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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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374 Abdominal and right thoracic subtotal esophagectomy
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The azygos vein is identified and ligated in continuity
10
or transfixed and then divided.
10
11
The esophagus and tumor are now dissected from
12
cardium, the right and left main bronchi, and the aorta.
Although avoiding opening into the tumor during the dissection is desirable, this option is preferable to an unexpected
aortic or bronchial laceration.
the trachea, and/or the aorta. Extension of dissection into the
pericardium is not a contraindication to resection, as a portion of pericardium can be excised safely. The pericardium is
opened in front of the adhesions and then divided around the
margin of the tumor. Dissection is almost never extended
into the right inferior pulmonary vein.
the surrounding structures, including the peri-
Difficulty in this dissection can occur at the pericardium,
The esophagus is mobilized above and below the
11
retraction during the tumor dissection.
tumor, and tapes are passed around it to aid in
12
The aorta is sometimes involved by neoplastic
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13
circumstances is to dissect between the intima and the adventitia of the aorta. Returning outside the adventitia once the
tumor is freed is important, however. The large esophageal
artery that arises from the aortic arch is best ligated and
divided. Sometimes the artery is involved in the tumor.
Ligation is not then possible, and the artery must be oversewn
after the tumor is resected.
spread. The technique used to free the cancer in these
Operations 375
13
14a
14b
In some cases the most difficult part of the
14a,b
trachea and the bronchus. When the neoplastic process
involves the cartilaginous rings or the carina, there is little risk
of opening the respiratory tree. When the membranous portion is involved, however, dissection is trickier. A plane can
usually be found between the trachea and a thin membrane
covering it. This dissection should be directed to cutting only
the neoplastic adhesions; otherwise, a tracheal tear can occur.
If such a tear appears, it can be repaired with interrupted
stitches of 5/0 polypropylene (Prolene). This is relatively
straightforward and usually successful.
dissection is to detach the tumor from the
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The thoracic duct is found in the groove between the
15
ferior portion must be ligated if a subsequent chylothorax is
to be avoided.
stomach is delivered into the chest. Care should be taken to
maintain the correct orientation and to avoid possible twists.
The nasogastric tube is withdrawn into the cervical esophagus.
GIA stapler or a TA 90, which is easily manipulated in the
thorax. The last 5 cm at the cardia is left unstapled.
esophagus and the vertebral bodies. At least its in-
Once the esophagus and cancer are fully mobilized, the
A gastric tube can be formed at this stage by using either a
16a
15
The proximal portion of esophagus is
16a–d
below. Two methods can be used to tie a purse string to the
anvil of the stapler. The first is to place a tie around the anvil
rod after it has been introduced into the esophagus. This is
done by placing three clamps on the esophageal wall to hold
open the lumen of the esophagus and then introducing the
anvil into the lumen and tying a ligature en masse around the
entire esophageal wall. Excess esophagus distal to the ligature
is then trimmed off. The second method is to place an overand-over purse-string suture in the esophageal stump (see
chapter on p. 363).
A gastrotomy is made below the apex of the gastric tube.
Often the convenient method is to make the gastrotomy in
the portion of the stomach destined to be removed. The stapling device is introduced through the gastrotomy into and
through the stomach, the anvil is attached and secured, and
the anastomosis is performed by fitting the stapler.
grasped with a Satinsky clamp and divided
16b
16c
16d
The remaining stomach is removed with the gastro-
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17
and the staple lines are then oversewn. The nasogastric tube is
passed down into the stomach and the thoracic drain
inserted. The chest is then closed.
tomy by stapling the remaining section of the tube,
Further reading 377
17
POSTOPERATIVE CARE
A nasogastric tube is positioned below the anastomosis
under visual control during thoracotomy, and the thoracotomy is closed around a thoracic drain placed at the base of
the thorax. Another drain is located at the apex in case of
air leakage. The patient is then transferred to the intensive
care unit and is intubated and ventilated for 24 hours
or longer until the blood gas levels are satisfactory. The
patient is then moved to the surgical ward. The drain is taken
out after 3 or 4 days when less than 150 mL of clear effusion is
present. Feeding by the jejunostomy is started as soon as
bowel activity commences. The nasogastric tube is usually
taken out after 7 days. Oral feeding is then progressively reinstated.
If anastomotic leakage is established, feeding is continued
via the jejunostomy until healing occurs. If leakage is suspected (fever), the authors prefer to cease oral feeding and
feed the patient by the jejunostomy.
OUTCOMES
This operation has proven overwhelmingly to be the most
popular approach in the Western world, for the removal of
esophageal cancer.
Overall it is associated with a clinically relevant anastomotic leakage rate of the order of 10% and an overall morality
rate of about 5%.
On a priori grounds one might expect the non thoracotomy esophagectomy (see Chapter 38) to have a higher
leakage rate and a lower mortality rate. However, randomised
studies have never shown significant differences between the
two techniques in major outcomes.
FURTHER READING
Campion JP, Grossetti D, Launois B. Circular anastomosis stapler.
Archives of Surgery 1984; 119: 232–3.
Lewis I. The surgical treatment of carcinoma of the oesophagus with
special reference to a new operation for growths of the middle third.
British Journal of Surgery 1946; 34: 18–31.
Santy P, Mouchet A. Traitement chirurgical du cancer de l’oesophage
thoracique. Journal de Chirurgie 1947; 63: 505–26.
Sweet RH. Surgical management of carcinoma of the midthoracic
esophagus. New England Journal of Medicine 1945; 223: 1–7.
Tanner NC. The present position of carcinoma of the oesophagus.
Postgraduate Medical Journal 1947; 23: 109–39.
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37
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Left thoracic subtotal esophagectomy
JUN-FENG LIU
Professor and Doctor in Chief, Department of Thoracic Surgery, Fourth Hospital, Hebei Medical University, The People’s Republic of China
HISTORY
More than 100 years ago, esophagectomy began to be used for
obstructive esophageal diseases. Czerny resected the cervical
esophagus for a 50-year old woman with esophageal cancer in
1877, and she survived for 15 months. Jejunal interposition
was performed in a patient with benign esophageal stricture
by Roux and Herzen in 1907. Kelling was the first to use colon
as a substitute for the esophagus in 1911. The first successful
thoracic esophagectomy was undertaken by Franz Torek in
1913. No attempt was made to perform a reconstruction and
the patient fed herself through a gastrostomy until she died
from a stroke 13 years later. Ohsawa performed a gastroesophagostomy through an abdominal approach after resection of a cardiac cancer in 1932. Adams and Phemister
performed a left thoracic subtotal esophagectomy for cancer
in 1938 and undertook an esophagogastric anastomosis in the
thorax. A combined left thoracoabdominal subtotal
esophagectomy for cancer was initially reported by Sweet in
1945. Ivor Lewis undertook a three stage esophagectomy first
in 1946, and three-field esophagectomy was first used in the
treatment for esophageal cancer by Akiyama in 1981.
PRINCIPLES AND JUSTIFICATION
Indications
This operation provides a means for resecting the thoracic
esophagus with anastomosis of the esophagus to the fundus
of the stomach in the thorax or in the neck from the left side.
The principal indication for this approach is resection of
tumors of the thoracic esophagus and cardia, but it is also
applicable to resection of a benign esophageal stricture. The
main advantages of this method of subtotal esophagectomy
are that it permits exploration of the tumor, dissection of the
esophagus, and mobilization of the stomach through a single
thoracotomy incision. This is quicker and simpler than a
right-sided three-stage approach, i.e. laparotomy, right thoracotomy, and right neck incision, and it permits dissection
of the tumor and its lymphatic or other extensions under
direct vision.
In general, indications for surgical therapy of esophageal
carcinoma are dictated by cancer stage and fitness of patients
for surgery. The stages 0, I, II, and T
can be radically resected. Palliative resection is usually performed for a T3intrathoracic esophageal cancer, but with
supraclavicular and/or upper abdominal lymph node metastasis. Although there is a steady increase in surgical mortality
with advancing age and a precipitous rise in mortality over
the age of 75, left thoracic subtotal esophagectomy can be well
tolerated by patients whose age is close to 80 years if they have
no obvious cardiopulmonary problems.
of stage III disease
3N1M0
Contraindications
The contraindications to this approach are when a tumor is
located at or above the aortic arch (judged by barium swallow
and not endoscopy) and when the upper part of the stomach
is involved by tumor and there is insufficient stomach to
reach the anticipated anastomotic site. It is also contraindicated when patients are cachectic, or have significant comorbid disease and are judged unfit to withstand the operation.
Clinical factors, which indicate an advanced stage of carcinoma, are recurrent laryngeal nerve paralysis, Horner’s syndrome, persistent spinal pain, paralysis of the diaphragm,
fistula formation, and malignant pleural effusion, and indicate inoperability. Factors that make surgical cure unlikely
are a tumor greater than 8 cm in length, abnormal axis of the
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esophagus on barium roentgenography, enlarged lymph
nodes, invasion of aorta or trachea on CT, and a weight loss
greater than 20 per cent.
PREOPERATIVE ASSESSMENT
Routine investigations
Investigations before operation are designed to assess the
patient’s fitness for operation and to determine whether there
is spread of the tumor beyond the limits of surgical resection.
Routine investigations include haematological and biochemical tests and measurement of renal and hepatic function.
Cardiac status is assessed by chest radiography, electrocardiography, and additional tests if indicated. Respiratory assessment includes routine spirometry, with full tests of
respiratory function and blood gases if significant abnormalities are found.
Possible spread of the tumor is investigated by barium
swallow, esophagoscopy, and biopsy, computed tomography
and/or ultrasonography in all cases, positron emission
tomography (PET) scan if available, with bronchoscopy,
indirect laryngoscopy, lymph node biopsy, cytology of effusions, and other tests as indicated by symptoms or the findings on physical examination.
plications, including retained secretions, atelectasis, pneumonia, and respiratory failure, are the most severe problems following thoracic surgical procedures. Patients who are heavy
smokers have a significantly increased risk of postoperative
complications. The ability to cough is important because
cough helps avoid postoperative atelectasis. Preoperative pulmonary function testing is undertaken routinely. The tests
range from the simplest medical assessment (history taking
particularly of past pulmonary disease, physical examination,
and stair climbing) to the most sophisticated exercise testing,
and even analysis of blood gases.
After deep inspiration, the ability to breath hold for more
than 30 seconds suggests normal lung function. A value less
than 20 seconds implies a high risk for thoracotomy. After
climbing stairs of three stories, a pulse rate of more than 120
beats per minute indicates a high risk for esophagectomy. In
our experience, a patient with MVV (maximum volume ventilation) and VC (vital capacity) more than 70 per cent of predicted values will tolerate a transthoracic esophagectomy;
however, if the MVV and VC are less than 50 per cent of predicted values, FEV
ond/forced vital capacity) less than 60 per cent, and SO2less
than 90 per cent after exercise, surgery is contraindicated.
/FVC (forced expiratory volume at 1 sec-
1
Cardiovascular assessment
Nutritional assessment
Since the predominant symptom of esophageal carcinoma is
difficulty in swallowing, most patients are nutritionally
depleted. The nutritional status of the patients is important in
predicting the outcome. A poor nutritional status decreases
host resistance to infection and affects healing of an anastomosis. Physical examination should look for peripheral
edema, specifically in the feet and flanks which, if present,
gives an initial clue for very poor nutritional status of the
patient. Measurement of the serum albumin is a more objective estimate of the status of the patient. A low value of serum
albumin (<34 g/L) increases the risk of surgical complications, including anastomotic leakage. A positive nitrogen balance is important for the patient’s safe passage through the
rigors of this major operation and postoperative stress.
Hyperalimentation may be necessary for patients with poor
nutritional status before surgery. Albumin or blood plasma
can be given to supplement nutrition in patients with
hypoproteinemia.
Pulmonary assessment
In addition to the effects of thoracotomy on pulmonary function, the intrathoracic stomach takes up room in the thorax
after esophagectomy, and this adversely affects pulmonary
function. Thus pulmonary function should be meticulously
assessed before resection of the esophagus. Pulmonary com-
The risk of both morbidity and mortality from thoracic surgery increases exponentially in patients with respiratory and
significant cardiovascular disease. It is important to have an
accurate cardiac history and know all cardiovascular medications used. If there is concern, a detailed assessment of the
cardiac state should be undertaken in consultation with a cardiologist within a formal risk assessment protocol.
Preparation
Adequate preoperative management will improve the ability
of the patient to tolerate the operation. Smoking is stopped
for at least 2 weeks before the operation, and all patients are
instructed by an experienced respiratory physiotherapist in
the breathing and coughing techniques that will be required
after operation and in the use of incentive spirometry.
Cessation of smoking, aggressive bronchopulmonary toilet,
and bronchodilators may improve a marginal FEV
with chronic lung disease do better if their operations are
scheduled for the afternoon, thus allowing them to ambulate
and cough up secretions that have accumulated in the lung
overnight.
Most esophageal cancer patients have difficulty swallowing, so preoperative nutritional support is important. Oral
intake is usually inadequate in patients with advanced
esophageal cancer, and hyperalimentation may be necessary.
Enteral alimentation via a nasogastric tube and intravenous
hyperalimentation are selected according to the status of the
patients.
Patients
1.
Operation 381
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In resection of the esophagus, the mediastinum is extensively dissected and the bacteriologically contaminated
esophagus is opened. Therefore, it is necessary to use prophylactic antibiotics, to reduce the incidence of wound infection
and anastomotic breakdown. Adequate doses of a broad spectrum antibiotic with adequate gram-positive and gram-negative coverage is prescribed intravenously. A nasogastric tube
is placed before surgery. Washout of esophageal content
through the nasogastric tube is necessary for patients who
have severe obstruction of the esophagus.
OPERATION
Incisions
The site of the incision is decided according to the
1
anatomical level of the tumor and the anticipated site of
anastomosis. If the tumor is in the cardia or the lower third of
the esophagus and the anastomosis is constructed below the
aortic arch, the incision is made through the seventh intercostal space or by resection of the seventh rib. When the
tumor is in the middle or upper third of the esophagus and
the anastomosis is to be constructed above the aortic arch or
in the neck, the incision is made through the sixth intercostal
space or by resection of the sixth rib. Usually, the sixth or seventh ribs are identified as the standard left thoracotomy incision, including anterior and posterior extensions when
necessary. The basic incision is made from the level of the
ANESTHESIA
After the administration of general anesthesia and endotracheal intubation with a single- or double-lumen tube (the latter is preferable), the patient is placed in the right lateral
decubitus position with the arm flexed at the elbow and
shoulder. The table is flexed or a soft pad is placed under the
right chest to widen the operative field.
costal cartilage in front to the paravertebral region at the
angle of the scapula behind. It may be extended upward
between the scapula and the vertebral column to the level of
the posterior end of the fourth rib. This allows the transection
of a higher rib, usually the fifth at the costal end, giving access
for a supra-aortic dissection of the esophagus and it also permits an easier high intrathoracic anastomosis.
A left thoracoabdominal incision is usually used for resection of the proximal stomach, or for obese patients. With the
patient in the right lateral position, an oblique lateral incision
is made starting in the left hypochondrium and continuing
over the costal margin and along the line of the seventh rib to
the angle of the rib posteriorly. The incision on the abdomen
is the oblique extension of the thoracic incision to the edge of
the rectus sheath. The peritoneum is opened in the line of the
incision, which provides excellent access to upper abdominal
organs.
1
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Dissection of the esophagus
For resection of the gastric cardia, the dissection of the esophagus needs to be carried out to the level of the inferior pulmonary vein. For cancer arising from the lower third of the
esophagus, the dissection of the esophagus should be conducted to the level of the bifurcation of the trachea. The
whole of the thoracic esophagus should be dissected for cancers which occur in the middle or upper third of the esophagus and also for cancers involving the cervical esophagus.
After a thorough exploration of the pleural cavity, the
2
mediastinal pleura overlying the esophagus is incised
anterior to the aorta and posterior to the pleural reflection at
the pericardium, and the tumor is identified and assessed for
resectability. If resection of tumor is thought possible, a tape
is placed around the esophagus just below the tumor to lift
the esophagus for facilitating its dissection. The inferior pulmonary ligament is mobilized to the level of the inferior pulmonary vein, and the lymph nodes within it are removed.
The esophagus is dissected from the hiatus below to a level
above or at least 5cm proximal to the tumor. To avoid dissection too close to the tumor, the descending aorta and pericardium are completely bared. The esophageal arterial
branches and the bronchial artery on the adventitia of the
aorta are divided. Para-esophageal adipose tissue and all
mediastinal lymph nodes are completely removed with the
esophagus. If invaded by tumor, resection of pulmonary ligament, pericardium, azygos vein, the right mediastinal pleural
membrane, and even a wedge of the lung can be undertaken.
2a
2b
Operation 383
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2c
For patients with a middle or upper third esophageal cancer, the whole of the thoracic esophagus is usually mobilized
for a curative resection. The technique of esophageal dissection at the aortic arch is critical, particularly for cancers
located at this level. The esophagus is freed from behind the
aortic arch by blunt dissection in the plane between the
esophageal muscle and the adventitia of the aortic arch. A finger is passed behind the aortic arch so that the finger tip
appears beneath the mediastinal pleura above the arch. At the
level of the upper edge of the aortic arch, the thoracic duct
runs from the posterior mediastinum to behind the subclavian artery on the left of the esophagus posteriorly. Therefore,
a longitudinal incision of the pleura over the upper mediastinum is made along the front edge of the thoracic spine, in
order to prevent damage to the thoracic duct. After the pleura
is opened, a tape is passed around the esophagus above the
aortic arch. This facilitates mobilization of the upper esophagus into the root of the neck, the level of which is identified by
palpation of the inner border of the first rib. If tumor adheres
to the arch of the aorta, and blind dissection is not possible,
2d
division of the uppermost intercostal aortic arterial branches
may be necessary to help in the mobilization of the arch itself,
but care must be taken not to divide more than three
branches to prevent the possibility of spinal cord ischemia.
The left recurrent laryngeal nerve is carefully preserved to
avoid being injured. Because the nerve passes by the side of
the aortic arch, loops below it, and ascends behind the aortic
arch to the left tracheo-esophageal groove, mobilization of
the upper thoracic esophagus should be close to its adventitia.
The thoracic duct is usually protected beyond the descending
aorta, using the left transthoracic approach, but chylothorax
can ensue if the dissection is carried out widely and towards
the right pleura. It is always wise to check for possible damage
to the duct. If the thoracic duct is injured, it is ligated below
the point of injury. In the author’s unit, the thoracic duct is
routinely ligated at a lower site, usually the level of the ninth
or tenth thoracic vertebrae. The azygos arch can also be
injured from the left side, and this must be carefully avoided.
The left main bronchus is examined to make sure there is no
injury to its membranous portion.
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