Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)
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C H A P T E R 17 • Esophagectomy—Transthoracic (Ivor Lewis) |
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The stomach is placed as high in the chest cavity as possible to avoid undue tension at the anastomotic site. A stapled anastomosis using an end-to-end anastomosis (EEA) stapling device can be used via a 1.0- to 1.5-cm gastrotomy or, alternatively, a hand-sewn anastomosis can be performed. The hand-sewn anastomosis is performed in two layers. First, the posterior row of interrupted 3-0 silk stitches is placed between the posterior wall of the esophagus, approximately 0.5 to 1.0 cm proximal to the cut end of the esophagus and the fundus of the stomach (Figures 17-7 and 17-8).
Tumor removed along
with portions of esophagus and fundus of stomach
FIGURE 17–7
FIGURE 17–8
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At this point, the anesthesiologist places a nasogastric tube as the surgeon guides it from the esophagus, through the gastrotomy, and into the stomach. A running 4-0 absorbable suture is used to perform the mucosa-mucosa anastomosis. An anterior row of interrupted 3-0 silk Lembert stitches completes the anastomosis (Figure 17-9).
The stomach should be tacked to the prevertebral fascia and esophageal hiatus with interrupted 3-0 silk stitches once the anastomosis is complete. A 36F chest tube is placed into the right side of the chest and exited through a separate stab incision below the thoracotomy.
B
A C
FIGURE 17–9
C H A P T E R 17 • Esophagectomy—Transthoracic (Ivor Lewis) |
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3. CLOSING
The abdominal incision is closed according to surgeon preference. The fascia is usually closed with a no. 0 or no. 1 interrupted or running absorbable monofilament suture, and skin is closed with staples. The thoracotomy is closed with interrupted no. 1 or no. 2 Vicryl figure-of-eight stitches. Muscle layers are individually reapproximated with running 2-0 Vicryl suture, and the skin is closed with staples or running 4-0 absorbable suture. Sterile dressings are applied (Figure 17-10).
A
Esophagus
Left lung
Stomach
Heart
B
FIGURE 17–10
2 0 2 S E C T I O N I I I • TH E E S O P H A G U S
STEP 4: POSTOPERATIVE CARE
Routine intensive care unit monitoring is not mandatory following transthoracic esophagectomy, but the decision is made for each individual based on length of operation, surgeon preference, patient comorbidities, and blood loss. On postoperative day 4 or 5, a contrast esophageal swallow study is performed to evaluate the anastomosis for leak. If no leak is present, a diet is initiated and output from the chest tube is monitored. Assuming no increase in output with feeding and a fully expanded lung and drained right hemithorax, the chest tube can be removed. Ambulation and chest physiotherapy should be initiated on postoperative day 1 and continued until discharge.
STEP 5: PEARLS AND PITFALLS
Identify and preserve the right gastric and right gastroepiploic arteries when mobilizing the stomach.
Test the esophagogastric anastomosis under water before closing to ensure no gross anastomotic dehiscence is present.
Avoid injury to the posterior membranous trachea during esophageal mobilization.
Act quickly to ensure adequate drainage of the thorax and mediastinum if signs of anastomotic leak occur in the postoperative period.
SELECTED REFERENCES
1. Junginger T, Gockel I, Heckhoff S: A comparison of transhiatal and transthoracic resections on the prognosis in patients with squamous cell carcinoma of the esophagus. Eur J Surg Oncol 2006;32:749-755.
2. Hulscher JB, van Sandick JW, de Boer AG, et al: Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus. N Engl J Med 2002;347:1662-1669.
C H A P T E R 18
ESOPHAGOGASTRECTOMY
Joseph B. Zwischenberger and Edward Y. H. Chan
STEP 1: SURGICAL ANATOMY
A comprehensive understanding of the anatomy of the thorax, esophagus, stomach, and abdomen is critical before undertaking surgical procedures on the esophagus and stomach.
STEP 2: PREOPERATIVE CONSIDERATIONS
Indications: Indications for esophagogastrectomy include malignant tumor of the lower esophagus or esophagogastric junction, which precludes a clear tumor margin to allow use of the stomach for esophageal reconstruction. Malignancies of the esophagogastric junction are most commonly adenocarcinomas of gastric origin (Figure 18-1).
A left thoracoabdominal approach is indicated if the tumor location necessitates resection of the distal esophagus and proximal stomach and when a Roux-en-Y anastomosis is to be used to reconstruct the resected stomach. If removal of the proximal stomach only is required to obtain adequate surgical margins, an anastomosis may be made between the distal stomach and the esophagus in the chest. However, this reconstructive approach may be associated with reflux esophagitis and dysphagia. Some surgeons prefer the alternative of a total resection of the stomach and distal esophagus with a Roux-en-Y jejunal interposition with an end-to-end anastomosis with the remaining esophagus. For a total esophagogastrectomy, a colon interposition is required. A double-contrast barium enema and colonoscopy will aid selection of the right (preferred), transverse, or left colon. During the procedure, length and blood supply also influence colon selection.
Preoperative planning: Informed consent is obtained and the patient is made nothing-by- mouth status at least 8 hours before the procedure. A bowel preparation is necessary 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. Central venous access is not routinely necessary; however, if access is needed, the right neck veins should be used to allow the surgeon complete access to the left side of the neck during operation. A double-lumen endotracheal tube is used to deflate and retract either lung to facilitate dissection. If a colonic interposition is planned, mesenteric angiography should be performed on patients with risk factors for atherosclerotic disease.
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Anesthesia: General endotracheal anesthesia is mandatory for this procedure.
Position: The patient is placed in the right lateral (left thoracoabdominal) position.
Operative preparation: The skin over the entire neck, chest, and abdomen should be prepped with povidone-iodine (Betadine).
Tumor in
distal esophagus
Incision
MC
FIGURE 18–1
C H A P T E R 18 • Esophagogastrectomy |
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STEP 3: OPERATIVE STEPS
1.INCISION
Incision and exposure: A left thoracotomy is performed between the sixth and seventh ribs. The serratus anterior muscle is separated to expose the intercostal muscles, which are removed from the superior aspect of the seventh rib to enter the chest (Figure 18-2).
A thoracoabdominal incision may provide greater exposure. However, this approach leads to longer operative time and may result in an unstable costal arch, chondritis, or persistent pain. A separate midline abdominal incision is often better tolerated (see Figure 18-1).
Incision
FIGURE 18–2
2 0 6 S E C T I O N I I I • TH E E S O P H A G U S
2. DISSECTION
Diaphragm incision: The left thorax is entered and a semilunar incision is made in the diaphragm near the costal arch, 2 cm from the costal margin. Retraction of the cut edge of the diaphragm exposes the left lobe of the liver and the left upper abdomen. Radial incisions may be made to expose and resect the adjacent diaphragm to achieve tumor-free margins when the tumor invades the crus. Crural resection has a greater risk of diaphragmatic paralysis postoperatively (Figures 18-3 and 18-4).
The abdomen should be carefully examined for peritoneal or hepatic metastases. The cardia of the stomach should be palpated through the lesser sac, and the mobility of the tumor should be assessed. If there are metastases or the tumor is fixed to the aorta or spine, the tumor is not resectable.
Esophageal mobilization: The pleura of the mediastinum is opened with visualization
of the esophagus and the esophageal tumor. Mobilization of the esophagus from the aorta is achieved and the esophagus proximal to the tumor is encircled by a Penrose drain. The surgeon must identify the anterior vagus nerve and the left bronchus and pulmonary vein. The esophageal vessels should be dissected, ligated, and divided. To provide local clearance of the tumor, the surgeon should take 1 cm of the crura in continuity with the
tumor (see Figure 18-4).
C H A P T E R 18 • Esophagogastrectomy |
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Tumor in
distal esophagus
Esophageal tumor
Left lung
Heart
FIGURE 18–3
Anterior vagus nerve
Left bronchus and pulmonary vein
Incision in diaphragm 
FIGURE 18–4
2 0 8 S E C T I O N I I I • TH E E S O P H A G U S
Mobilization of the stomach: The mobilization of the stomach proceeds along the greater curvature in the direction of the pylorus, with division of the omentum maintaining a 1-cm margin from the right gastroepiploic artery and vein. Attention should be paid to avoiding excessive traction on the omental artery arcade. The right gastroepiploic vessels should be preserved until the extent of dissection is determined. The stomach is retracted to the right to provide tension on the short gastric vessels. Dissection proceeds cephalad along the greater curvature until the proximal stomach and distal esophagus are freed (Figure 18-5).
The freed stomach is reflected to visualize the celiac axis on the posterior aspect. The posterior gastric artery and recurrent branch of the left inferior phrenic artery should be identified, ligated, and divided. Node-bearing tissue is removed from the superior aspect of the pancreas, around the celiac axis, and along the left gastric artery for en bloc removal with the specimen. The left gastric artery and vein are ligated.
The lesser sac is examined to determine whether the pancreas or spleen is involved with the tumor. The lesser omentum is divided and removed from the right side of the esophagus to the pylorus, with care taken to preserve the right gastric artery and vein.
MCMC
Stomach
Liver
Cut edge of diaphragm
FIGURE 18–5