Esophagectomy (Ivor Lewis)

Why are we operating?

Removal of the esophagus for cancer through abdomen then right chest, with the stomach refashioned into a tube and brought up to replace it, one of surgery's biggest physiological insults, staged as two operations in one.

Indication: Resectable carcinoma of the middle or lower esophagus after staging and usually after neoadjuvant therapy, in a patient fit for two body cavities.

The operation in 4 steps

1. 01Abdominal phase

   Laparotomy or laparoscopy: the stomach is mobilised on the right gastroepiploic arcade, the left gastric pedicle taken with its nodes, and a pyloric drainage procedure considered.

   Why: The whole reconstruction hangs on one vessel: the right gastroepiploic artery. Every move in the abdomen is played around preserving that arcade, because the new esophagus lives on it.

2. 02Making the conduit

   The stomach is stapled into a narrow tube along the greater curve, excising the lesser curve and cardia with the specimen side.

   Why: A narrow tube empties better and reaches further than a whole stomach, and the staple line removes the territory the tumour and its nodes drain to, oncology and plumbing in one manoeuvre.

3. 03Thoracic phase

   Right thoracotomy or VATS: the azygos vein is divided, the esophagus mobilised en bloc with its nodes, and divided above the tumour.

   Why: The right chest is the esophagus's home ground: the whole thoracic course is reachable there, under the azygos arch. The nodal harvest here is where the staging becomes real.

4. 04The anastomosis

   The conduit is delivered into the chest without twisting and joined to the esophageal remnant with staples or sutures; a drain guards the join and a feeding route is established.

   Why: This anastomosis leaks more than any other a general surgical trainee will meet, tension, a single blood supply and the chest's negative pressure all conspire, which is why its checks are obsessive and its drain is non-negotiable.

Anatomy you need

The esophagus's full course from pharynx to stomach, and the stomach that will be tubed and lifted to replace it.

What can go wrong

• Anastomotic leak

  Day 3–7: tachycardia, fever, abdominal pain, ileus that fails to resolve, or subtle deterioration that 'doesn't add up'.

• Atelectasis & pulmonary complications

  Low-grade fever and mild desaturation in the first 48 hours, especially after upper-abdominal incisions.

• Venous thromboembolism

  Unilateral leg swelling, or sudden dyspnoea, pleuritic pain, tachycardia, sometimes the only sign is unexplained hypoxia.

• Surgical-site infection

  Wound erythema, warmth, discharge, and pain out of proportion, typically from postoperative day 4–7.