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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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364 Use of the stomach as an esophageal substitute
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The anastomosis is splinted by a transnasal gastric
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the stomach. The wound is closed by subcutaneous and skin
sutures.
tube to guarantee postoperative decompression of
As an alternative, the cervical anastomosis can be performed using a stapling technique (see chapter 34). The
detachable head of the EEA stapler is introduced into the
esophageal stump, which is closed around the mandrel by a
purse-string suture. The most appropriate size of stapler is
usually size 28; smaller staplers tend to induce postoperative
anastomotic stenosis. The recommendation is that the specially designed shorter head of the EEA stapler be used for
introduction into the cervical esophagus because it can more
easily be placed into the esophageal stump. The stapler is
inserted through an incision at the top of the stomach, and
the central spike is driven out 5–7 cm aborad through the
stomach front wall. After the stapler is turned in the direction
of the esophageal remnant, the central pin is connected with
the mandrel, and the stapler is closed, fired, and removed.
The site of introduction into the stomach is closed using a TA
55 linear stapler.
Elevation of the stomach and intrathoracic
anastomosis
If an intrathoracic anastomosis is planned, it should be performed toward the apex of the pleura. It is important for the
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postoperative long-term results that the stomach be completely transferred into the thorax. This means that the preparation of the stomach is identical to the preparation for an
abdominocervical interposition. When the preparation of the
stomach has been finished, the gastric tube is pushed through
the esophageal hiatus into the posterior mediastinum and the
right pleural cavity. The abdominal approach is closed, and
the patient is turned for a right thoracic approach to the
esophagus. The anastomosis is now performed directly
between the esophageal stump and the stomach, either endto-end or as an implantation of the esophageal remnant on
the front wall of the stomach. The suture technique can either
be performed by hand or by stapling. If the gastric tube is long
enough to preserve a blind oral part of the stomach above the
anastomosis, then this can be used to cover the front wall
suture line of the esophagogastrostomy. This procedure also
has an antireflux effect.
Drainage
The cervical anastomosis is drained by a Penrose or other soft
drain. In an intrathoracic anastomosis the pleural cavity is
drained by a thoracic tube.
Further reading 365
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Finishing of the abdominal operation
After the esophagogastric anastomosis in the neck is finished,
the abdominal operation should be completed. The operative
field is checked for hemostasis. Drainage of the peritoneal
cavity is not necessary. When the gastric interposition is positioned well, the pylorus should be located in the area of the
diaphragm. The abdomen is closed in layers.
POSTOPERATIVE CARE
Postoperative care should follow the course described for
gastroesophagectomy for adenocarcinoma of the cardia in
Chapter 46.
Complications
The most common complication of gastric interposition is
leakage from the cervical anastomosis. In the authors’ experience this complication is unlikely if the gastric tube is elevated
as proximally as possible so that the end-to-end anastomosis
is performed in a well-vascularized area of the stomach.
Other kinds of cervical anastomoses cannot be recommended, as often the gastric part orad to the anastomosis
develops necrosis.
If leakage does develop, a salivary fistula results, which usually heals without complications provided sufficient external
drainage is present. If drainage is insufficient, a phlegmon
may develop in the cervical soft tissue. Therefore, whenever a
fever of unknown origin develops postoperatively, the cervical anastomosis should be checked. This can be performed
radiologically using contrast medium, but sometimes a safer
method is to check the anastomosis directly by opening the
cervical incision.
If leakage has occurred, open treatment of the cervical
wound is appropriate. Early and adequate external drainage
of a cervical leak is necessary to avoid spread of infection into
the mediastinum.
More major (or even complete) necrosis of the interposed
stomach is extremely rare as the gastric tube usually has a very
good blood supply. Very occasionally, postoperative
pylorospasm may occur that leads to clinically relevant delay
in gastric emptying. Such a situation can easily be treated by a
careful endoscopic dilatation of the pylorus. Gastric dilatation as a consequence of postoperative paralysis is extremely
rare after gastric tube formation by this technique. A dislocation of the interposed stomach from the mediastinum into
one of the pleural cavities is also very rare. If the stomach is
shown to be distended with air on postoperative thoracic
radiography, temporary placement of a nasogastric tube is
suggested. This avoids compression of mediastinal organs
and also avoids aspiration.
The most important long-term complication is the
development of an anastomotic stricture. This is usually
caused by scarring as a result of anastomotic vascular insufficiency, but use of too small a stapler could also cause dysphagia from anastomotic stenosis. In either case the problem
can be solved by endoscopic dilatation. If it has no lasting
effect, resection of the stenosis and reanastomosis is recommended.
OUTCOME
Functional studies of patients with intrathoracic stomach as
esophageal replacement have shown good long-term results.
Despite a persistent acid secretion of the vagotomized thoracic stomach, no pathological gastroesophageal reflux or
esophagitis was found proximal to the cervical anastomosis.
Gastric biopsies mostly reveal mild gastritis of the antral
mucosa, and metaplasia is rare. The intrathoracic stomach
needs no drainage to facilitate emptying. Postoperative reflux
esophagitis is prevented by complete intrathoracic stomach
transposition with cervical esophagogastrostomy.
In young patients with benign esophageal diseases
requiring an esophagectomy, the authors prefer to use the
colon as an esophageal substitute to preserve the gastric
reservoir.
FURTHER READING
Aly A, Jamieson GG, Pyragius M, Devitt PG. Antireflux anastomosis
following esophagectomy. Australian and New Zealand Journal of
Surgery 2004; 74: 434–38.
Atkins BZ, Shah AS, Hutcheson KA, et al. Reducing hospital morbidity
and mortality following esophagectomy. Annals of Thoracic Surgery
2004; 78: 1170–76.
Collard JM, Romagnoli R, Otte JB et al. The denervated stomach as an
esophageal substitute is a contractile organ. Annals of Surgery 1998;
227: 33–9.
Hölscher AH, Bollschweiler E, Bumm R, Bartels H, Siewert JR. Prognostic
factors of resected adenocarcinoma of the esophagus. Surgery 1995;
118: 845–55.
Hölscher AH, Schröder W, Bollschweiler E, et al. How safe is high
intrathoracic esophagogastrostomy? Chirurg 2003; 74: 726–33.
Law S, Fok M, Chu KM, Wong J. Comparison of hand-sewn and stapled
esophagogastric anastomosis after esophageal resection for cancer:
a prospective randomized controlled trial. Annals of Surgery 1997;
226: 169–73.
Siewert JR, Stein HJ, Feith M et al. Histologic tumor type is an
independent prognostic parameter in esophageal cancer: lessons
from more than 1.000 consecutive resections at a single center in
the western world.
Annals of Surgery 2001; 234(3): 360–69.
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Abdominal and right thoracic subtotal
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esophagectomy
BERNARD LAUNOIS MD, FACS
Professor of Digestive and Transplantation Surgery, Hospital Pontchaillou, Rennes, France
GUY J. MADDERN PhD, MS, FRACS
R. P. Jepson Professor of Surgery, Department of Surgery, University of Adelaide, Adelaide, South Australia, Australia;
Director, Division of Surgery, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
36
HISTORY
Before 1946, the only widely practiced approach to the thoracic esophagus had been described by Sweet using a leftsided thoracotomy. Although this operation permitted
relatively good access to the lower third of the esophagus,
cancers of the middle and upper third of the esophagus were
dissected with greater difficulty because of the overlying aortic arch. In 1946, Lewis described the abdominal and right
thoracic approach for subtotal esophagectomy. This operation was adopted by Tanner in the United Kingdom (LewisTanner operation) and by Santy in France (Lewis-Santy
operation), and has remained the favored operation for an
abdominal and right thoracic subtotal esophagectomy.
OPERATIONS
Abdominal approach
The operation is usually commenced with the abdominal
approach, which enables the assessment of liver metastases,
the involvement of draining lymph nodes, and the performance of gastrolysis.
368 Abdominal and right thoracic subtotal esophagectomy
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INCISION
A midline incision is used, with the approach
1a,b
retractor. This provides improved access to the intra-abdominal esophagus.
to the hiatus being facilitated by a substernal
1a
1b
Operations 369
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The first step is to tie and divide the vessels of
2a,b
vessels. During the mobilization of the greater curve of the
stomach, identification and preservation of the right gastroepiploic vessels is important. The abdominal esophagus is
dissected next. The left triangular ligament of the liver is
divided, and the left lobe is retracted to the right to reveal the
esophageal hiatus. This should be dissected with scissors
the gastrocolic ligament and the short gastric
under direct vision after the peritoneum is divided in front of
the esophagus. Opening the tissues to the left and right of the
esophagus permits a curved clamp to be introduced and a
tape to be passed around the esophagus. The tape can then be
used to provide traction on the abdominal esophagus, which
aids in the ligation and division of the remaining short gastric
vessels.
2a
2b
370 Abdominal and right thoracic subtotal esophagectomy
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From inside the lesser sac, with the mobilized greater
3
curve of the stomach held upward and to the right, the
left gastric vascular pedicle and its associated lymph nodes are
dissected. The left gastric vein and artery are individually
identified, ligated, and divided.
4
3
The lesser omentum is then ligated and divided from the
4
hiatus down to the pylorus. Mobilization of the duodenum (Kocher maneuver) is not routinely performed for this
operation but can be undertaken if increased gastric mobility
is required.
A pyloroplasty or a pyloroclasia is performed to help prevent delay in gastric emptying, which sometimes occurs after
this procedure. Pyloroclasia is usually performed by using the
thumb and middle finger as dilators that pass through the
pylorus by invaginating the gastric or duodenal wall to disrupt the sphincteric mechanism.
The right crus is divided and the hiatus opened. The intraabdominal esophagus is then freed from all its hiatal attachments by a combination of blunt and sharp dissection.
A gastric tube can be constructed at this stage,
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5a,b
part of the operation. The gastric tube is constructed from
below the ‘crow’s foot’ on the antrum of the stomach up to
the hiatus. This procedure is most readily performed by using
a surgical stapler (e.g. Endo GIA) and leaving the last 5 cm at
the cardia unstapled until the esophagus and stomach have
been successfully mobilized and delivered into the chest. The
danger of completing the gastric tube at this stage is that,
should the esophageal cancer prove unresectable, then a complete obstruction has been created unnecessarily. The staple
line is oversewn to ensure hemostasis and minimize the possibility of a leak.
A feeding jejunostomy can now be created to facilitate
postoperative enteric nutrition.
although this can be delayed until the thoracic
Operations 371
5a
WOUND CLOSURE
A closed suction drain is placed behind the stomach up to the
hiatus, and the abdomen is closed.
5b
372 Abdominal and right thoracic subtotal esophagectomy
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Thoracic approach
POSITION OF PATIENT
The patient is placed on the left side with a sandbag
6
under the left ribs. Great care should be taken to ensure
not only that the patient is well supported and secured, but
that no unsupported pressure points exist. The right arm is
most conveniently strapped to a padded overhead rail.
INCISION
Two thoracic incisions are possible, one using a rib resection
and the other passing through the intercostal space. The
authors have found an unacceptable incidence of paradoxical
respiration after rib resection and now recommend an intercostal approach, either through the sixth intercostal space for
lower-third cancers or through the fifth intercostal space for
cancers of the middle and upper third. Gradual increase in rib
retraction at intervals during the procedure can produce adequate retraction without rib fracture, even in elderly patients.
The scapula, once freed from its muscular attachments inferiorly, should be retracted upward. At this stage the location of
the ribs can be confirmed by counting from the second rib,
felt at the apex of the thorax, down to the desired interspace.
The periosteum of the rib is lifted with a periosteal elevator,
and the intercostal space is opened on the lower border of the
rib. The pleura is then opened.
A Finochietto or Lortat-Jacob retractor is positioned and
gently opened. Any pleural attachments are freed, and the
lung is mobilized to the hilus. The lung is retracted forward
and collapsed. It can be held in this position by fixing a broad
blade attached to the rib retractor.
6
7
The right pulmonary triangular ligament is divided close
7
to the posterior edge of the inferior lobe of the right lung,
up to the right inferior pulmonary vein.
Scissors are introduced vertically between the peri-
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8
cardium and the posterior mediastinum. Opening the
scissors reveals a plane close to the pericardium, and one can
then dissect upward along this plane.
Operations 373
8
The fingers of the left hand can palpate the posterior
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aspect of the esophagus and retract it from the posterior
mediastinum. The pleura is then opened along the vertebral
column. The scissors are opened horizontally to expose the
esophageal arteries, which are tied and divided.
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