DOI: 10.1148/rg.272065034
RadioGraphics 2007;27:409-429
© RSNA, 2007
Postoperative Imaging of Esophageal Cancer: What Chest Radiologists Need to Know1
Tae Jung Kim, MD,
Kyoung Ho Lee, MD,
Young Hoon Kim, MD,
Sook Whan Sung, MD,
Sanghoon Jheon, MD,
Suk-ki Cho, MD and
Kyung Won Lee, MD
1 From the Departments of Radiology (T.J.K., K.H.L., Y.H.K., K.W.L.) and Thoracic Surgery (S.W.S., S.J., S.-K.C.), Seoul National University Bundang Hospital, Seoul National University College of Medicine, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do 463-707, South Korea; and the Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, South Korea (T.J.K., K.H.L., Y.H.K., K.W.L.). Recipient of a Certificate of Merit award for an education exhibit at the 2005 RSNA Annual Meeting. Received March 20, 2006; revision requested May 31; final revision received September 20; accepted September 25. All authors have no financial relationships to disclose.
Address correspondence to K.W.L. (e-mail: lkwrad{at}radiol.snu.ac.kr).
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Abstract
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A variety of surgical procedures are used in the treatment of esophageal cancer. These procedures include transthoracic esophagectomy (Ivor Lewis procedure, McKeown procedure, left thoracoabdominal approach), transhiatal esophagectomy, and various forms of bypass surgery. Although meticulous surgical techniques and improved postoperative care have markedly reduced the complications associated with these techniques, esophageal resection is still associated with various intraoperative complications (hemorrhage, injury to the tracheobronchial tree, recurrent laryngeal nerve injury) and postoperative complications (anastomotic leak; mediastinitis; respiratory problems, including pleural effusion, pneumonia, and acute respiratory distress syndrome; cardiac and functional complications). Postoperative tumor recurrence is not uncommon in patients undergoing curative resection for esophageal cancer and can be categorized as either locoregional (locoregional lymph node metastases, anastomotic recurrence) or distant (hematogenous metastases, pleural or peritoneal seeding). Hematogenous metastases most commonly involve the liver, lungs, and bones, followed by the adrenal glands, brain, and kidneys. Hematogenous metastases may also involve multiple organs simultaneously. The sophisticated surgical procedures used in esophagectomy can result in anatomic changes and confound image interpretation. The radiologist must understand how these procedures can affect imaging data and be familiar with the appearances of postoperative anatomic changes, complications, and tumor recurrence to ensure accurate evaluation of affected patients.
© RSNA, 2007
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LEARNING OBJECTIVES FOR TEST 3
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After reading this article and taking the test, the reader will be able to:- List the various surgical techniques used for esophageal cancer.
- Discuss the anatomic changes and complications that can occur after each type of esophageal surgery.
- Describe the patterns of recurrent postoperative esophageal cancer seen at CT.
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Introduction
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Esophageal cancer is the third most common gastrointestinal malignancy and one of the 10 most prevalent cancers worldwide (1). The management of esophageal cancer has evolved from surgery alone to definitive and preoperative chemotherapy–radiation therapy. A variety of different approaches are available as treatment modalities for this disease, and stage-directed therapy may prove useful. Surgery remains the standard with which all other modalities are compared and is an acceptable option for patients with early-stage disease. For patients with locally advanced disease who are not surgical candidates, definitive chemotherapy–radiation therapy with concurrent and adjuvant chemotherapy has been established as the present standard of care (2,3). Esophageal resection followed by reconstructive surgery has been the most reliable modality for helping patients with esophageal cancer overcome swallowing difficulties. However, the diversity of surgical procedures and the resultant postoperative anatomic changes make image interpretation difficult. Familiarity with the postoperative complications associated with various surgical options and awareness of patterns of tumor recurrence are essential for evaluating the effectiveness of surgery and for early diagnosis and treatment in patients undergoing curative resection for localized resectable esophageal cancer.
In this article, we review various surgical techniques used in esophageal cancer surgery and discuss and illustrate the imaging features associated with a variety of postoperative anatomic changes, intra- and postoperative complications, and tumor recurrence.
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Esophageal Resection Techniques
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Transthoracic Esophagectomy
The most commonly applied transthoracic esophagectomy procedures are the Ivor Lewis procedure, the McKeown procedure, and the left thoracoabdominal approach.
Ivor Lewis Procedure (Laparotomy and Posterolateral Right Thoracotomy).—
The Ivor Lewis procedure usually involves an initial laparotomy followed by a right thoracotomy (Fig 1). The surgical procedure begins with mobilization of the stomach, followed by mobilization of the esophagus within the hiatus. The stomach is then used to create a gastric tube or conduit that will replace the resected esophagus, followed by the resection of lymph nodes along the celiac trunk and the splenic and common hepatic arteries. Pyloromyotomy or pyloroplasty is performed to prevent postvagotomy gastric outlet obstruction due to pylorospasm.
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Figure 1. Drawings illustrate transthoracic esophagectomy with a laparotomy and a right thoracotomy (Ivor Lewis procedure). In A, an upper abdominal incision (arrowhead) and a posterolateral thoracotomy (arrow) are made. In B, the esophagus and its adjacent structures are dissected en bloc. Lymph node dissection is also performed. Arrows indicate resection lines. In C and D, an anastomosis is created between the remaining esophagus and the gastric tube. Straight arrow indicates the pyloromyotomy, curved arrow indicates the intrathoracic (C) and cervical (D) anastomosis sites, arrowhead indicates the original cardioesophageal junction.
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After closure of the laparotomy, the patient is repositioned in the left lateral decubitus position and a standard posterolateral thoracotomy is performed. The chest is entered through the fifth intercostal space (Fig 1), which permits optimal visualization of the posterior mediastinum. The azygos vein is divided, and the esophagus and its adjacent structures, including the thoracic duct, are dissected en bloc from the vertebral body to the pericardium (Fig 1). The periesophageal, aortopulmonary, and subcarinal lymph nodes are then dissected. If indicated, a meticulous dissection of the lymph nodes along the left recurrent laryngeal nerve can be undertaken during the same procedure. The gastric conduit is then pulled into the chest. The anastomosis is created above the level of the azygos vein, as high in the thorax as possible, to achieve an adequate margin and decrease the prevalence of gastroesophageal reflux (Fig 1) (4–9). The gastric tube is most commonly located in the prevertebral space of the posterior mediastinum, but may be located in the substernal or right paravertebral space (Fig 2).
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Figure 2a. Routes of esophagogastric anastomosis after an Ivor Lewis procedure. Computed tomographic (CT) scans (5-mm section thickness) show the mobilized gastric tube (arrow) in the prevertebral space of the posterior mediastinum (a), its most common location; in the substernal space of the anterior mediastinum (b); and in the right paravertebral space (c).
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Figure 2b. Routes of esophagogastric anastomosis after an Ivor Lewis procedure. Computed tomographic (CT) scans (5-mm section thickness) show the mobilized gastric tube (arrow) in the prevertebral space of the posterior mediastinum (a), its most common location; in the substernal space of the anterior mediastinum (b); and in the right paravertebral space (c).
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Figure 2c. Routes of esophagogastric anastomosis after an Ivor Lewis procedure. Computed tomographic (CT) scans (5-mm section thickness) show the mobilized gastric tube (arrow) in the prevertebral space of the posterior mediastinum (a), its most common location; in the substernal space of the anterior mediastinum (b); and in the right paravertebral space (c).
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The Ivor Lewis procedure is the most common technique used throughout the world for the surgical management of carcinoma in the middle and lower third of the esophagus (10). This procedure is most useful and is probably the preferred approach when the tumor is located at the level of the carina, an area that is difficult to visualize and dissect using a transhiatal approach (Fig 3). The Ivor Lewis procedure is not indicated for high thoracic or cervical esophageal carcinomas and can be difficult to perform in patients who have previously undergone a right thoracotomy (4). Major complications associated with the Ivor Lewis procedure include (a) respiratory insufficiency resulting from thoracotomy or prolonged mechanical ventilation, and (b) mediastinitis and sepsis resulting from an intrathoracic anastomotic leak (11,12).
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Figure 3a. Ivor Lewis procedure in a 68-year-old man with squamous cell carcinoma (SCC) of the middle thoracic esophagus. (a) Pre-operative CT scan (5-mm section thickness) shows diffuse circumferential esophageal wall thickening (arrow). (b) Barium esophagogram obtained 2 months after surgery shows intrathoracic anastomoses (arrows) at the level of the aortic arch.
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Figure 3b. Ivor Lewis procedure in a 68-year-old man with squamous cell carcinoma (SCC) of the middle thoracic esophagus. (a) Pre-operative CT scan (5-mm section thickness) shows diffuse circumferential esophageal wall thickening (arrow). (b) Barium esophagogram obtained 2 months after surgery shows intrathoracic anastomoses (arrows) at the level of the aortic arch.
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McKeown Procedure (Anterolateral Right Thoracotomy, Laparotomy, and Cervical Anastomosis).—
In the McKeown procedure, the patient is placed in the supine position with the right side of the chest elevated. This position permits an abdominal midline laparotomy, an anterolateral thoracotomy through the fourth or fifth right intercostal space, and a cervical incision on either the right or left side to be performed simultaneously. The techniques of gastric mobilization, abdominal lymphadenectomy, and transthoracic mobilization of the esophagus are essentially the same as those described earlier for the Ivor Lewis procedure. The anastomosis is created in the neck through a separate left-sided cervicotomy, which mitigates the potential for sepsis resulting from an intrathoracic anastomotic leak and postoperative bile reflux (Figs 1D, 4). The main disadvantage of this procedure is the relative difficulty of radical lymphadenectomy compared with the Ivor Lewis procedure (13,14).
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Figure 4a. McKeown procedure in a 64-year-old man with SCC of the upper thoracic esophagus. (a) CT scan (5-mm section thickness) obtained at the level of the thyroid gland 2 months after surgery shows a cervical esophagogastric anastomosis (arrow). (b) Barium esophagogram obtained 2 months after surgery shows the cervical anastomosis (arrow). Arrowheads indicate a small amount of barium aspirate in the left lower lobe.
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Figure 4b. McKeown procedure in a 64-year-old man with SCC of the upper thoracic esophagus. (a) CT scan (5-mm section thickness) obtained at the level of the thyroid gland 2 months after surgery shows a cervical esophagogastric anastomosis (arrow). (b) Barium esophagogram obtained 2 months after surgery shows the cervical anastomosis (arrow). Arrowheads indicate a small amount of barium aspirate in the left lower lobe.
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Left Thoracoabdominal Approach.—
The left thoracoabdominal approach provides thoracoabdominal exposure of both the superior abdominal compartment and the posterior mediastinum through a single incision (Fig 5). This approach is considered optimal for carcinoma of the lower esophagus and cardia (14) and can be used in combined surgical procedures for double primary cancer of the left lung and the lower esophagus (Fig 6). After mobilization and resection of the lower esophagus, the gastric tube is brought upward through the hiatus and behind the aortic arch. Extensive lymphadenectomy in both the abdomen and the posterior mediastinum can easily be performed with this approach. Esophagogastric reconstruction is performed in the mediastinum or neck (Figs 5, 6) (14,15).
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Figure 5. Drawings illustrate transthoracic esophagectomy with a left thoracoabdominal approach. In A, the posterior mediastinum and superior abdominal compartment are approached with a single incision through the left sixth intercostal space (arrow). In B, the esophagus and its adjacent structures are dissected en bloc. Lymph node dissection is also performed. Arrows indicate resection lines. In C, an anastomosis is created between the remaining esophagus and the gastric tube. Arrow indicates the original cardioesophageal junction.
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Figure 6a. Transthoracic esophagectomy with a left thoracoabdominal approach in a 66-year-old man with double primary cancer of the left lung and the lower esophagus. (a) Preoperative CT scan (5-mm section thickness) obtained at the level of the right inferior pulmonary vein shows an esophageal mass (arrow) and a 3-cm mass in the lingular segment of the upper lobe of the left lung (arrowhead). (b) Fluorodeoxyglucose (FDG) positron emission tomographic (PET) scan shows two separate hypermetabolic lesions, one in the lower esophagus (standardized uptake value [SUV] = 11.2) and one in the left upper lobe (SUV = 14.3). (c) Barium esophagogram obtained 2 months after surgery shows an intrathoracic anastomosis with focal narrowing (arrow), a finding that suggests an anastomotic stricture. Arrowheads indicate the surgical clips used for lymph node dissection of the lung cancer.
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Figure 6b. Transthoracic esophagectomy with a left thoracoabdominal approach in a 66-year-old man with double primary cancer of the left lung and the lower esophagus. (a) Preoperative CT scan (5-mm section thickness) obtained at the level of the right inferior pulmonary vein shows an esophageal mass (arrow) and a 3-cm mass in the lingular segment of the upper lobe of the left lung (arrowhead). (b) Fluorodeoxyglucose (FDG) positron emission tomographic (PET) scan shows two separate hypermetabolic lesions, one in the lower esophagus (standardized uptake value [SUV] = 11.2) and one in the left upper lobe (SUV = 14.3). (c) Barium esophagogram obtained 2 months after surgery shows an intrathoracic anastomosis with focal narrowing (arrow), a finding that suggests an anastomotic stricture. Arrowheads indicate the surgical clips used for lymph node dissection of the lung cancer.
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Figure 6c. Transthoracic esophagectomy with a left thoracoabdominal approach in a 66-year-old man with double primary cancer of the left lung and the lower esophagus. (a) Preoperative CT scan (5-mm section thickness) obtained at the level of the right inferior pulmonary vein shows an esophageal mass (arrow) and a 3-cm mass in the lingular segment of the upper lobe of the left lung (arrowhead). (b) Fluorodeoxyglucose (FDG) positron emission tomographic (PET) scan shows two separate hypermetabolic lesions, one in the lower esophagus (standardized uptake value [SUV] = 11.2) and one in the left upper lobe (SUV = 14.3). (c) Barium esophagogram obtained 2 months after surgery shows an intrathoracic anastomosis with focal narrowing (arrow), a finding that suggests an anastomotic stricture. Arrowheads indicate the surgical clips used for lymph node dissection of the lung cancer.
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Transhiatal Esophagectomy
Transhiatal esophagectomy is performed in three phases—abdominal, cervical, and mediastinal—with the patient supine. The procedure is initiated through a supraumbilical midline incision extending from the xiphoid process to the umbilicus to provide access for the distal esophageal dissection (Fig 7). In the subsequent cervical phase, an incision is made that parallels the anterior border of the left sternocleidomastoid muscle just below the cricoid cartilage and allows dissection of the proximal esophagus (Fig 7). In the final (mediastinal) phase, the esophagus is dissected transhiatally by insertion of the surgeon’s hand through the abdominal incision (Fig 7). After mobilization of the entire intrathoracic esophagus, division of the cervical esophagus, and delivery of the stomach with the attached esophagus out of the abdomen, a partial proximal gastrectomy with removal of the esophagus is performed (Fig 7). Finally, after closure of the abdominal incision, a cervical esophagogastric anastomosis is created and the cervical wound is closed (Fig 7) (16–19).
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Figure 7. Drawings illustrate transhiatal esophagectomy without a thoracotomy. In A, a cervical incision parallel to the anterior border of the left sternocleidomastoid muscle (arrowhead) and an upper abdominal incision (arrow) are made. In B, the esophagus is dissected transhiatally by the surgeon passing his or her hand through the widened hiatus. Combined circumferential dissection of the esophagus through both the cervical and abdominal wounds allows the esophagus to be completely mobilized. In C, the esophagus and its adjacent structures are dissected. Lymph node dissection is also performed. Arrows indicate resection lines. In D, anastomoses are created between the remaining esophagus and the gastric tube. Straight arrow indicates the pyloromyotomy, curved arrow indicates the intrathoracic anastomosis site, arrowhead indicates the original cardioesophageal junction.
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Transhiatal esophagectomy is used for the curative resection of tumors of the lower third of the esophagus or gastric cardia (Fig 8). This approach is contraindicated when tracheobronchial tumor invasion or adherence of the esophagus to the aorta is suggested because, at this level, accidental laceration resulting from sharp or forced blunt surgical dissection of the trachea or aorta is difficult to repair without a thoracotomy (Figs 9, 10) (16,20). Mediastinal inflammation from prior surgeries, perforations, or radiation therapy is also considered to be a relative contraindication. The transhiatal approach has the potential to minimize respiratory compromise, and anastomotic complications are usually managed easily. The primary disadvantages associated with this approach include the inability to perform a complete node dissection and difficulty in completely visualizing the tumor. However, several studies comparing transthoracic and transhiatal esophagectomy for esophageal cancer have not reported any significant differences in mortality, morbidity, or length of survival between these two procedures (21,22). The perception that transhiatal esophagectomy represents a suboptimal oncologic procedure with decreased morbidity has led some surgeons to reserve it for patients with high-grade dysplasia arising from Barrett esophagus or for patients who are at high surgical risk.
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Figure 8a. Transhiatal esophagectomy with a cervical esophagogastrostomy in a 60-year-old woman with SCC. (a) Preoperative CT scan (5-mm section thickness) obtained at the level of the liver dome shows an esophageal mass (arrow). (b) Barium esophagogram obtained 3 months after surgery shows a cervical esophagogastric anastomosis (arrow).
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Figure 8b. Transhiatal esophagectomy with a cervical esophagogastrostomy in a 60-year-old woman with SCC. (a) Preoperative CT scan (5-mm section thickness) obtained at the level of the liver dome shows an esophageal mass (arrow). (b) Barium esophagogram obtained 3 months after surgery shows a cervical esophagogastric anastomosis (arrow).
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Figure 9. Contraindication for transhiatal esophagectomy due to tracheal invasion in a 56-year-old man with SCC of the upper thoracic esophagus. CT scan (5-mm section thickness) obtained at the level of the left innominate vein shows an upper esophageal mass with suspicious invasion of the trachea (arrow) and an aberrant left subclavian artery (arrowhead) from the right-sided aortic arch. Ivor Lewis esophagectomy revealed tumoral invasion of the trachea and left subclavian artery.
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Figure 10. Contraindication for transhiatal esophagectomy due to aortic invasion in a 60-year-old man with SCC of the lower thoracic esophagus. CT scan (5-mm section thickness) obtained at the level of the left atrium shows a large esophageal mass abutting the descending thoracic aorta, with a contact area of more than 90° (arrows). Ivor Lewis esophagectomy revealed a dense tumor adhesion to the aorta.
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Bypass Surgery
Bypass surgery provides an alternative food passageway when the esophagus is completely obstructed by cancer or is made dysfunctional by severe stricture or motor disorders. The stomach, jejunum, and colon have all been used for this purpose (Fig 11) (23–25). There are several possible bypass routes, including substernal, posterior mediastinal, and subcutaneous routes. The substernal route is the route of choice for placement of the esophageal substitutes in most bypass procedures. A benefit of this route is that it is anatomically separated from the tumor, which affords protection against tumoral obstruction of the bypass segment and offers a portal for palliative radiation therapy (Fig 11b) (23,26,27). However, the substernal route is tortuous and the substitute may be compressed at the areas of the xiphoid process, leading to vascular compromise. The posterior mediastinal route represents the shortest distance between the neck and the abdomen; however, this route may be unavailable if the mediastinum is inflamed, scarred, or involved by cancer (23–25,27).
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Figure 11a. Bypass surgery (esophagocologastrostomy) in a 57-year-old man with esophageal obstruction due to lower esophageal cancer. The patient underwent palliative surgery for hepatic metastases. (a) Pre-operative CT scan (5-mm section thickness) obtained at the level of the left atrium shows a bulky obstructing mass (arrow) in the lower thoracic esophagus. (b) Postoperative barium esophagogram shows substernal right colon interposition between the esophagus and the stomach.
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Figure 11b. Bypass surgery (esophagocologastrostomy) in a 57-year-old man with esophageal obstruction due to lower esophageal cancer. The patient underwent palliative surgery for hepatic metastases. (a) Pre-operative CT scan (5-mm section thickness) obtained at the level of the left atrium shows a bulky obstructing mass (arrow) in the lower thoracic esophagus. (b) Postoperative barium esophagogram shows substernal right colon interposition between the esophagus and the stomach.
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Surgical Considerations
Extent of Surgery.—
An R0 resection (ie, macroscopically and microscopically complete removal of the tumor) has been thought to offer the best chance for a cure of esophageal cancer (28). However, there is currently some controversy over the extent of R0 esophagectomy. Some surgeons, especially in Japan, insist that survival is prolonged if extensive surgery is used to remove all of the involved lymph nodes. This surgery consists of a three-field lymphadenectomy (ie, bilateral cervical, upper and lower mediastinal, and upper abdominal lymphadenectomy) or en bloc esophagectomy (29,30). An extended esophagectomy with a three-field lymphadenectomy offers the highest quality of tumor clearance and the capacity to prolong patient survival. However, this procedure is contraindicated for patients with (a) five or more positive nodes, (b) simultaneous metastasis to three anatomic compartments, or (c) cervical metastasis from lower esophageal cancer (31). In addition, intramural metastasis, which is defined as a metastatic lesion from a primary esophageal tumor to the adjacent esophageal or gastric wall with a prevalence of up to 30% of cases (32), is also a contraindication, since there is no evidence of survival benefits among these patients (33).
Esophagectomy performed with thoracoscopic and laparoscopic techniques is feasible; mobilization of the esophagus and stomach, gastric pull-up, and esophagogastric anastomosis can be achieved using such endoscopic instruments (Fig 12). However, such an esophagectomy combined with a systematic lymphadenectomy may not qualify as minimally invasive because the morbidity rates are equivalent to those for open radical esophagectomy (34).
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Figure 12. Drawings illustrate thoracoscopic port placement for minimally invasive esophagectomy. In A, four thoracoscopic ports are introduced. The camera port (10 mm) is placed at the seventh intercostal space on the midaxillary line. A 10-mm port is placed at the eighth or ninth intercostal space 2 cm posterior to the posterior axillary line for the ultrasonic coagulating shears. Two additional ports are placed, one (5 mm) posterior to the tip of the scapula and one (10 mm) at the fourth intercostal space at the anterior axillary line for retraction of the lung and esophageal countertraction during dissection. Dotted line indicates the diaphragm. In B, five abdominal ports are placed on the anterior abdominal wall: one cut-down 10-mm port in the right side of the epigastrium and four 5-mm ports in the bilateral subcostal, left epigastric, and right flank locations. Long dotted line indicates the diaphragm, short dotted line indicates the position of the neck incision. In C, a pyloroplasty (arrowhead) is performed using ultrasonic shears, and the incision is closed transversely. Then, a gastric tube (arrow) is constructed by dividing the stomach starting at the distal lesser curve while preserving the right gastric vessels. In D, an anastomosis (arrow) is created between the esophagus and the gastric tube. The gastric tube is sutured using an end-to-end anastomosis stapler.
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Choice of Conduit.—
The stomach, a segment of colon (Fig 11b), and the jejunum (Fig 13b) have all been reported as replacement conduits for the esophagus following resection (35–37). The most commonly used conduit in patients undergoing esophagectomy for malignancy is a gastric tube formed with either an intrathoracic or a cervical esophagogastrostomy (Figs 2–8). The stomach is the optimal conduit to replace the resected esophagus, since it has a very reliable blood supply and can reach any level in the chest up to the hypopharynx (35). The stomach may be brought up to the esophagus by means of a substernal, posterior mediastinal, or intrapleural route (Fig 2). If the stomach is not available due to intrinsic disease or previous gastric surgery, the colon is an acceptable second choice. The right colon has the advantage that it may be used in an isoperistaltic position, whereas the left colon is most commonly used in an antiperistaltic position. The use of a colonic interposition reduces the prevalence of reflux esophagitis and stricture associated with esophagogastrostomy (36). The jejunum can also be used as a conduit. It is most often used as a free jejunal graft with microvascular anastomosis to replace the cervical esophagus (Fig 13) (37).
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Figure 13a. Jejunal interposition (pharyngojejunoesophagostomy with jejunal free graft) in a 51-year-old man with SCC of the cervical esophagus. (a) Pre-operative CT scan (5-mm section thickness) obtained at the level of the cricoid cartilage shows a mass (arrow) in the cervical esophagus. (b) Postoperative barium esophagogram shows anastomoses at the pharyngojejunostomy (arrowhead) and jejunoesophagostomy (arrow) sites. Note the normal valvular conniventus of the jejunum.
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Figure 13b. Jejunal interposition (pharyngojejunoesophagostomy with jejunal free graft) in a 51-year-old man with SCC of the cervical esophagus. (a) Pre-operative CT scan (5-mm section thickness) obtained at the level of the cricoid cartilage shows a mass (arrow) in the cervical esophagus. (b) Postoperative barium esophagogram shows anastomoses at the pharyngojejunostomy (arrowhead) and jejunoesophagostomy (arrow) sites. Note the normal valvular conniventus of the jejunum.
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Complications of Esophageal Resection
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Regardless of the surgical technique used, esophageal resection is a high-risk procedure associated with considerable morbidity and mortality. Over the past 30 years, there have been significant improvements in perioperative management and techniques that have led to a decrease in both morbidity and mortality rates for esophageal resection. The mortality rates have dropped from 12% in the 1970s and early 1980s to 3% in the late 1980s and early 1990s (38). However, the mortality and morbidity rates can vary markedly depending on whether the procedure is performed in a low- or high-volume center. A recent study demonstrated that the morbidity and mortality rates vary greatly depending on the surgical volumes, hospital size, and degree of cancer specialization (39).
Furthermore, the number of cases involving complications has decreased from 72% to 60% over the past 30 years (39). Anastomotic leak, mediastinitis and sepsis, and respiratory failure are the most serious complications. Complications following esophagectomy and reconstruction can be categorized into intraoperative and postoperative complications.
Intraoperative Complications
Intraoperative complications include arrhythmias and hypotension, hemorrhage, injury to the recurrent laryngeal nerve, and injury to the tracheobronchial tree.
Recurrent Laryngeal Nerve Injury.—
Intraoperative injury to the recurrent laryngeal nerve usually occurs during dissection of the esophagus in the neck. Injury is most commonly caused by medial retraction of the trachea and thyroid gland, resulting in traction injury to the nerve. Intrathoracic mobilization of the esophagus and lymph node dissection are also potential sources of injury to this nerve. The prevalence of injury to the recurrent laryngeal nerve is estimated to be as high as 24% with transhiatal esophagectomy, and even higher rates have been reported with three-field dissection (40). Injuries to the recurrent laryngeal nerve can impair the ability of the patient to cough and can cause aspiration pneumonia. With the recent advance of extended lymphadenectomy in esophageal cancer surgery, accurate dissection of lymph nodes along the recurrent laryngeal nerve chains and the preservation of these nerves are important surgical issues (Figs 14, 15) (4–6,14,29,30).
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Figure 14. Drawing illustrates the anatomic location of the recurrent laryngeal nerves (arrowheads) and their relationship to adjacent structures. Arrows indicate the vagus nerves. Note the lymph nodes along the recurrent laryngeal nerves. Accurate dissection of the recurrent laryngeal nerve lymph nodes and preservation of these nerves are important surgical issues.
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Figure 15a. Right recurrent laryngeal nerve lymph node metastasis in a 57-year-old man with SCC of the upper esophagus. (a) Preoperative CT scan (5-mm section thickness) obtained at the level of the thoracic inlet shows metastatic lymph nodes (arrow) in the right recurrent laryngeal nerve lymph node chain. (b) FDG PET scan shows two hypermetabolic lesions, one in the upper esophagus (SUV = 10.8) (arrow) and one in the right recurrent laryngeal nerve lymph node chain (SUV = 8.7) (arrowhead).
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Figure 15b. Right recurrent laryngeal nerve lymph node metastasis in a 57-year-old man with SCC of the upper esophagus. (a) Preoperative CT scan (5-mm section thickness) obtained at the level of the thoracic inlet shows metastatic lymph nodes (arrow) in the right recurrent laryngeal nerve lymph node chain. (b) FDG PET scan shows two hypermetabolic lesions, one in the upper esophagus (SUV = 10.8) (arrow) and one in the right recurrent laryngeal nerve lymph node chain (SUV = 8.7) (arrowhead).
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Tracheobronchial Tree Injury.—
Injury to the trachea or mainstem bronchi usually occurs in the membranous portion of the airway. Such injury can lead to fistula formation and resultant respiratory compromise due to recurrent pneumonia or empyema, requiring stent placement or surgical repair (11,12).
Postoperative Complications
Postoperative complications include pulmonary complications, anastomotic leak, anastomotic stricture, chylothorax, redundancy and delayed emptying, herniation of the abdominal viscera through the hiatus, and reflux esophagitis.
Pulmonary and Pleural Complications.—
Pulmonary complications following esophageal resection include atelectasis, pneumonia, aspiration, pleural effusion, and respiratory failure leading to acute respiratory distress syndrome (Fig 16) (11,12,41). These complications are the most important cause of early postoperative mortality and are more likely to occur after transthoracic than after transhiatal esophagectomy (41). Pleural effusions usually result from an injury to the pleura on the contralateral hemithorax, allowing drainage of air or fluid from the field of dissection (12). These effusions are usually managed with observation and percutaneous or thoracotomy drainage.
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Figure 16a. Acute respiratory distress syndrome in a 71-year-old man with middle thoracic esophageal cancer. The patient had undergone an Ivor Lewis procedure. (a) CT scan (5-mm section thickness) obtained at the level of the right main pulmonary artery 7 days after surgery shows bilateral diffuse ground-glass attenuation (arrowheads) and pleural effusions (arrows). The patient’s condition improved after steroid pulse therapy. (b) Frontal radiograph also demonstrates bilateral ground-glass opacity and a large amount of right pleural effusion.
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Figure 16b. Acute respiratory distress syndrome in a 71-year-old man with middle thoracic esophageal cancer. The patient had undergone an Ivor Lewis procedure. (a) CT scan (5-mm section thickness) obtained at the level of the right main pulmonary artery 7 days after surgery shows bilateral diffuse ground-glass attenuation (arrowheads) and pleural effusions (arrows). The patient’s condition improved after steroid pulse therapy. (b) Frontal radiograph also demonstrates bilateral ground-glass opacity and a large amount of right pleural effusion.
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Anastomotic Leak.—
Anastomotic leak is one of the major postoperative complications following esophagectomy (Fig 17) and is reported to occur in up to 50% of patients (42). Historically, anastomotic leak has had a high mortality rate (60%–90% of patients) (43,44). However, more recent data indicate that modern surgical management of intrathoracic leaks results in a mortality rate of only 3.3% and has no impact on long-term survival (45). Anastomotic leak may occur either in the early postoperative period (2–3 days) due to technical failure, or later (3–7 days), when it is commonly ascribed to ischemic changes in the stomach, usually at or just below the anastomosis site, occasionally as a result of necrosis of the proximal end of the gastric tube (14). One-half of intrathoracic leaks are subclinical. These leaks can be detected at a routine contrast study, which is usually performed on postoperative day 7. Most subclinical leaks heal without any treatment. Minor leaks require conservative treatment such as antibiotics, nasogastric tube placement, and total parenteral nutrition. Larger leaks are treated in the same way but often require adequate drainage of a contained collection in the vicinity of the anastomosis (11). Intrathoracic leaks can be treated with placement of a pigtail catheter or chest tube under fluoroscopic or CT guidance. Uncontained leak, which is defined as a large leak with contrast material freely flowing into the pleural space, may require surgical intervention (44). Anastomotic leak can cause fistula formation with adjacent anatomic structures, such as esophagobronchial, esophagopleural (Fig 18), or esophagocutaneous (Fig 19) fistula. Patients who develop anastomotic leaks have a higher chance of eventual stricture formation and should be considered for early esophageal dilation (Fig 20) (11,12).
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Figure 17. Intrathoracic leak and mediastinal abscess due to anastomotic leak in a 60-year-old man with adenocarcinoma of the esophagogastric junction. The patient had undergone an Ivor Lewis procedure. CT scan obtained at the liver dome shows a fluid collection (arrow) in the posterior mediastinal space. Note the air bubbles within the abscess cavity. Primary closure of the stomach and reinforcement with diaphragmatic muscle were performed immediately.
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Figure 18a. Esophagopleural fistula and empyema in a 61-year-old man with SCC of the middle thoracic esophagus. The patient had undergone an Ivor Lewis procedure. (a) CT scan (5-mm section thickness) obtained at the level of the aortic arch 15 days after surgery shows a fistula (arrowheads) between the gastric tube and the right pleural space. Note the fluid collection with pleural enhancement and thickening, findings that suggest empyema. (b) Gastrograffin fistulogram through the thoracotomy site shows a fistulous tract (arrowheads) between the pleural space and the stomach (arrow). The patient was treated with placement of a chest tube through the fistulous tract.
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Figure 18b. Esophagopleural fistula and empyema in a 61-year-old man with SCC of the middle thoracic esophagus. The patient had undergone an Ivor Lewis procedure. (a) CT scan (5-mm section thickness) obtained at the level of the aortic arch 15 days after surgery shows a fistula (arrowheads) between the gastric tube and the right pleural space. Note the fluid collection with pleural enhancement and thickening, findings that suggest empyema. (b) Gastrograffin fistulogram through the thoracotomy site shows a fistulous tract (arrowheads) between the pleural space and the stomach (arrow). The patient was treated with placement of a chest tube through the fistulous tract.
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Figure 19a. Esophagocutaneous fistula in a 55-year-old man with SCC of the upper thoracic esophagus. The patient had undergone a McKeown procedure. (a) CT scan (5-mm section thickness) obtained at the level of the thyroid gland 7 days after surgery shows an esophagocutaneous fistula (arrowhead). (b) Barium esophagogram shows a leak at the cervical anastomosis site (arrowheads). The leakage was successfully managed conservatively.
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Figure 19b. Esophagocutaneous fistula in a 55-year-old man with SCC of the upper thoracic esophagus. The patient had undergone a McKeown procedure. (a) CT scan (5-mm section thickness) obtained at the level of the thyroid gland 7 days after surgery shows an esophagocutaneous fistula (arrowhead). (b) Barium esophagogram shows a leak at the cervical anastomosis site (arrowheads). The leakage was successfully managed conservatively.
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Figure 20a. Anastomotic stricture in a 69-year-old man with SCC of the middle thoracic esophagus. The patient had undergone an Ivor Lewis procedure. (a) Barium esophagogram obtained 3 months after surgery shows eccentric narrowing at the anastomosis site (arrow) with proximal esophageal dilatation. (b) Esophagogram shows dilatation of the anastomotic stricture.
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Figure 20b. Anastomotic stricture in a 69-year-old man with SCC of the middle thoracic esophagus. The patient had undergone an Ivor Lewis procedure. (a) Barium esophagogram obtained 3 months after surgery shows eccentric narrowing at the anastomosis site (arrow) with proximal esophageal dilatation. (b) Esophagogram shows dilatation of the anastomotic stricture.
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Anastomotic Stricture.—
Anastomotic stricture in the early postoperative period is due to wound healing, and the prevalence increases if there is an anastomotic leak. Dilatation of the stricture can be accomplished with repeated balloon dilation (Fig 20). Patients who develop anastomotic stricture in the late postoperative period should be carefully evaluated for recurrent disease with endoscopy and CT.
Chylothorax.—
Chyle leak with thoracic duct injury is a complication seen in all types of esophagectomy (12). The reported prevalence is higher in transthoracic than in transhiatal esophagectomy (46). During an Ivor Lewis procedure, the thoracic duct is resected en bloc with the tumor and adjacent lymph nodes, and the residual thoracic ducts are ligated above and below the resection site (11). Chest tube drainage greater than 200–400 mL per shift for a period greater than 48 hours likely indicates a thoracic duct injury. Approximately one-half of patients with such injuries can be treated with restriction of oral intake and intravenous hyperalimentation. However, others require surgical ligation of the thoracic duct, which is associated with a high rate of morbidity (12). Recently, percutaneous embolization therapy using glue and coils has been described (47).
Delayed Emptying.—
A large air-fluid level in the mediastinum is a good indicator of delayed emptying (Fig 21a), even if the patient is not vomiting or complaining of discomfort. Causes of delayed emptying include lack of a pyloric drainage procedure, obstruction at the level of the hiatus, and a redundant intrathoracic stomach or colon with consequent twisting or kinking (Fig 21b) (14). Delayed emptying can be managed with endoscopic balloon dilation, along with pro-kinetic drugs. If conservative management fails, repeat surgery with an adequate drainage procedure or repositioning of the gastric tube may be necessary (14).
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Figure 21a. Delayed emptying and intrathoracic redundancy. (a) Delayed gastric emptying in a 60-year-old man with SCC of the middle thoracic esophagus. The patient had undergone palliative esophagocologastrostomy for esophageal obstruction. Chest radiograph shows a distended gastric tube with a large air-fluid level (arrow), findings that suggest delayed gastric emptying. (b) Drawing illustrates the mechanism of delayed emptying due to intrathoracic redundancy after esophagocologastrostomy. Dotted lines indicate the kinking points.
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Figure 21b. Delayed emptying and intrathoracic redundancy. (a) Delayed gastric emptying in a 60-year-old man with SCC of the middle thoracic esophagus. The patient had undergone palliative esophagocologastrostomy for esophageal obstruction. Chest radiograph shows a distended gastric tube with a large air-fluid level (arrow), findings that suggest delayed gastric emptying. (b) Drawing illustrates the mechanism of delayed emptying due to intrathoracic redundancy after esophagocologastrostomy. Dotted lines indicate the kinking points.
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Recurrence
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Esophagectomy has long been the mainstay treatment for esophageal cancer. The prognosis in patients undergoing curative esophageal resection depends largely on the stage of the tumor. Reported 5-year survival rates in patients with resected stage I esophageal cancer range from 50% to 80% (48–51), which are far better than those in patients with more advanced disease. The reported overall 5-year survival rates vary from 5% to 35% (52–56), and the recurrence rates after curative surgery range between 34% and 79% (50,56–59).
The lack of desired success in the surgical management of esophageal cancer has led to the investigation of preoperative and postoperative adjuvant therapies. Postoperative radiation therapy has been added to improve local control, and chemotherapy has been administered to avoid or delay systemic metastasis. Whether adjuvant chemotherapy with or without radiation therapy can effectively prolong patient survival remains controversial (60); however, the use of multimodality treatment has improved the prognosis in subsets of patients who respond well to these treatments (61–64).
Postoperative Imaging Follow-up
To accurately evaluate affected patients, radiologists must be familiar with the factors affecting recurrence, the patterns of recurrence, and the resultant imaging findings associated with recurrence.
Barium examination can be performed to assess tumor recurrence at the anastomosis site. However, this test is limited due to its inability to show mural disease and surrounding adenopathy.
Serial postoperative CT plays a major role in detecting recurrent tumors in advance of symptoms (Fig 22). The overall accuracy of CT in determining recurrence is reported to be 87% (65). Whole-body FDG PET or integrated PET-CT has proved to be a useful adjunct to conventional imaging studies, since FDG PET may demonstrate functional activity of recurrent tumor before any anatomic changes are evident at conventional imaging. Such tests may also be superior to conventional imaging in the detection of distant metastases. However, FDG PET and integrated PET-CT are also limited by their relative lack of sensitivity and their inability to help detect small (<1-cm) or necrotic metastatic lesions (Fig 23).
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Figure 22a. Locoregional recurrence in a 72-year-old man with SCC of the middle thoracic esophagus. The patient had undergone an Ivor Lewis procedure. (a) Initial follow-up CT scan (5-mm section thickness) obtained at the level of the thoracic inlet 3 months after surgery shows a round, 4-mm lymph node (arrow) in the right recurrent laryngeal nerve lymph node chain. (b, c) Follow-up CT scans (5-mm section thickness) obtained at the level of the thoracic inlet (b) and bronchus intermedius (c) 6 months after surgery show an increase in the size of the metastatic lymph node (arrow in b) and soft-tissue thickening around the bronchus intermedius (arrow in c).
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Figure 22b. Locoregional recurrence in a 72-year-old man with SCC of the middle thoracic esophagus. The patient had undergone an Ivor Lewis procedure. (a) Initial follow-up CT scan (5-mm section thickness) obtained at the level of the thoracic inlet 3 months after surgery shows a round, 4-mm lymph node (arrow) in the right recurrent laryngeal nerve lymph node chain. (b, c) Follow-up CT scans (5-mm section thickness) obtained at the level of the thoracic inlet (b) and bronchus intermedius (c) 6 months after surgery show an increase in the size of the metastatic lymph node (arrow in b) and soft-tissue thickening around the bronchus intermedius (arrow in c).
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Figure 22c. Locoregional recurrence in a 72-year-old man with SCC of the middle thoracic esophagus. The patient had undergone an Ivor Lewis procedure. (a) Initial follow-up CT scan (5-mm section thickness) obtained at the level of the thoracic inlet 3 months after surgery shows a round, 4-mm lymph node (arrow) in the right recurrent laryngeal nerve lymph node chain. (b, c) Follow-up CT scans (5-mm section thickness) obtained at the level of the thoracic inlet (b) and bronchus intermedius (c) 6 months after surgery show an increase in the size of the metastatic lymph node (arrow in b) and soft-tissue thickening around the bronchus intermedius (arrow in c).
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Figure 23a. Celiac lymph node recurrence in a 71-year-old man with SCC of the middle thoracic esophagus. The patient had undergone an Ivor Lewis procedure. (a) CT scan (5-mm section thickness) obtained 2 months after surgery shows a small (8-mm) celiac lymph node (arrow), a finding that suggests metastasis. However, FDG PET performed 2 days later was negative. (b) Follow-up CT scan obtained 4 months after surgery shows a 3-cm necrotic celiac lymph node metastasis (arrow). (c) FDG PET scan obtained the same day as b is still negative.
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Figure 23b. Celiac lymph node recurrence in a 71-year-old man with SCC of the middle thoracic esophagus. The patient had undergone an Ivor Lewis procedure. (a) CT scan (5-mm section thickness) obtained 2 months after surgery shows a small (8-mm) celiac lymph node (arrow), a finding that suggests metastasis. However, FDG PET performed 2 days later was negative. (b) Follow-up CT scan obtained 4 months after surgery shows a 3-cm necrotic celiac lymph node metastasis (arrow). | |
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Abstract
LEARNING OBJECTIVES FOR TEST...
