Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)
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C H A P T E R 18 • Esophagogastrectomy |
209 |
3. SELECTION OF PARTIAL OR TOTAL GASTRECTOMY
Proximal esophagogastrectomy with esophagogastrostomy should be undertaken if the tumor can be adequately resected with a 5-cm margin by removal of the proximal stomach. The stomach has a blood supply that is less likely to be affected by atherosclerotic disease and requires only a single anastomosis, as opposed to using an intestinal conduit.
Gastric remnant reconstruction: The margin of resection should be 4 to 6 cm from the esophagogastric junction, from halfway on the lesser curvature to a medial point on the fundus. A gastrointestinal anastomosis (GIA) stapler is placed at a right angle and transects the proximal stomach from the lesser curvature toward the fundus. The staple line is oversewn with inverting 3-0 suture. Care should be taken to maintain tension along the stomach to prevent shortening of the lesser curvature. A pyloromyotomy may be necessary to prevent gastric stasis secondary to division of the vagus nerves (Figure 18-6).
Tumor removed along
with portions of esophagus and fundus of stomach
A
FIGURE 18–6 |
B |
2 1 0 S E C T I O N I I I • TH E E S O P H A G U S
The gastric remnant is brought into the thorax through the hiatus and behind the proximal esophagus. The margin should be at least 10 cm. If the margin is adequate, the posterior wall of the esophagus is anastomosed to the end of the gastric tube. If the margin is inadequate, the gastric tube length should be determined. If the length of stomach is inadequate to achieve a clear proximal remnant, the left side of the colon can be used as an alternative between the gastric remnant and the cervical esophagus (Figure 18-7).
A
Esophagus
Left lung
Stomach
Heart
B
FIGURE 18–7
C H A P T E R 18 • Esophagogastrectomy |
211 |
Esophagogastric anastomosis: The esophagus is cut at a 45-degree angle with the anterior wall longer than the posterior wall. Stay sutures should be placed with 4-0 Vicryl at the midpoint of the anterior wall, as well as the posterior wall. A 2-cm gastrotomy is made between the stapled end of the lesser curvature and the greater curvature. The stay suture from the posterior esophageal wall is passed through the full thickness of the cephalad portion of the gastrotomy. A 45-mm endoscopic GIA stapler is placed with the thick part in the stomach and the narrow part in the esophagus. Two suspension sutures are tied on each side of the anastomosis, one at the tip and one at the base. The stapler is fired to complete the posterior section of the anastomosis (Figure 18-8, A-B).
Care should be paid to ensure that the staple line is adequately clear of the previous staple line along the lesser curvature. Overlap of the staple lines could result in ischemia and a subsequent leak.
The anterior portion of the anastomosis is made in two layers: the inner layer with continuous full-thickness 4-0 inverting polydioxanone structure (PDS) and the outer layer with interrupted sutures. Particular attention should be given to where the hand-sewn portion intersects with the stapled portion at the corners. Start the inner layer at the corner and incorporate at least 5 mm of the staple line (Figure 18-8, C).
Total gastrectomy with Roux-en-Y esophagojejunostomy is undertaken if a proximal gastrectomy does not allow the tumor to be resected with adequate 5-cm margins on the stomach.
B
C
FIGURE 18–8 |
A |
2 1 2 S E C T I O N I I I • TH E E S O P H A G U S
The right gastroepiploic and right gastric vessels are suture-ligated and divided distal to the pylorus. The duodenum is divided distal to the pylorus with a linear stapler. The staple line should be inverted with interrupted 3-0 nonabsorbable sutures and covered with omentum to prevent duodenal stump blowout (Figures 18-9 and 18-10).
Gastrointestinal anastomosis stapler
Duodenum
FIGURE 18–9
Duodenum
FIGURE 18–10
C H A P T E R 18 • Esophagogastrectomy |
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The esophagus is mobilized to the level of the inferior pulmonary vein. A monofilament nylon purse-string suture is placed around the circumference of the proximal esophagus. The esophageal lumen should be distended with a no. 24 Foley catheter and a 20-mL balloon, which is advanced into the esophagus and gently inflated (Figure 18-11).
Distal end of esophagus
Proximal end of duodenum
FIGURE 18–11
2 1 4 S E C T I O N I I I • TH E E S O P H A G U S
A jejunal interposition is created using the Roux-en-Y technique (Figures 18-12 and 18-13). The jejunum should be mobilized sufficiently to permit anastomosis with the thoracic esophagus, necessitating division of several jejunal arteriovenous arcades.
Jejunum divided with GIA stapler
FIGURE 18–12
C H A P T E R 18 • Esophagogastrectomy |
215 |
B
Duodenum
Jejunum
Proximal end of jejunum
|
GIA stapler |
A |
(Roux-en-Y anastomosis) |
|
FIGURE 18–13 |
C |
|
2 1 6 S E C T I O N I I I • TH E E S O P H A G U S
Loading: An end-to-end anastomosis (EEA) stapler is passed through the jejunum into the esophagus and fired. The jejunum is anchored to the proximal esophagus. To minimize bile reflux, the surgeon should anastomose the duodenal loop to the jejunum at least
50 cm distal to the esophagojejunal anastomosis. The blind end of the jejunal loop is stapled closed (Figures 18-14 and 18-15).
Securing anastomosis with interrupted
Distal end of sutures esophagus
Proximal end of jejunum
A B
FIGURE 18–14
C H A P T E R 18 • Esophagogastrectomy |
217 |
Esophagus
Jejunum
Duodenum
Transverse colon
Jejunum |
Descending |
|
|
|
colon |
Sigmoid colon
FIGURE 18–15
2 1 8 S E C T I O N I I I • TH E E S O P H A G U S
4. CLOSING
In repairing the diaphragm, the gastric or jejunal interposition is secured to the crura with interrupted sutures. The remainder of the diaphragm is closed with interrupted mattress sutures. A chest tube should be placed into the pleural space near the anastomosis to ensure adequate fluid drainage. The left lung is reexpanded and the costal cartilages are left to float free. Tissue and skin are closed according to surgeon preference.
Total gastrectomy with descending colon graft: Whereas the stomach is better than the colon as an esophageal substitute, the colon may be used if the stomach is not a viable option because of prior surgery or tumor extension. The descending colon is preferred to the ascending colon, because the smaller lumen is more similar in diameter to the esophagus. However, the inferior mesenteric artery that supplies the descending colon is more likely to have atherosclerotic disease than other mesenteric vessels (Figure 18-16).
After the surgeon thoroughly explores the abdomen for metastases, the length of the required graft should be measured. The middle colic artery should be clamped with a bulldog clamp to evaluate the adequacy of collateral circulation.
The descending colon is prepared by mobilizing the splenic flexure and separating the attached omentum. The remaining colon is reanastomosed and the mesentery is reapproximated (Figures 18-17 and 18-18).
Superior
mesenteric Transverse colon artery
Incision
Middle |
Descending |
|
colon |
||
colic artery |
||
|
Left
colic artery
Inferior mesenteric artery
FIGURE 18–16