Key Points

• The left thoracoabdominal approach Is an excellent option for locally advanced gastroesophageal junction malignancies or complex reoperative hiatal surgery.
• The flexibility of the approach allows for Roux-en-Y reconstruction after total gastrectomy and distal esophagectomy as well cervical or low chest esophagogastrostomy.
• Meticulous closure is essential in order to prevent costochrondral-related wound complications.
• Familiarity with the anatomy viewed from a lateral approach is essential as this can be somewhat disorienting for the uninitiated.

Esophagectomy through a left thoracotomy approach was described almost 70 years ago by Sweet.[1] It ushered in the new era of transpleural and transmediastinal placement of the gastric conduit and confirmed the safety of the intrathoracic anastomosis. Prior to this, extrathoracic subcutaneous passage was used to facilitate the cephalad transfer of the gastric conduit to the neck for the esophagogastric anastomosis.[2] This was favored at the time because of the trepidation of performing an intrapleural anastomosis.

Esophagectomy through a left thoracotomy remained a common approach for the ensuing 30 years. It has now largely been supplanted by other techniques,[3],[4],[5] although none of the more commonly performed procedures for esophageal resection truly replaced the left thoracotomy approach. By the late 1970s, Ivor Lewis and McKeown procedures seemed more appropriate for midesophageal squamous cell carcinoma, and transhiatal (blunt) esophagectomy appeared to be the best approach for the then, less common, adenocarcinoma of the distal esophagus.

Current trends suggest a marked shift in the frequencies of histologic subtypes in the United States has occurred. Adenocarcinoma of the distal esophagus and gastroesophageal junction is now the predominant cancer. Thus, when considering any operation for esophageal cancer, optimal exposure to the distal esophagus and gastric cardia is critical, because this will be the location of the cancer in the majority of patients. Moreover, since N1 lymph node involvement is a likely early characteristic, exposure of the esophageal hiatus and distal posterior mediastinum for lymphadenectomy (or relevant sampling) must be considered a critical component of any operation for adenocarcinoma of the esophagus. To achieve optimal exposure of the hiatus and posterior mediastinum for resection of esophageal cancer, there is no better procedure than the left thoracoabdominal approach (Ginsberg, 2002).[6]Moreover, benign complex or reoperative hiatal surgery, including acute perforation, can be expertly managed by the outstanding exposure to the hiatus this approach offers.

To date, no randomized studies exist that advocate which of several esophageal resection techniques provides the most complete resection for cancer, nor do any propose what technique may have the greatest potential for a highly successful outcome. Attempts were made retrospectively to compare outcomes of different procedures performed at the same institution. Unfortunately, no consensus was elicited among these.[7],[8] However, a recently published Society of Thoracic Surgeons (STS) database study does suggest that lesser operations (e.g. transhiatal esophagectomy) might have less morbidity compared with any approach utilizing a thoracotomy[9]. This must be balanced by a suspected higher locoregional cancer recurrence rate after transhiatal resection.[10]

When considering management of an esophageal malignancy, if one simply abides by the basic tenets of cancer surgery—(1) optimal exposure of the cancer field, (2) complete resection that includes radial margins, and (3) extensive locoregional lymphadenectomy for accurate staging—the best operative approach for esophageal cancer in the 21st century may very well be the left thoracoabdominal esophagectomy with cervical esophagogastric anastomosis (Figure 1A-B). Morbidity of the approach can be reduced by careful preoperative patient selection, meticulous surgical technique, and early recognition and management of evolving postoperative problems.

Figure 1

(A) Overview of area to be resected. (B) The proposed incision. (REPRINTED WITH THE PERMISSION OF THE CLEVELAND CLINIC FOUNDATION.)

In addition, for complex or reoperative benign esophageal disease, the flexibility of the approach might simplifiy the operation if minimally invasive techniques are not applicable or available. Gastroesophageal junction erosion of mesh placed for attempted repair of paraesophageal hernia is, unfortunately, becoming more common, and is an extremely challenging problem to manage. The left thoracoabdominal approach allows for simultaneous supra- and sub-diaphragmatic visualization as well as any possible treatment strategy to be performed (primary repair, Sweet esophagectomy, gastrectomy and roux-en-Y, thoracic esophagectomy and proximal gastrectomy with cervical esophagogastric anastomosis).