; respira-tory complication, up to54%‡

Transthoracic esophagectomythrough a left thoracotomy

Benign and malignant lesions of thedistal esophagus, gastroesopha-geal junction, and gastric cardia

17 (range, 1–33)* Overall, 44%; anastomoticleak, up to 12%; respira-tory complication, up to34%§

Radical en bloc esophagec-tomy

Potentially curable tumor in pre-and intraoperative staging

8 (range, 2.4–11)� Overall, 59%; anastomoticleak, up to 6%; respira-tory complication, up to27% �

*Source.—Reference 9.†Sources.—References 1, 3, 7–9, 13–16.‡Sources.—References 1, 3, 9, 11–16.§Sources.—References 3, 5, 9, 16, 18.�Sources.—References 21–24.

1120 September-October 2001 RG f Volume 21 ● Number 5

Figure 1. Drawings illustrate transthoracic esophagectomy through a right thoracotomy. Drawing ashows how tumors of the upper thoracic esophagus are assessed through a right thoracotomy (arrow) andupper abdominal incision (arrowhead). Drawing b demonstrates how the esophagus is partially resectedthrough the right thoracotomy. Arrows indicate resection lines. Drawings c and d show how an intratho-racic (c) or cervical (d) anastomosis is created between the remaining esophagus and the esophageal sub-stitute. Open arrows indicate the anastomosis site, solid arrows indicate the original cardioesophagealjunction, and arrowheads indicate pyloromyotomy.

Figure 2. Transthoracic esophagectomy and cervical esophagogastrostomy through a right tho-racotomy in a 69-year-old man with squamous cell carcinoma of the upper thoracic esophagus.(a) Preoperative esophagogram shows a 4-cm segment of an esophageal mass with luminal narrow-ing (arrows) and mucosal irregularity at the level of the aortic arch. (b) Barium esophagogram ob-tained 7 days after surgery shows a cervical esophagogastric anastomosis (arrows).

RG f Volume 21 ● Number 5 Kim et al 1121

most frequently performed procedure for resec-tion of the thoracic esophagus (Fig 3). An uppermidline abdominal incision is made, and the ab-domen is explored to mobilize the stomach (Fig3a). Thereafter, a standard posterolateral rightthoracotomy is performed. The esophagus is dis-sected out of its bed. The stomach is pulled upinto the thorax through the esophageal hiatus andis divided at its cardiac portion to allow creationof an anastomosis between the distal end of theesophagus and the fundus of the stomach (Fig3b). Then, the esophageal segment containing themass is removed (Fig 3c) (1,4,5,12,20).

Right thoracotomy for esophagectomy is pre-ferred for lesions of the upper two-thirds of theesophagus to avoid interference caused by the

aortic arch. The aortic arch limits access to le-sions of the upper two-thirds of the esophagus inleft thoracotomy.

The Ivor Lewis procedure is an excellent surgi-cal technique for patients with midesophagealcarcinomas (Fig 4). In addition to esophagealcancer, indications for this procedure includehigh-grade dysplasia in Barrett esophagus, de-struction of the distal two-thirds of the esophagus

Figure 3. Drawings illustrate an Ivor Lewis esophagectomy. (a) During the abdominal stage of the procedure, thestomach is elevated by grasping its greater curve (external to the right gastroepiploic artery), and the short gastric ar-teries (thick white arrow) are clamped and tied. The greater omentum is dissected distally near the pylorus with careto avoid injuring the right gastroepiploic artery (thick black arrows). The gastrohepatic ligament (thin white arrow) isthen carefully divided to preserve the right gastric artery. The esophageal hiatus and distal esophagus are dissectedfree, and a pyloromyotomy (arrowhead) is performed. Note the tongue of the omentum (thin black arrows) attachedto the greater curvature of the stomach; it will be used to wrap the anastomosis. Dotted lines indicate resection lines.(b) Following right thoracotomy, the azygos vein is divided and the esophagus is dissected out of its bed. Dissectionis continued up to the apex of the thorax. The stomach is then pulled up into the chest and divided. Dotted line rep-resents proposed resection line for gastric division. (c) An anastomosis is created between the end of the esophagusand the fundus of the stomach. The remaining (tumor-containing) esophagus is divided and removed. The omentumthat was preserved with the stomach is wrapped around the anastomosis (arrows). Arrowheads indicate the originalcardioesophageal junction.


by caustic ingestion, peptic stricture and ulcer,persistent reflux esophagitis causing pulmonarycomplications that fail to respond to antirefluxprocedures, and, rarely, perforation of the mid- todistal esophagus (20). The Ivor Lewis procedureis not indicated for high esophageal carcinomaslocated within 20 cm of the incisors. The proce-dure is relatively contraindicated in patients whohave undergone a previous right thoracotomy dueto postoperative adhesion (20).

The overall hospital mortality rate for the righttransthoracic approach is about 16% (5%–27%)(1). According to several reports, the surgicalmortality rate for Ivor Lewis esophagogastrec-tomy is 3%–4% (4,5). The causes of mortality arerespiratory failure and sepsis (Table 1). Sixty per-cent of patients with esophageal squamous cell

Figure 4. Uneventful Ivor Lewis procedure in a69-year-old man with squamous cell carcinoma ofthe middle thoracic esophagus. (a) Preoperativeesophagogram shows a 7-cm segment of an esopha-geal mass (arrows) with luminal narrowing and mu-cosal destruction. (b) Barium esophagogram ob-tained 6 months after Ivor Lewis esophagectomyshows indentation at an intrathoracic esophagogas-tric anastomosis site (arrow) above the aortic arch.The pylorus (arrowhead) is seen in the distal part ofthe intrathoracic stomach. These are standard post-operative findings in the Ivor Lewis procedure.(c, d) Postoperative contrast material–enhancedCT scans obtained at the level of the thoracic inlet(c) and carina (d) 7 months after surgery show theintrathoracic anastomosis with metallic clips (ar-rows in c) and a partially collapsed, elevated stom-ach (arrows in d) in the right posterior mediastinumanterior to the vertebral body.


carcinoma who underwent Ivor Lewis esophagec-tomy have recurrent tumor (Fig 5) at 2.3-yearfollow-up (4). These recurrent tumors include (indecreasing order of frequency) distant metastasis(29% of cases), simultaneous regional and distantmetastasis (12%), regional metastasis (11%), andtumor at the anastomosis site (5%) (4). The over-all 5-year survival rate is 22.8%–33.3% (4,21).

Transhiatal Esophagec-tomy without ThoracotomyTranshiatal esophagectomy has recently beenproposed as a viable alternative to traditionaltransthoracic esophagectomy and has been usedfrequently since that time. This is mainly becauserecent reports suggest that this surgical procedurehas morbidity and mortality rates comparable tothose of esophagectomy with thoracotomy (6–11).

In transhiatal esophagectomy, a cervical inci-sion is made, the esophagus is mobilized inferiorlydown to the azygos arch, and the stomach is dis-sected through an abdominal incision (Fig 6a).The lower part of the esophagus is mobilized

through the esophageal hiatus (Fig 6b), and thecervical esophagus is transected at an appropriatelevel. The esophagus distal to the transection isbrought down through the posterior mediastinuminto the abdomen. The esophagus is transected atthe gastroesophageal junction, and the stomach isbrought into the neck through the posterior medi-astinum for esophagogastrostomy (Fig 6c) (10,11).

Transhiatal esophagectomy has been used forcurative or palliative resection of thoracic andcervicothoracic esophageal malignancy (Fig 7)and for benign esophageal conditions. The latterinclude esophageal stricture, neuromotor dys-function (achalasia, spasm, scleroderma), recur-rent gastroesophageal reflux, perforation, caustic

Figure 5. Tumor recurrence in a 60-year-old man with squamous cell carcinoma of the esophagus who hadundergone the Ivor Lewis procedure. (a) Contrast-enhanced CT scan (7-mm collimation) obtained at the levelof the inferior pulmonary vein 7 months after surgery shows a heterogeneous soft-tissue mass (arrows) withaortic invasion and smooth indentation of the left atrium (�). Note also the nodular thickening of the left pari-etal pleura (arrowheads) with effusion, a finding that suggests malignant effusion. (b) Barium esophagogramshows tethering and thickening of the mucosal folds due to tumor infiltration in the left side of the elevatedstomach below the carina (white arrows). Note the extraluminal mass (straight black arrows) and left pleuraleffusion (curved arrows). An intrathoracic anastomosis is also identified (arrowhead).


Figure 6. Drawings illustrate transhiatal esophagectomy without thoracotomy. (a) Cervical (arrowhead) and upperabdominal midline (arrow) incisions are made. (b) Mobilization of the stomach for esophageal replacement is per-formed through a laparotomy with pyloroplasty. The right gastric and gastroepiploic arteries are preserved. Theesophagus is mobilized from the back wall of the trachea through the cervical incision. From below, the surgeon’shand passes through the widened hiatus. Any remaining attachments of the muscular esophageal tube are avulsedfrom the esophageal wall. (c) The cervical esophagus is clamped, leaving adequate length for reconstruction by pre-serving 3–4 cm of peristaltic esophagus (open arrow). The esophagus is then extracted from the mediastinum. Thestomach is divided at the proximal region with a stapler or clamp (solid arrow). Pyloromyotomy is performed at thedistal portion with a suture technique (arrowhead). Finally, the remaining portion of the stomach is advanced to theneck for esophagogastric anastomosis.

Figure 7. Transhiatal esophagectomy with cervicalesophagogastrostomy in a 52-year-old man with squa-mous cell carcinoma of the cervicothoracic esophagus.(a) Preoperative esophagogram shows a focal filling defect(arrows), a finding that suggests esophageal cancer at thelevel of the thoracic inlet. (b) Barium esophagogram ob-tained 5 months after surgery shows a cervical esophago-gastric anastomosis (arrow). Metallic clips are also noted(arrowheads).


injury, and removal of the thoracic esophagusafter pharyngectomy or pharyngolaryngectomyfor carcinoma (2). Close adhesion between thetumor and mediastinal structures such as the air-ways and aorta constitute a major risk during sur-gery. At this level, accidental laceration resultingfrom sharp or forced blunt surgical dissection ofthe trachea, main-stem bronchi, or aorta is diffi-cult to repair without thoracotomy. Therefore,transhiatal esophagectomy is considered a safeprocedure only when tracheobronchial (Fig 8) oraortic (Fig 9) involvement is not suggested at CT(22).

The overall hospital mortality rate for transhia-tal esophagectomy is about 11% (3%–19%) (1).Orringer et al (2) reported the hospital mortalityrate for transhiatal esophagectomy as low as 5%for benign and malignant esophageal diseases.The leading causes of death are pulmonary prob-lems such as pneumonia and respiratory insuffi-ciency. Other causes of mortality may includecardiac problems, hemorrhage, mediastinal orretroperitoneal abscess, renal failure, and sepsis(2). Transhiatal esophagectomy with cervicalesophagogastric anastomosis avoids the morbidityassociated with thoracotomy and removes thepotential for sepsis from an intrathoracic leak.

According to several reports, no statisticallysignificant difference in the surgical mortalityrates for transhiatal and transthoracic approacheshas been shown (6–8). The overall morbidityrates for the two approaches, although variable,are also not significantly different. No statisticallysignificant differences in survival for patients whounderwent transthoracic versus transhiatal esoph-agectomy for esophageal carcinoma have beendemonstrated (Table 1) (1,9). Tumor stage at thetime of surgery is the only significant determinantof long-term outcome. No significant differencesin survival based on the extent or type of surgeryperformed have been shown.

Transthoracic Esophagec-tomy through a Left ThoracotomyEsophageal resection through a left thoracotomy(Fig 10) is less commonly used than the IvorLewis procedure or transhiatal esophagectomy.When esophagectomy is performed through a leftthoracotomy, either posterolateral thoracotomy(Fig 10a) or a thoracoabdominal incision may beused. After mobilization and resection of the

lower half of the thoracic esophagus (Fig 10b),reconstruction is performed in the mediastinum(Fig 10c) or, preferably, in the neck between theremaining portion of the esophagus and the gas-tric fundus (13).

A left thoracotomy provides free access to theesophagus from the level of the aortic arch to thehiatus. This procedure is usually performed fordistal esophageal and gastroesophageal lesions(Fig 11). Although less popular than either theIvor Lewis approach or transhiatal esophagec-tomy, it continues to be useful in the treatment ofesophageal or gastric tumors near the gastro-esophageal junction (12,13). The overall hospitalmortality rate for the left transthoracic approachis about 17% (1%–33%) (1). Postsurgical resultsare the same as those seen with esophagogastrec-tomy performed with other incisional techniques(Table 1) (12).

Figures 8, 9. (8) CT contraindication for transhiatalesophagectomy (tracheal invasion) in a 66-year-oldman with squamous cell carcinoma of the esophagus.Contrast-enhanced CT scan obtained at the level of thethoracic inlet shows tracheal displacement and indenta-tion in the posterior wall (arrows) due to an upper tho-racic esophageal mass. Total esophagectomy through aright thoracotomy and cervical esophagogastrostomyrevealed tracheal invasion. Careful dissection was per-formed between the posterior tracheal wall and theesophageal cancer. (9) CT contraindication for transhi-atal esophagectomy (aortic invasion) in a 65-year-oldman with squamous cell carcinoma of the esophagus.Contrast-enhanced CT scan (7-mm collimation) ob-tained at the level of the left atrium shows an esopha-geal tumor abutting the descending thoracic aorta witha contact area of more than 90° (arrows). The IvorLewis procedure was performed and revealed directinvasion of the aorta. Adhesiolysis was performed forthe severe adhesion between the aortic wall and theesophageal cancer.


Figure 10. Drawings illustrate transthoracic esophagectomy through a left thoracotomy. Drawing ashows how the thorax is usually entered through the left sixth intercostal space. To further expose theesophagus, the incision may be extended posteriorly (as in posterolateral thoracotomy). The incision maybe extended anteriorly across midline or inferiorly as a midline incision. Drawings b and c show how re-section of the lower esophagus and cardia is performed with end-to-side esophagogastrostomy.

Figure 11. Transthoracic esophagectomy with left thoracotomy in a 65-year-old man with squamous cell car-cinoma of the distal esophagus with extension to the gastroesophageal junction and gastric cardia. (a) Preop-erative barium esophagogram shows a 4-cm segment of luminal narrowing with ulceration (long arrow) andwith extension to the gastroesophageal junction (short arrow) and gastric cardia (arrowhead). (b) Bariumesophagogram obtained 19 months after surgery shows an intrathoracic end-to-side esophagojejunostomy aftertotal gastrectomy performed through a laparotomy and distal esophagectomy through a left thoracotomy. E �esophagus, J � jejunum.


Radical En Bloc Resectionversus Standard EsophagectomyThe extent of resection, whether limited or moreradical, depends primarily on the expertise andpreference of the surgeon. Standard esophagec-tomy involves dissection of the esophagus andremoval of any obviously enlarged lymph nodes(23). Unlike with radical en bloc resection, noeffort is usually made to remove the pleura, peri-cardium, thoracic duct, dorsal mesoesophagus,or azygos vein in standard esophagectomy (14,23,24).

Radical en bloc resection is performed whenpre- and intraoperative staging indicate that thetumor is potentially curable. A potentially curabletumor is defined as one in which the disease islimited to the esophageal wall, with locoregionalinvolvement within the limits of the proposed re-section and without evidence of hematogenousspread (Fig 12) (15,16).

The goal of en bloc resection is to completelyremove the digestive tract, including the normalhollow viscera up to 10 cm on either side of thetumor, along with an upper abdominal lymphad-enectomy and posterior mediastinectomy. An enbloc esophagectomy includes the tumor-bearingsegment of the esophagus, with a wide envelopeof tissue that includes both pleural surfaces later- ally, the pericardium anteriorly, and all lymphatic

and vascular tissue between the prevertebral fas-cia and the esophagus (14,15).

Figure 12. Radical en blocresection with cervical esopha-gogastrostomy in a 65-year-old man with squamous cellcarcinoma of the midesopha-gus. (a) Preoperative contrast-enhanced CT scan (10-mmcollimation) obtained at thesubcarinal level shows anesophageal mass in the mid-esophagus (arrow). Radical enbloc resection of the tumor-bearing segment of the esoph-agus, azygos vein, thoracicduct, adjacent lung paren-chyma and mediastinal pleurawas performed through a rightthoracotomy. (b) Bariumesophagogram obtained 7days after right transthoracicesophagectomy and cervicalesophagogastrostomy showsindentation at the cervicalesophagus (arrow) due to anesophagogastric anastomosis.Tracheal aspiration is alsoseen (arrowheads).

Figure 13. Drawing illustrates different types of by-pass surgery. The three potential routes of neoesopha-geal passage during esophageal bypass surgery are thetransthoracic (solid arrow), substernal (open arrow),and subcutaneous routes (arrowhead). The substernalroute is most often used, followed by the transthoracicroute and, rarely, the subcutaneous route.


The overall hospital mortality rate is about 8%(2.4%–11%) (14–17). The causes of hospitalmortality include myocardial infarction, pulmo-nary complications, hemorrhage, and intratho-racic anastomotic leak. Despite the theoreticaladvantages of en bloc resection and full lymphad-enectomy, studies comparing these procedureswith transhiatal esophagectomy show no differ-ence in the overall survival rate for patients whoundergo one or the other approach for esophagealcancer. There is also no statistically significantdifference in mortality and morbidity rates be-tween radical en bloc resection and standardesophagectomy (1,9,23).

PalliativeResection or Bypass Surgery

Potentially curative surgical resection may be per-formed in only 25% of patients with esophagealcarcinoma (25). The remaining patients, whocannot undergo curative surgery, may undergopalliative resection or bypass surgery to decreaselocal recurrence or to produce good symptomaticresults. This procedure is most commonly per-formed substernally but may be performed trans-thoracically or, rarely, subcutaneously (Figs 13–15) (25–27). The transthoracic route may allowbetter maintenance of an esophageal substituteover time. This approach utilizes the shortest andmost direct route between the neck and the ab-dominal cavity. However, it requires excision ofthe segment of the native esophagus involved byprimary tumor. With residual tumor in the medi-astinum, this approach may impose the risk ofrecurrent obstruction of the esophageal substitute(26). The substernal route offers the best directconduit to the neck when the primary tumor is

Figure 14. Drawings illustrate substernal approachesto esophageal bypass surgery. (a) Interposition of along segment of the colon is prepared based on ascend-ing branches (AB) of the left colic artery (LC) to reachthe neck and the division of the midcolic artery (MC).IC � ileocolic artery, IMA � inferior mesenteric artery,MA � marginal artery, RC � right colic artery, SMA �superior mesenteric artery. (b) Substernal left colonbypass surgery. (c) Substernal stomach bypass surgery.Long arrow indicates the stump of the cardia, arrow-head indicates the (divided) left gastric artery, shortarrow indicates the (intact) gastroepiploic artery.


Figure 15. Drawings illustrate the subcutaneous approach to esophageal bypass surgery. (a) The transverse colon,mesocolon, ileum, and mesentery are divided (dotted lines) based on the midcolic artery (MC). IC � ileocolic artery,IMA � inferior mesenteric artery, LC � left colic artery, RC � right colic artery, SMA � superior mesenteric artery.(b) Subcutaneous right colon bypass surgery. If the ascending colon and a portion of the transverse colon provideproper colonic length for the esophageal substitute, the cecum and terminal ileum may be amputated.

Figure 16. Substernal right colon interposition without esophagec-tomy in a 32-year-old man with esophageal obstruction due to lye in-gestion. (a) Postoperative contrast-enhanced CT scan shows the proxi-mal portion of the colon located in the substernal area (arrow). Wallthickening is seen in the proximal esophagus (arrowheads). (b) Postop-erative barium esophagogram shows substernal colon interposition.Apparent narrowing is seen at the cervical esophagocolic anastomosissite (arrow).


left in situ due to involvement of mediastinalstructures or a fistula (25). This route reduces thepossibility of recurrent malignant dysphagia ormalignant fistulization and allows creation of aportal for palliative radiation therapy that avoidsthe esophageal substitute. However, the subster-nal route requires a more tortuous and hazardouscourse for the substitute than does the transtho-racic route. Therefore, along its course, the sub-stitute may be compressed at the areas of the xi-phoid, substernal tunnel, and narrow superiorthoracic outlet, leading to obstruction of venousdrainage and loss of the transplant. The subcuta-neous or presternal route is safer. Any leakage willbe superficial, and if the bypass should demon-strate infarction, this can be recognized quicklyand the bypass easily removed (27). It also allowscreation of a portal for palliative radiation ther-apy. However, it is reserved for rare situations inwhich the substernal route is unavailable due toprevious cardiac or mediastinal surgery.

There are a variety of indications for bypasssurgery. Reconstructive bypass surgery with orwithout concurrent esophagectomy may be per-formed in tracheoesophageal fistula, previousesophagectomy without reconstruction, and, insome cases, obstruction due to lye ingestion (Fig16). Bypass surgery is also performed in cases ofunresectable esophageal cancer (25–27).

MiscellaneousSurgical Procedures

Antireflux repairs are performed through a thora-cotomy (Belsey Mark IV operation) or lapa-rotomy (Nissen, Hill, and Guarner procedures).The basic underlying principle of antireflux repairis to restore and maintain the function of the in-traabdominal segment of the esophagus as a loweresophageal sphincter. For this purpose, the intra-abdominal segment of the esophagus is wrappedwith a portion of the gastric cardia or the fundus.Antireflux repair has been shown to control refluxin approximately 85%–90% of cases with variablefollow-up lasting up to 10 years (28,29).

In patients with esophageal strictures that aredifficult to dilate or that have recurred after previ-ous antireflux surgery, resection of the esophagusmay be necessary. Motor disorders such as acha-lasia (Fig 17) and diffuse esophageal spasm arecharacterized by muscular dysfunction; conse-quently, myotomy is included in the treatment.Zenker diverticulum, a protrusion of mucosacephalad to the cricopharyngeal sphincter, is themost common diverticulum of the pharynx andesophagus. In diverticular disease such as Zenker

Figure 17. Esophagomyotomy through a right thoracotomy in a 42-year-old woman with achalasiawho presented with progressive dysphagia. (a) Preoperative barium esophagogram shows a markedly di-lated esophageal lumen proximal to an abruptly narrowed distal esophagus and gastroesophageal junc-tion with terminal beaking (arrow). (b) Follow-up esophagogram obtained after an esophagomyotomyapproximately 3 cm in length and including the gastroesophageal junction (arrows) shows a decrease inboth esophageal dilatation and passage disturbance.


diverticulum, myotomy with or without diverticu-lectomy aids in treatment (Fig 18) (30).

Leiomyoma is the most common nonmalig-nant tumor of the esophagus. The surgical ap-proach is chosen on the basis of the tumor level asdetermined at endoscopy. If the tumor is in thedistal esophagus, a left thoracotomy is preferred,whereas a leiomyoma in the middle or upper thirdis approached through a right thoracotomy. Themuscularis overlying the lesion is incised longitu-dinally, and the mass is enucleated by means ofblunt or sharp dissection, usually without injuringthe mucosa, after which the incision in the mus-cularis is closed (Fig 19).

There are a number of causes of esophagealrupture. The esophagus may rupture spontane-ously, after instrumentation, with penetratingtrauma, or with an underlying disease processsuch as Barrett ulcer or neoplasm. In esophagealrupture related to Barrett ulcer or neoplasm,esophageal resection and reconstruction may benecessary. For perforation of an esophagus thathad no specific abnormality prior to the rupture,treatment options include primary repair, esopha-geal diversion, and, rarely (if the injury is exten-sive), resection (Fig 20).

Selection ofEsophageal Substitutes

Several anatomic structures may be used to re-construct the resected esophagus, including thewhole stomach, gastric tube, left or right colon(Figs 14b, 16), jejunum (Fig 11b), and free revas-cularized grafts.

The stomach is the most convenient esopha-geal substitute and is the most widely used be-cause it has a reliable blood supply and is easilyconnected to the remaining esophagus with asingle anastomosis (Figs 2b, 4b, 7b, 12b) (31,32).The right gastric and right gastroepiploic arteriesare preserved when the stomach is used as anesophageal substitute. However, the stomach maybe inappropriate as a substitute because it incurshigh morbidity in cases of anastomotic failure,shows a tendency to dilate and cause defectivepropulsion, and may frequently be related to latecomplications (recurrent esophagitis and stenosis,gastric ulceration, hemorrhage) (32,33).

The use of the colon for esophageal replace-ment is indicated when long-term patient survivalis confidently expected. Indications for colonicsubstitutions include types IB and II congenitalesophageal atresia, complications related to resec-tion of benign strictures or tumors, advanced

Figure 18. Diverticulectomy for epiphrenic diverticulum of the distal esophagus in a 64-year-oldwoman. (a) Preoperative barium esophagogram shows a large diverticulum (arrows) containingair-fluid–contrast material levels and protruding to the right of the distal esophagus. (b) Bariumesophagogram obtained after diverticulectomy through a left thoracotomy shows slight mucosalrigidity at the diverticulectomy site (arrows).


functional disorders following multiple previouslyfailed antireflux procedures, and certain cases ofmalignant obstruction with an apparently goodprognosis following radical surgery (34). The leftcolon is preferred to the right due to its smallerdiameter, more constant and reliable blood sup-ply (from the left colic artery), adequate lengthfor total esophageal replacement, and superiorability to propel a solid bolus (34,35). The inter-position of colonic substitutes that are isoperistal-tic relative to the unidirectional pulsation of thecolon is mandatory because there is little chanceof functional obstruction or reflux and the proce-dure prohibits aspiration.

Jejunal interposition is indicated for recon-struction of the pharyngeal and cervical esopha-gus after radical resection (36). Pre- or postopera-tive irradiation is used in many patients who haveundergone partial or complete pharyngolaryngec-tomy for supraglottic, glottic, or subglottic can-cer. The stricture associated with the irradiationcan be very difficult to alleviate with dilationalone. In this setting, free jejunal replacement isperformed after resection of the irradiated andscarred tissue. Jejunal transposition can also beused for the treatment of benign, isolated, cervicalesophageal strictures that have not responded todilation (36). If a stricture due to caustic inges-tion is limited to the upper portion of the esopha-gus, a free jejunal graft can adequately replace thediseased segment. If, on the other hand, causticingestion has produced a diffuse stricture involv-ing more than a 25-cm length of the esophagus,

Figure 19. Enucleation of an esophageal leiomyoma through a right thoracotomy in a 35-year-old man. (a) Preoperative coronal T1-weighted MR image (repetition time msec/echo timemsec � 967/16) shows a large, pear-shaped soft-tissue mass (arrows) that is isointense relative tosurrounding tissue in the right aspect of the descending thoracic aorta (�). (b) Barium esophago-gram obtained 2 days after enucleation shows no evidence of mucosal injury.

Figure 20. Esophageal perforation due to ingestion of afish bone in a 56-year-old man. CT scan (7-mm collima-tion, lung windowing) obtained at the level of the aorticarch shows pneumomediastinum around the trachea andesophagus (arrows), an air-containing abscess cavity in theright paramediastinal area (�), and necrotizing pneumoniain the right upper lobe (arrowheads). The patient was suc-cessfully treated with esophageal diversion and totalesophagectomy with cervical esophagocologastrostomy.


the stomach or colon should be used. The suit-ability of organs for reconstruction varies amongpatients (31–36).

Complications of EsophagealResection and Reconstruction

Various complications may occur intra- and post-operatively with esophageal resection and recon-struction (Table 2) (1,2,37,38). Intraoperative

complications include hemorrhage, injury to thetracheobronchial tree (Fig 21), recurrent laryn-geal nerve injury, and pneumothorax. Postopera-tive complications include delayed hemorrhage,anastomotic leak (Fig 22), mediastinitis, atelecta-

Figures 21, 22. (21) Fistula between the intrathoracicstomach and upper trachea in a 66-year-old man withsquamous cell carcinoma of the upper thoracic esophagus.The patient had undergone right transthoracic esophagec-tomy and cervical esophagogastrostomy. Barium esopha-gogram obtained 19 days after surgery demonstrates a fis-tula (arrows) between the elevated stomach and uppertrachea during barium swallowing. A wide fistulous tract isseen at the cervical anastomosis site (arrowhead) and wasconfirmed at surgery. The patient subsequently underwentfocal tracheal resection with end-to-end anastomosis fol-lowed by transposition flap with the pectoralis majormuscle for closure of the gastric fistula. (22) Anastomoticleak in a 66-year-old man with squamous cell carcinomaof the upper thoracic esophagus. The patient had under-gone total esophagectomy through a right thoracotomyand cervical esophagogastrostomy. Barium esophagogramobtained 9 days after surgery shows a small amount ofleakage at the cervical esophagogastric anastomosis site(arrows). Stoppage of the leak was achieved with conser-vative treatment.

Table 2Complications of Esophageal Resection and Reconstruction

Intraoperative complicationsHemorrhageInjury to the tracheobronchial treeRecurrent laryngeal nerve injuryPneumothorax

Postoperative complicationsDelayed hemorrhageAnastomotic leakMediastinitisPulmonary complications (atelectasis, pneumonia, adult respiratory distress

syndrome, aspiration bronchiolitis)Arrhythmia, myocardial infarction, pericardial tamponadeDelayed gastric emptyingChylothoraxHerniation of abdominal viscera through the hiatus

Functional complications of esophageal replacementAnastomotic strictureRedundancy and impaired emptyingObstruction at the upper thoracic inlet or diaphragmatic hiatusReflux esophagitisUlceration of the esophageal substitutePostvagotomy dumping


sis, pneumonia, adult respiratory distress syn-drome (Fig 23), arrhythmia, myocardial infarc-tion, pericardial tamponade, delayed gastric emp-tying, chylothorax, herniation of abdominal vis-cera through the hiatus (Fig 24), and functionaldisturbance of the esophageal substitute (eg,anastomotic stricture [Fig 25], obstruction, refluxesophagitis, ulceration [37,38]).

The most common complications are thoracicor pulmonary and include pneumothorax, pleuraleffusion, pneumonia, aspiration bronchiolitis,empyema, and respiratory failure. These compli-cations are the most frequent cause of morbidityin patients undergoing esophagectomy and occurin almost 50% of cases (38).

Mediastinitis and sepsis due to disruption atthe anastomosis site are the most dreaded compli-cations and cause serious postoperative morbidity

Figure 23. Adult respiratory distress syndrome in a50-year-old man with middle thoracic esophageal carci-noma who had undergone the Ivor Lewis procedure.Conventional chest radiograph obtained 9 days aftersurgery shows increased opacity in both lower lungzones and in the left upper lung zone, findings that sug-gest pulmonary edema.

Figure 24. Diaphragmatic hernia in a 65-year-old man with distal esophageal cancer. The patient had undergoneesophagojejunostomy with distal esophagectomy and total gastrectomy 1 year earlier. The procedure had been per-formed through a left thoracotomy and laparotomy. (a) Chest radiograph shows opacity in the right hemithorax,which contains dilated and gas-filled bowel loops with pleural effusion. (b) Unenhanced CT scan (7-mm collima-tion) obtained at the level of the cardiac chamber shows herniation of proximal jejunal loops with edematous wallthickening (arrows). Herniation of engorged mesenteric vessels (arrowheads) and mesenteric fat are also seen. Notethe large amount of right pleural effusion with mediastinal shifting to the left. Herniation through the esophageal hia-tus was seen at surgery, and the hiatus was repaired.


and mortality (Fig 26). Ischemia around the anas-tomosis site and error in surgical technique aremajor etiologic factors in anastomotic leaks. Cer-vical anastomoses have consistently higher leakrates (10%–25% of cases) than do intrathoracicanastomoses (�10%). Leaks from thoracic anas-tomoses require aggressive surgical treatment (Fig26) because mediastinitis and shock caused byintrathoracic leak have a mortality rate of 60%–90% (39,40).

ConclusionsVarious surgical procedures are performed forbenign or malignant esophageal lesions. Radiolo-gists should be familiar with these surgical op-tions, the resultant anatomic changes associatedwith each option, and the expected findings atpostoperative imaging. Such information is essen-tial for evaluating the effectiveness of surgical pro-cedures and for the early detection and manage-ment of surgery-related complications.

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Figure 26. Intrathoracic leak and mediastinitis due to graft (elevated stomach) necrosis in a 71-year-old man withsquamous cell carcinoma of the esophagus. The patient had undergone the Ivor Lewis procedure. (a) Radiographobtained with water-soluble contrast material 15 days after surgery shows leakage of contrast material (straight ar-rows) from the right side of the elevated stomach distal to the anastomosis site (curved arrow). Note also the leakagefrom the left side of the elevated stomach (arrowhead). (b) CT scan obtained 2 cm distal to the anastomosis siteshows communication between the mediastinum and elevated stomach (arrow) due to gastric perforation. Intratho-racic leakage with perforation due to ischemic necrosis of an elevated stomach was noted at surgery 2 cm below theanastomosis site. Primary closure of the perforated stomach was achieved with a pericardiopleural patch.


This article meets the criteria for 1.0 credit hour in category 1 of the AMA Physician’s Recognition Award. To obtaincredit, see accompanying test at http://www.rsna.org/education/rg_cme.html.

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