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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_747_Библиотеки_им_академика_М_И_Перельмана
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354 Use of the stomach as an esophageal substitute
https://t.me/med1917
is infiltrating the cardia or the subcardial area, the safety margin between the lower edge of the tumor and the resection
line of the gastric tube may not be sufficient. Lymph node
metastases to the lesser curvature (compartment I according
to the classification in gastric cancer) and the celiac trunk
(compartment II) should be detected by preoperative endoscopic ultrasonography.
In all cases the colon should be prepared by bowel lavage
and colonoscopy so that it may be used if the stomach should
prove unusable.
Anatomical points
A knowledge of the arterial blood supply of the
1a–d
substitute. The arterial supply of the stomach originates from
the celiac trunk. This vessel has a short stem that immediately
divides into three branches. The left gastric artery runs in a
cranial ventral direction, covered by the peritoneum of the
posterior wall of the lesser sac. Subcardially it turns to the
lesser curvature in an aborad direction, where it supplies the
anterior and posterior gastric wall by small branches. The left
gastric artery has anastomoses with the right gastric artery,
which originates from the common hepatic artery and
approaches from the region of the pylorus. By these means,
an arterial ring along the lesser curvature is completed, with
its strongest inflow being from the left gastric artery.
The second vessel of the celiac trunk is the splenic artery,
which runs along the upper border of the pancreas behind the
posterior wall of the omental bursa to the hilum of the spleen.
At the splenic hilum the short gastric vessels originate; they
proceed to the fundus and the cranial third of the greater curvature of the stomach. The left gastroepiploic artery arises
from the splenic artery and runs through the gastrocolic ligament parallel to the greater curvature of the stomach in a caudad direction. This artery gives gastric branches to both walls
of the stomach and epiploic branches to the greater omentum. It anastomoses with the right gastroepiploic artery,
which comes from the region of the pylorus. Thus the greater
curvature also has a vascular ring, with its strongest supply
being from the right gastroepiploic artery. This artery has a
number of anatomical variations, which may be relevant to
gastric interposition.
The third vessel of the celiac trunk, the common hepatic
artery, turns to the right, in the direction of the hepatoduodenal ligament of the small omentum. There it divides into the
hepatic and gastroduodenal arteries. The hepatic artery runs
through the hepatoduodenal ligament to the liver and usually
gives rise to the right gastric artery, which proceeds to the
lesser curvature of the stomach. The right gastric artery may
also originate from the gastroduodenal artery. The gastroduodenal artery runs posterior to the superior part of the
duodenum distal to the pylorus and comes out caudad to the
duodenum, where it divides into the right gastroepiploic and
stomach is essential for its use as an esophageal
Anesthesia
The type of anesthesia used depends more on the type of
esophagectomy than on the method of reconstruction. If an
intrathoracic anastomosis is to be performed, a doublelumen endotracheal tube should be used.
1a
1c
superior pancreaticoduodenal arteries. All gastric arteries
anastomose between themselves directly or indirectly by
intramural or extramural branches. Therefore, the ligation of
two or even three gastric arteries preserves the blood supply
of the stomach under normal circumstances.
The veins of the stomach lead the blood to the portal vein.
With only minor exceptions they correspond in their courses
to the four gastric arteries. From the gastric fundus the short
gastric veins run through the gastrosplenic ligament to the
splenic vein. The left gastroepiploic vein from the greater curvature also proceeds in this direction to the left side. It reaches
the splenic vein through the gastrosplenic ligament. The right
gastroepiploic vein accompanies its artery to the area of the
pylorus. At this point, the vein turns in a posterior direction
and flows into the superior mesenteric vein. At the lesser curvature, a venous arch runs along both arteries (coronary or
left gastric vein). This vein flows near the right gastric artery
into the portal vein or splenic vein within the hepatoduodenal ligament. At the cardia, the venous arch follows the left
gastric artery up to the area of the celiac trunk.
1b
1d
OPERATION (Open technique)
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The laparoscopic technique for preparation of the gastric
conduit is described in Chapter 48.
Position of patient
The patient lies in a supine position with the head turned
2
to the right to provide a free approach to the left side of
the neck. A rolled-up towel or a sandbag is placed behind the
shoulders to facilitate the approach to the anterior mediastinum, and under the lumbar region to facilitate access to
the stomach.
Operation 355
2
3
Preparation of the stomach
Skeletonization of the stomach begins along the
greater curvature outside the gastroepiploic arch. It is
performed stepwise in the direction of the fundus.
Although the supply to the stomach from the right
gastroepiploic artery shows variations (as illustrated
in Figure 1), it is sufficient in nearly all cases to guarantee a blood supply to the gastric tube. After division
of the left gastroepiploic artery, the preparation of the
upper third of the gastric fundus may be performed
close to the stomach wall.
Incision
The abdomen is opened by a transverse incision
3
extended by an upper midline incision in the direction of
the xiphoid process. This ensures a good view of the epigastric
area.
In an aborad direction the preparation must be
4
done very carefully outside the gastroepiploic
arch to the origin of the right gastroepiploic artery
from the gastroduodenal artery.
4
356 Use of the stomach as an esophageal substitute
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Maintaining the venous drainage via the right gastro-
5
epiploic vein is also important.
6
5
Lymph node dissection
The gastroduodenal artery is dissected immediately distal to
the pylorus. This allows the common hepatic artery to be easily identified. Dissection proceeds in a medial direction to
preserve the origin of the right gastric artery from the common hepatic artery. The right gastric artery may aid the vascularization of the gastric tube, and it should be spared if
possible.
The lymph nodes are dissected in a manner similar to
6
that used in gastric cancer, which means that all lymph
nodes along the common hepatic artery, the celiac trunk, and
the medial part of the splenic artery are dissected and taken
with the specimen. The ligation of the left gastric artery is performed near its trunk of origin.
After dissection of the lesser omentum, the esophagus,
which has previously been dissected by a transthoracic or
transmediastinal approach, is pulled out of the esophageal
hiatus for the final preparation of the gastric tube.
Formation of the gastric tube
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Akiyama recommends that the highest point of the
7
stomach be marked by two stay sutures. This point is
located quite a long way to the left of the cardia. The skeletonization of the lesser curvature involves approximately
two-thirds of the lesser curvature, which means it starts distal
to the third or fourth branch of the left gastric artery, at the
region of the ‘crow’s foot’, and continues close to the gastric
wall in the direction of the cardia.
Operation 357
7
The lesser omentum should be divided in this area and
8
the vascular arcade suture ligated. The stomach now can
be cut in mediastinuman oblique direction between the distal
point of skeletonization and the highest point of the gastric
fundus (interrupted line in Figures 7 and 8). This means that
approximately half of the gastric fundus, including the lymphatic drainage along the left gastric artery (compartment I),
is removed. The resulting gastric tube has a width of 3–4 cm.
8
358 Use of the stomach as an esophageal substitute
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Before the stomach is finally cut along this
9a–c
the cardia and a pair of long forceps inserted to carry out an
intraluminal pyloric dilatation. This helps to avoid early postoperative pylorospasm. The best way to divide the stomach is
to use a linear stapler (TA 90). Two applications of this stapler
are usually required to close the quite long resection line.
line, the gastric fundus should be opened near
9a
9b
9c
If the stomach appears too short for elevation to the
https://t.me/med1917
10
and then closing the mucosa by stapler results in greater elasticity of the gastric tube.
neck, cutting the seromuscular layer with a scalpel
Operation 359
10
If additional suturing of the staple line is undertaken,
11
interrupted rather than running sutures are best used
to avoid shortening of the tube by a purse-string effect.
11
360 Use of the stomach as an esophageal substitute
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Interposition of the whole stomach
The whole stomach, rather than a gastric tube, can be used as
the esophageal interposition. This can be done only if the
tumor is not infiltrating the gastroesophageal junction. The
skeletonization should start at the same point and in the same
manner as for the formation of the gastric tube. However, it is
continued along the lesser curvature up to the cardia.
The staple line (using a TA 55 stapler) is then placed
12
fundus.
before stapling.
esophageal substitute is that the gastroesophageal anastomosis does not include the tangential staple line at the highest
point of the gastric fundus. This may avoid a ‘locus minoris
resistentiae’ of such an anastomosis.
directly below the cardia to preserve the whole gastric
Pyloric dilatation can be performed through the cardia
The advantage of using the whole stomach as the
Duodenal mobilization
An essential prerequisite for a tension-free stomach interposition is a careful and extensive duodenal mobilization. This
Kocher maneuver is performed in the usual way from the
right side and should be continued until the vena cava and the
aorta up to the superior mesenteric artery are freed. This
12
means that the duodenum and the head of the pancreas are
quite mobile.
Another important step is to separate the right colonic
flexure from the head of the pancreas and the duodenum.
This mobilization should be performed up to the middle colic
vein. After this maneuver the pylorus can easily be moved up
to the esophageal hiatus or even higher.
Preparation of the tunnel for the interposition
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If the interposition is to be placed in the posterior
13
must be drawn down as the esophagus is removed. This is
attached to the stomach so that the gastric tube can be pulled
upward without further preparation, in the bed of the former
esophagus. If the plan is for the interposition to be placed in
the anterior mediastinum, a retrosternal tunnel is prepared
by blunt dissection.
mediastinum, some form of tape or Penrose tubing
Operation 361
14
13
This blunt dissection can be performed with the
14
essential to limit this preparation strictly to the midline
and always with contact to the posterior part of the sternum. Once the sponge-holding forceps has reached the
cervical incision, the channel is dilated in a stepwise fashion so that the interposition can be accommodated without compression.
help of a swab in sponge-holding forceps. It is
362 Use of the stomach as an esophageal substitute
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Elevation of the stomach and cervical
anastomosis
While the abdominal team is operating, another
15
left lateral incision along the sternocleidomastoid muscle.
The omohyoid muscle and the inferior thyroid artery are ligated and divided, the left thyroid lobe is mobilized, and the
recurrent laryngeal nerve is dissected and preserved.
esophageal remnant and extracting it from the posterior
mediastinum is usually easy. The preparation of the esophagus should be extended in the direction of the hypopharynx
until it is completely free so that the esophagus passes directly
to the anastomosis without kinking.
the retrosternal space must also be opened from the cervical
incision to complete the tunnel from the abdominal and cervical directions. It is a good idea to place the stomach in a
plastic bag when drawing it through the tunnel to avoid any
trauma to the organ. This part of the operation is facilitated
by placing a tube via the cervical incision through the anterior
or posterior mediastinum.
team starts the cervical part of the operation using a
After transthoracic esophagectomy, mobilizing the
If the interposition is placed in the anterior mediastinum,
15
16
The stomach is then sutured to the lower tip of the
16
mediastinum in an upward direction. It is important to push
the stomach upward from the abdomen as well.
tube. The stomach can be slowly pulled through the
Operation 363
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The gastric interposition usually has
17a–c
length and reaches the neck without tension. Often the cervical esophageal stump overlaps the gastric tube, and an additional resection of the stomach can be performed. The
vascularization of the top of the fundus is unreliable and
should be resected. The anastomosis with the cervical esophagus is performed in the upper part of the gastric corpus. The
anastomosis is usually located just above the clavicle. Before
the anastomosis is performed, the back wall of the stomach is
fixed to the neck by two or three sutures. The back wall of the
anastomosis is constructed using interrupted sutures, which
emerge between the mucosa and muscularis; the anterior wall
is completed using all-layer interrupted sutures.
sufficient (and sometimes even excessive)
17a
17b
17c
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