Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

1 9 2 S E C T I O N I I I • TH E E S O P H A G U S

The neck wound is filled with saline and the anesthesiologist gently introduces 50 mL of air into the NG tube while the surgeon occludes the distal stomach and observes for air bubbles at the anastomosis in the neck. The completed anastomosis should lie high in the neck without tension (Figure 16-27).

3. CLOSING

Before closure, the entire stomach should be inspected for areas of necrosis. The abdominal fascia is closed with an 0-looped running polydioxanone suture (PDS) or according to surgeon preference, then the skin closed with staples. In the neck, a small Jackson-Pratt drain is placed in the surgical bed and exited through a separate stab incision in the lateral neck. The platysma is approximated with a running 4-0 absorbable suture, then the skin closed with a second 4-0 to 5-0 absorbable stitch. A chest radiograph should be obtained in the operating room to ensure no pneumothorax or hemothorax is present. If pneumothorax or hemothorax is present, appropriate chest tubes should be inserted.

Trachea

Heart

Esophagus

Stomach

Aorta

FIGURE 16–27

STEP 4: POSTOPERATIVE CARE

The need for extensive postoperative monitoring in the intensive care unit (ICU) is based on surgeon preference, patient comorbidities, blood loss, and length of procedure. However, routine ICU care is not required postoperatively.

Hallmarks to a rapid recovery lie in adequate pain control, physical therapy, and pulmonary toilet.

The esophagogastrostomy should be evaluated on postoperative day 4 or 5 with a contrast swallow study. If no leak is present, a diet is initiated and the drain is removed as long as the output does not increase with feeding.

If an anastomotic leak occurs, the neck incision should be opened and packed with moist gauze 2 to 3 times daily. The wound is allowed to granulate and close secondarily.

STEP 5: PEARLS AND PITFALLS

Identify and preserve the right gastroepiploic and right gastric arteries during mobilization of the stomach.

Vagal fibers around the midesophagus can be difficult to dissect bluntly. Using the vertebral bodies posteriorly as an anvil against which to compress tissues can facilitate blunt dissection.

Communicate with the anesthesiologist, especially during transthoracic dissection when periods of hypotension are common.

Keep dissection close to the proximal esophagus to minimize potential injury to the recurrent laryngeal nerves.

SELECTED REFERENCES

1. Orringer MB, Marshall B, Iannettoni MD: Eliminating the cervical esophagogastric anastomotic leak with a side-to-side stapled anastomosis. J Thorac Cardiovasc Surg 2000;119:277-288.

2.Orringer MB, Marshall B, Stirling MC: Transhiatal esophagectomy for benign and malignant disease. J Thorac Cardiovasc Surg 1993;105:265-276.

C H A P T E R 17

ESOPHAGECTOMY—TRANSTHORACIC (IVOR LEWIS)

David B. Loran and Joseph B. Zwischenberger

STEP 1: SURGICAL ANATOMY

A comprehensive understanding of the anatomy of the esophagus is critical before undertaking surgical procedures on the esophagus.

Figure 17-1 demonstrates key anatomic features that should be considered before performing a transthoracic esophagectomy.

STEP 2: PREOPERATIVE CONSIDERATIONS

Indications for transthoracic esophagectomy include carcinoma, caustic injury with stricture or dysplastic mucosal changes, and other benign diseases. Most surgeons agree that benign disease is best treated with transhiatal esophagectomy, which eliminates the risk of intrathoracic anastomotic leak and spares the patient the discomfort of thoracotomy without compromising outcomes. If dense adhesions are expected, a transthoracic approach can afford a safer dissection of the intrathoracic esophagus under direct vision and eliminate the blind dissection and potential for massive hemorrhage, which is rarely associated with transhiatal esophagectomy. For tumors of the proximal esophagus and mid-esophagus, a right thoracotomy is preferred, whereas a left thoracotomy is preferred for distal esophageal tumors.

Advocates of the transthoracic approach for cancer resection point out that a more complete lymph node dissection can be accomplished by direct visualization of the operative field. Advocates of the transhiatal approach point to a perceived overall lower morbidity rate. Despite multiple studies over the years with trends in both directions, the aggregate experience has shown no difference in morbidity, mortality, or outcome between the transthoracic and transhiatal approaches. The most important determining criteria are experience of the surgeon, need for exposure, and patient selection.

Informed consent is obtained and the patient is made nothing-by-mouth status at least 8 hours before the procedure. A bowel preparation can be given to the patient the day before the procedure in case the colon is needed as a reconstruction conduit. In the operating room, a radial artery catheter should be used for continuous blood pressure monitoring.

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