Esophagogastrectomy: Superiority of the Combined Abdominal-Right Thoracic Approach (Lewis Operation)

The advantages of the combined abdominal-right thoracic approach to operating upon carcinoma of the esophagus (Lewis operation) are reviewed; they include elimination of the need for incision of the diaphragm or costal arch; easier mobilization of the esophagus; better visualization of the anastomosis through a high thoracotomy incision; and no interference by the heart and aortic arch.The operation is performed in one stage, using separate abdominal (upper midline) and thoracic (excision of the fourth rib) incisions. A careful two-layer anastomosis is performed using a separate circular opening in the stomach and invaginating the esophagus into the stomach by suturing the gastric serosa to the mediastinal fascia and pleura. Important principles of postoperative care include monitoring in the intensive care unit for five to seven days, use of a sump-type nasogastric tube, and frequent measurement of body weight, blood volume, blood gases, and electrolytes. Colloid infusions are preferred to crystalloid solutions in order to avoid fluid overload. Vigorous nasotracheal suction is important, and early tracheostomy is performed if bronchopulmonary secretions tend to accumulate.This operation was performed on 37 unselected patients during a seven-year period without operative mortality or anastomotic leak. Thirty-three patients had metastases at the time of resection, but all were relieved of dysphagia and the degree of palliation was very encouraging.