Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_794_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter • Subtotal Esophagectomy: Abdominothoracic Approach
Step 4 (continued)
Para-aortic lymphadenectomy is performed. e esophageal branches of the thoracic aorta
have to be dissected very carefully and should be ligated with suture ligation (
. Fig. 12.7).
. Fig.12.7
Section II • Esophagus, Stomach, and Duodenum
1
2
3
4
5
6
7
8
9
10
Step 4 (continued)
Identication and careful dissection of the thoracic duct with double ligations directly above
the diaphragm and at the level of the main carina (
Mediastinal lymphadenectomy is completed with the removal of the le sided para-aortic
and retropericardial lymph nodes, as well as the intermediate and lower lobe bronchus down to
the esophageal hiatus.
Aer complete mobilization of the esophageal specimen, chest tubes are placed in the right
thoracic cavity.
. Fig. 12.8).
11
12
13
14
15
16
17
18
19
20
21
. Fig.12.8
For cervical part, see ▶ Chap. 11 on the transhiatal approach.
In case of a mid or lower esophageal carcinoma, an intrathoracic anastomosis can be accomplished.
High intrathoracic anastomosis
High intrathoracic anastomosis may be performed without compromising oncological requirements alternatively to a collar anastomosis for treatment of intrathoracic tumors, that is, if located
distally to the tracheal bifurcation. e benets of considerably shorter operating times are associated with the risk of developing mediastinitis when anastomotic leakage occurs.
22
23
Chapter • Subtotal Esophagectomy: Abdominothoracic Approach
Step 5
High intrathoracic anastomosis
Transection of the esophagus is carried out 5 cm below the upper thoracic aperture over a Pursestring 45clamp. Alternatively the esophagus is transected and a running suture (monolament,
2-0) is applied as a pursestring suture.
Dilation of the proximal esophageal stump with a blunt clamp is performed. e anvil of a
circular stapler (preferably 28 mm or larger if possible) is introduced into the esophageal stump
and xation is done by tying the pursestring suture.
Mobilization of the gastric tube through the diaphragmatic esophageal hiatus is performed,
followed by resection of the apex of the gastric tube. e gastric tube is usually longer than required. en introduce the stapler into the gastric tube and perforate the gastric wall at the proposed site of the anastomosis without tension with the head of the stapling device (
Connection with the anvil is followed by ring of the instrument (
Check for completeness of the anastomotic rings and for clear resection margins using frozensection-analysis in suspected malignancy. e stapler is removed and closure and resection of the
protruding part of the gastric tube are done with a linear stapler. A nasogastric feeding tube is then
inserted through the anastomosis and placed into the rst jejunal loop for decompression and
postoperative enteral feeding. oracic drainage is placed into the right thoracic cavity.
Alternatively, this method can be performed in the same manner in the case of colonic interposition aer esophagogastrectomy (
. Fig. 12.9c,d).
. Fig. 12.9b).
. Fig. 12.9a).
. Fig.12.9
1
2
Section II • Esophagus, Stomach, and Duodenum
Standard Postoperative Investigations
See ▶ Chap. 11 on the transhiatal approach.
3
4
5
6
7
8
9
10
11
12
Postoperative Complications
See ▶ Chap. 11 on the transhiatal approach.
Tricks of the Senior Surgeon
If the trachea is injured use direct suture and pericardial ap
-
Injury of the gastroepiploic arcade necessitates colonic interposition.
-
An additional length of the gastric tube is achieved by mobilization of the duodenum
-
(Kocher maneuver). By this, the end of the gastric tube designated for the anastomosis is
located closer to the gastroepiploic pedicle. The improved vascular supply reduces the risk of
anastomotic leakage.
In contrast to cervical esophagogastric anastomosis, in any case of suspected intrathoracic
-
leakage, emergency endoscopy should be done. Even if an anastomotic leak cannot be denitely visualized, the indications for stenting should be very liberal as long as clinical signs
suggest a anastomotic leak to prevent catastrophic mediastinitis.
In case of limited length of the gastric tube with worry of tension at the anastomosis, the
-
stapling device is inserted through a ventral gastrostomy and an end-to-end gastroesophagostomy or a hand-sewn anastomosis is performed.
z Acknowledgments
e authors acknowledge the contribution of Stefan B. Hosch.
13
14
15
16
17
18
19
20
21
22
23
Laparoscopic and Conventional Limited Resection
of the Gastroesophageal Junction with Isoperistaltic
Jejunal Interposition
Thorsten Dohrmann, Oliver Mann, Jacob R. Izbicki
Limited en-bloc resection of the gastroesophageal junction includes complete removal of the
esophageal segment with metaplastic mucosa, the lower esophageal sphincter, and a part of the
lesser gastric curvature and formation of a neofundus. Because even early adenocarcinomas of
the distal esophagus (T1b) seed lymph node metastases in up to 20 % of patients, removal of the
lymph nodes of the lesser curvature, the hepatic and splenic arteries, the celiac trunk, the paraaortal region, and the inferior mediastinum is an essential part of the operation.
In patients with early tumors, staged as uT1a or b on preoperative endosonography or severe
dysplasia in the distal esophagus (Barrett’s esophagus), a limited resection of the proximal stomach, cardia, and distal esophagus with interposition of a pedicled isoperistaltic jejunal segment
oers excellent functional and oncological results.
Due to recent technical developments, laparoscopic surgery has become quite common even in
more complicated operative procedures. e benet of reduced postoperative pain, faster recovery,
and shorter hospitalization is evident. In patients presenting with early stages of distal esophageal
carcinoma or benign diseases as mentioned above, laparoscopic resection of the gastroesophageal
junction should be taken into consideration as the technical results concerning lymphadenectomy
and anastomosis are equivalent to the open procedure.
Indications
Contraindications
Indications and Contraindications
Severe dysplasia in the distal esophagus (Barrett’s esophagus)
-
Distal adenocarcinoma of the esophagus (stage T1a and b)
-
For palliative reasons (stenotic tumor with severe dysphagia or profuse hemorrhage in selec-
-
tive patients)
Esophageal carcinoma staged T2 and more
-
Long Barrett’s segment above the carina
-
Morbid obesity (laparoscopic approach)
-
Prior major upper gastrointestinal surgery (laparoscopic approach)
-
Preoperative Investigations/Preparation for the Procedure
Esophagogastroscopy with extensive biopsies
-
Endosonography of the esophagus
-
Computed tomography of the chest and abdomen
-
Abdominal ultrasound
-
Pulmonary function test
-
P.-A. Clavien, M. G. Sarr, Y. Fong, M. Miyazaki (Eds.), Atlas of Upper Gastrointestinal and Hepato-Pancreato-Biliary Surger y,
DOI 10.1007/978-3-662-46546-2_13, © Springer-Verlag Berlin Heidelberg 2016
1
2
Section II • Esophagus, Stomach, and Duodenum
Procedures
As the individual steps for this procedure are similar comparing open and laparoscopic surgery,
only the dierences for laparoscopic approach are mentioned.
3
4
5
6
7
8
9
10
11
12
13
Step 1
Positioning and Access
e patient is placed in supine position with hyperlordosis. An upper transverse incision with
median T-shape is made to access the epigastric region. Aer placement of Rochard retractor or
any other self-retaining retraction system to elevate the costal margin, thorough exploration of
the abdominal cavity is carried out. Good exposition of the site is crucial, as access to the hiatus
can sometimes be dicult.
Laparoscopic Surgery
e patient is placed in the beach chair position, as this enables best access to the hiatus. e operating surgeon stands between the legs, with the rst assistant on the patient’s le and the second
assistant on the patient’s right side. For trocar positions, see “Laparoscopic Gastrectomy”. Open
technique for gaining the pneumoperitoneum is favored.
14
15
16
17
18
19
20
21
22
23
Chapter • Laparoscopic and Conventional Limited Resection of the Gastroesophageal Junction
Step 2
Exposure of the inferior posterior mediastinum
e le liver lobe is mobilized completely and the lesser omentum is incised just medial to the
anterior and posterior gastric vagal branches. e distal esophagus including the paraesophageal
tissue is then mobilized beginning with dissection of the le crus. e right crus and gastrosplenic
ligament and short gastric veins are separated. A longitudinal median diaphragmal incision enables better exposure of the inferior posterior mediastinum.
Intraoperative esophagoscopy identies the cranial limit of the Barrett’s segment. is also
marks the proximal limit of resection. A lymphadenectomy around the splenic and hepatic artery is performed, the le gastric vein is divided, and the le gastric artery is divided at the celiac
trunk. en the celiac trunk and the para-aortic region above the celiac trunk are cleared from
lymphatic tissue (
. Fig. 13.1).
Laparoscopic surgery
Vessel sealing devices or ultrasound dissectors reduce preparation time and allows reliable sealing
of blood vessels during tissue dissection (. Fig. 13.2).
. Fig.13.1
. Fig.13.2
Section II • Esophagus, Stomach, and Duodenum
1
2
3
4
5
6
7
8
9
10
Step 3
Transection of the esophagus and stomach
Approximately 1 cm proximal to the cranial limit of the Barrett’s segment, a purse-string clamp is
placed and the esophagus is divided. Removal of the cardia and lesser curvature is performed by
placing multiple linear staplers down to the border between antrum and body. us, a neofundus
is formed. In case an advanced tumor stage is encountered, possible extension of the operation
including transhiatal esophagectomy or esophagogastrectomy should be performed (
Laparoscopic surgery
Transsection of the esophagus and cardia are performed using an articulating linear stapler. For
transection of both esophagus and cardia, the best working angle is accomplished when inserting the stapler through the upper le trocar. e specimen is then recovered using a specimenretrieving bag inserted through the upper right trocar. Enlarging the incision can be done at this
point, as it is necessary later for stapling the esophagojejunostomy (
. Fig. 13.4).
. Fig. 13.3).
11
12
13
14
15
16
17
18
19
20
21
. Fig.13.3
22
23
. Fig.13.4
Chapter • Laparoscopic and Conventional Limited Resection of the Gastroesophageal Junction
Step 4
Transposition of the proximal jejunum segment;
esophagojejunostomy
A 15–20 cm segment of the proximal jejunum is isolated and is transposed with its mesenteric
root to the diaphragmatic region through the mesocolon and behind the stomach. Care has to
be taken to dissect the vascular pedicle of this jejunal interposition carefully to provide adequate
length. It is imperative to form an isoperistaltic jejunal interposition, which should be pulled up
retrogastric and retrocolic. e proximal anastomosis is then performed by a circular stapling
device as a end-to-side esophagojejunostomy. e stapler is introduced into the end of the jejunal
interposition (. Fig. 13.5a). Aer ring the anastomosis, the blind end of the loop is resected by
a linear stapler and then oversewn (
. Fig. 13.5b).
. Fig.13.5
Section II • Esophagus, Stomach, and Duodenum
1
2
3
4
5
6
7
8
9
10
Step4 (continued)
Laparoscopic surgery
For anastomosis, the stapler anvil is placed in the esophagus by opening the stapler line and
performing a manual purse-string suture. Alternatively, a pre-tilted anvil assembly for transoral
insertion (OrVil; Covidien; Manseld, MA, USA) can be used: a small incision is made in the
center of the esophageal stapler line and the gastric tube with attached anvil is inserted transorally
and pulled through (. Fig. 13.6).
e circular stapler is inserted directly through the previously enlarged upper right incision
aer removing the trocar. As another alternative, a side-to-side esophagojejunostomy is also possible. Choice of technique performed depends on the surgeon’s Laparoscopic skills.
. Fig.13.6
11
12
13
14
15
16
17
18
19
20
21
Step 5
Jejunogastrostomy and reconstruction of enteric passage
Close to the base of the neofundus the gastric stapler line is removed over a distance of 3–4 cm and
a end-to-side or laterolateral jejunogastrostomy is performed. e remaining gastric suture line
is oversewn. A terminoterminal jejunojejunostomy reconstructs the enteric passage. Drainage of
the mediastinum is warranted by two so drains from the abdomen. Finally an anterior and/or
posterior hiatal repair is performed (
. Fig. 13.7).
22
23
. Fig.13.7