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 |
219 |
Incising lateral peritoneum to mobilize descending colon
FIGURE 18–17
Transverse colon
Descending colon
Dividing descending colon with GIA stapler
FIGURE 18–18
2 2 0 S E C T I O N I I I • TH E E S O P H A G U S
The proximal end of the anastomosis may be performed first to measure the length of the graft more accurately (Figure 18-19). The colon is passed along the posterior mediastinum, which is the shortest route between the stomach and the esophagus (Figure 18-20). The substernal and transpleural routes are also secondary possibilities but may result in greater kinking of the graft and subsequent emptying problems (Figures 18-21 and 18-22). The proximal anastomosis may be hand-sewn in two layers or stapled (Figure 18-23). The distal anastomosis between the proximal jejunum and colon is closed with an EEA stapler
(Figure 18-24).
Text continued on p. 225
Transverse colon
Descending colon
Left
colic artery
FIGURE 18–19
C H A P T E R 18 • Esophagogastrectomy |
221 |
Esophagus
Heart
Posterior mediastinal route
Colon
Abdominal aorta
Duodenum
Jejunum 
Esophagus
FIGURE 18–20
Heart
Substernal route
Colon
Abdominal aorta
Duodenum
Jejunum 
FIGURE 18–21
2 2 2 S E C T I O N I I I • TH E E S O P H A G U S
Esophagus
Left lung
Right lung
Transpleural route
Heart
FIGURE 18–22
C H A P T E R 18 • Esophagogastrectomy |
223 |
Esophagus
Colon
A
B
Securing colon and esophagus with running sutures
Reinforcing anastomosis of colon and esophagus
with interrupted sutures
C
FIGURE 18–23
2 2 4 S E C T I O N I I I • TH E E S O P H A G U S
Proximal jejunum
Distal end of colon
A
B
C
FIGURE 18–24
C H A P T E R 18 • Esophagogastrectomy |
225 |
The graft should be sutured to the crus of the diaphragm to avoid migration of the colon into the thoracic cavity. The remainder of the closure is carried out as described previously
(Figure 18-25).
Total gastrectomy with ascending colon graft: The ascending colon may be used if the descending colon has been affected by severe diverticular disease, atherosclerotic disease of the inferior mesenteric artery, or splenic vein thrombosis that extends to the inferior mesenteric vein.
Esophagus
Descending colon
Duodenum
Descending colon
Ascending colon 
Sigmoid colon
FIGURE 18–25
2 2 6 S E C T I O N I I I • TH E E S O P H A G U S
The blood supply of the right colon from the marginal artery should be inspected by clamping the ileocolic and right colic arteries. The ascending colon is harvested, leaving the marginal artery intact (Figure 18-26).
|
Transverse colon |
Incision |
Middle |
colic artery |
Descending colon
Superior mesenteric artery
Left
colic artery
FIGURE 18–26
C H A P T E R 18 • Esophagogastrectomy |
227 |
A section of ileum and the ileocecal valve may be included as part of the graft, because the size of the ileum matches well with that of the esophagus and because the valve may provide some protection against reflux. However, reflux esophagitis is unusually high in the neck and the valve may result in mild obstruction.
After measuring out the length of colon needed, the surgeon divides the ascending colon with a GIA stapler and reanastomoses the remaining colon. The graft is rotated and the proximal end is brought into the neck for the anastomosis. The distal anastomosis can be performed with an EEA stapler or a side-to-side stapled technique. The closure is performed as described previously (Figure 18-27).
Esophagus
Ascending colon
Duodenum |
Transverse colon |
|
Ileum |
Descending |
colon |
Sigmoid colon
FIGURE 18–27
2 2 8 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
After recovery from anesthesia, the patient can be taken to a floor bed.
The patient should be encouraged to ambulate as early as postoperative day 1. Incentive spirometry and good pulmonary physiotherapy are essential.
The nasogastric tube may be removed on the second postoperative day, and jejunostomy tube feedings are started. Sips of clear liquids may be allowed when bowel function normalizes. Between postoperative days 5 and 7, a barium swallow should be performed to evaluate the anastomosis. If the anastomosis is intact, a soft diet is started. As diet is advanced, bulky food and carbonated beverages should be avoided.
STEP 5: PEARLS AND PITFALLS
When using a jejunal graft, one should be prepared to substitute a colonic graft if the jejunum is inadequate, either because the length is insufficient to replace the full length of the esophagus or because the blood supply is damaged during harvesting.
Studies comparing the quality of life of patients after esophagectomy with age-matched controls demonstrated no significant differences in outcomes between the populations.
SELECTED REFERENCES
1. Meneshian A, Heitmiller RF: Surgical management of esophageal cancer. In Yuh D (ed): Johns Hopkins Manual of Cardiothoracic Surgery. New York, McGraw-Hill, 2007, pp 273-294.
2. Deschamps C, Nichols FC III, Cassivi SD, et al: Long-term function and quality of life after esophageal resection for cancer and Barrett’s. Surg Clin North Am 2005;85:649-656.
3. Linden PA, Swanson SJ: Esophageal resection and replacement. In Sellke F (ed): Sabiston & Spencer: Surgery of the Chest. Philadelphia, Elsevier, 2005, pp 627-651.