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 • Laparoscopic and Conventional Limited Resection of the Gastroesophageal Junction
Step5 (continued)
Laparoscopic surgery
e anastomosis technique is slightly dierent. A typical side-to-side stapled anastomosis for
jejunogastrostomy is performed. e linear stapler is inserted through two small incisions at the
caudal end of the anastomosis. Aer stapling, the remaining defect is closed by manual suture.
Side-to-side stapled jejunojejunostomy for reconstruction of the enteric passage is carried out in
the same manner.
Standard Postoperative Investigations
Daily check of drains for leakage of the intrathoracic esophagojejunostomy
Postoperative Complications
Leakage of the esophagojejunostomy or the intra-abdominal anastomosis
-
Necrosis of the transposed jejunal segment
-
Mediastinitis
-
Peritonitis
-
Pleural empyema
-
Pancreatitis
-
Postoperative gastroesophageal reux
-
Delayed gastric emptying
-
Tricks of the Senior Surgeon
Use intraoperative endoscopy in any case of long-segment irregularities or evidence of multi-
-
centric lesions.
Insertion of the stapler device through the oral end of the pedicled jejunal segment.
-
Laparoscopic Procedure
Do not hesitate to place additional trocars if the exposure is insucient or the working angle
-
is not suitable.
Three-Field Lymphadenectomy for Esophageal Cancer
Takashi Aikou
Introduction
Lymphatic drainage from the upper two-thirds of the thoracic esophagus occurs mainly toward
the neck and upper mediastinum, although there is also some drainage to the nodes along the
le gastric artery. In 1981, the rst reported study of three-eld lymphadenectomy in Japan noted
that 10 of 36patients with esophagectomy had skip metastases to the neck or abdominal lymph
nodes in the absence of associated intrathoracic spread. In this chapter, we focus on the lymph
node dissection of the upper mediastinal and cervical regions.
Indications and Contraindications
Indications
Contraindications
Tumors of the supracarinal esophagus (> T1m stage)
-
Supercial carcinoma (T1m stage)
-
Severe comorbidity (heart disease, pulmonary and/or liver dysfunction)
-
No evidence of cervical lymph node metastases preoperatively in high-risk patients (rela-
-
tive)
Infracarinal tumors (relative)
-
Preoperative Investigation/Preparation for the Procedure
See transhiatal approach
-
Ultrasound plus computed tomography scan of the neck, consider PET scan
-
In locally advanced tumors: primary radiochemotherapy and surgery is done secondarily
-
Procedure
z Access
Anterior-lateral thoracotomy through the right 5thintercostal space
-
Supine position and T-shaped incision in the neck
-
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_14, © Springer-Verlag Berlin Heidelberg 2016
Section II • Esophagus, Stomach, and Duodenum
1
2
3
4
5
6
7
8
9
10
Step 1
Exposure and lymphadenectomy of the right upper mediastinum
e arch of the azygos vein is resected, and the right bronchial artery is ligated and secured at its
root to evaluate the tumor for its resectability. is procedure provides a good exposure of the
upper and middle mediastinum. e brachiocephalic and right subclavian arteries are exposed
in order to remove
nodes followed by carefully ligating the branches of the inferior thyroid artery (arrow indicates
the direction of lymphadenectomy) (
the nodes along the right recurrent laryngeal nerve and the right paratracheal
. Fig. 14.1).
11
12
13
14
15
16
17
18
19
20
21
. Fig.14.1
22
23
Chapter • Three-Field Lymphadenectomy for Esophageal Cancer
Step 2
Transection and resection of the esophagus and completion of lymph
node clearance
Aer proximal transection of the esophagus at the level of the aortic arch, the nodes along the le
recurrent laryngeal nerve (le paratracheal nodes) are removed. e middle mediastinal nodes,
comprising the infra-aortic, infracarinal, and periesophageal nodes, are cleared in conjunction
with the esophagus.
is exposes the main bronchus, the le pulmonary artery, branches of the vagus nerve, and
the pericardium. Both pulmonary branches of both vagus nerves and the le bronchial artery
originating from the descending aorta near the le pulmonary hilum are preserved. However, the
esophageal branches of the vagus nerves are severed, and the thoracic duct is also ligated because
it is removed together with the esophagus (
. Fig. 14.2).
. Fig.14.2
Section II • Esophagus, Stomach, and Duodenum
1
2
3
4
5
6
7
8
9
10
Step 3
T-shaped neck incision
A T-shaped neck incision is made and the sternothyroid, sternohyoid, and sternomastoid muscles
are divided at the clavicle head and the fascia of the omohyoid muscle is incised. Aer identication of the recurrent laryngeal nerve, lymph nodes along this nerve (which are in continuity with
the nodes previously dissected out in the superior mediastinum) are dissected. e inferior thyroid
arteries are then ligated and divided. e para-esophageal nodes, including the nodes along the
recurrent laryngeal nerve at the cervicothoracic junction, are classied as either cervical or upper
mediastinal nodes, according to their position relative to the bifurcation of the right common
carotid and right subclavian arteries (. Fig. 14.3).
11
12
13
14
15
16
17
18
19
20
21
. Fig.14.3
22
23
Chapter • Three-Field Lymphadenectomy for Esophageal Cancer
Step 4
Cervical lymphadenectomy
e jugular vein, common carotid artery, and vagus nerve are subsequently identied and preserved. On the lateral side, aer careful preservation of the spinal accessory nerve, lymph nodes
situated lateral to the internal jugular vein are removed. e thyrocervical trunk and its branches
and the phrenic nerve are then identied. In this procedure, the cervical nodes (internal jugular
nodes below the level of the cricoid cartilage, supraclavicular nodes, and cervical paraesophageal
nodes) are cleared bilaterally (arrow indicates the direction of lymphadenectomy) (
See transhiatal approach for standard postoperative investigations and complications.
. Fig. 14.4).
. Fig.14.4
Tricks of the Senior Surgeon
A better exposure of the upper mediastinum requires transection of the medial head of the
-
sternocleidomastoid muscle and/or partial upper sternotomy.
Minimally Invasive Esophagectomy
Jonathan D’Cunha, David D. Odell, Ryan M. Levy, James D. Luketich
Over the past decade, minimally invasive esophagectomy (MIE) has become an accepted surgical approach for esophageal malignancy as well as certain benign conditions. When performed
at high-volume centers, MIE results in morbidity, mortality, and oncological outcomes similar
to those of open esophagectomy while oering the advantages inherent to minimally invasive
surgery. MIE techniques have evolved from the intial hybrid approaches of thoracoscopy combined with laparotomy to the present combination of laparoscopy and thoracoscopy for a totally
minimally invasive esophagectomy. Whereas the totally minimally invasive approach is technically
demanding and associated with a signicant operator learning curve, it is an excellent option for
esophageal resection. In our experience, MIE is associated with a reduction in blood loss, decreased respiratory complications, improved pain cotrol, and a decrease in hospital length of stay.
At present, minimally invasive approaches for esophagectomy include laparoscopic-transhiatal, laparoscopic-thoracoscopic three-hole (McKeown), and laparoscopic-thoracoscopic Ivor
Lewis esophagectomy. e choice between MIE approaches is largely based upon the preference
of the surgeon. However, tumor location or other anatomical factors may inuence the choice of
surgical approach. e anticipated morbidity of the operation also varies with the choice of surgical approach. e creation of a cervical anastomosis has a higher incidence of recurrent laryngeal
nerve injury. Cervical anastomoses may also be more prone to anastomotic leak, stricture, and
pharyngoesophageal swallowing dysfunction. By comparison, transthoracic approaches have a
higher incidence of cardiopulmonary complications and potentially greater morbidity if an anastomotic leak occurs.
Our initial approach to MIE utilized a modied McKeown (three-hole) technique that proved
to have equivalent oncological outcome and morbidity to the open technique. Owing to concerns
regarding cervical dissection and anastomosis, our preferred approach is now a completely laparoscopic-thoracoscopic (Ivor Lewis) esophagectomy with abdominal (celiac, le gastric, splenic)
and mediastinal (paraesophageal and subcarinal) lymphadenectomy. e minimally invasive Ivor
Lewis approach works well for most distal esophageal cancers, gastroesophageal junction tumors
with gastric cardia extension, and short-to-moderate length Barrett’s esophagus with high-grade
dysplasia. In addition, when there is concern for the length of the gastric conduit, an intrathoracic
anastomosis is preferable. In cases of primary gastric tumors with signicant lesser curve extension
that involve the incisura, we prefer a total gastrectomy with roux-en-Y reconstruction. Total laparoscopic and thoracoscopic Ivor Lewis resections should not be performed for upper third or midesophageal cancers with signicant proximal extension owing to concern for adequate proximal
resection margin. e following describes our current technique for laparoscopic-thoracoscopic
Ivor Lewis minimally invasive esophagectomy.
Indications/Contraindications
Indications
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_15, © Springer-Verlag Berlin Heidelberg 2016
1. Esophageal cancer
a. Adenocarcinoma
i. Primary treatment
ii. Following induction chemotherapy and/or radiation treatment
b. Squamous carcinoma
i. Primary treatment
ii. Following induction chemotherapy and/or radiation treatment
c. Barrett’s esophagus/high-grade dysplasia
Section II • Esophagus, Stomach, and Duodenum
1
2
3
4
5
6
7
8
9
10
11
12
13
Contraindications
2. Benign disease requiring esophagectomy
a. End-stage achalasia
i. If not a candidate for Heller myotomy
b. Megaesophagus
i. Owing to primary dysmotility
ii. Secondary to distal obstruction
c. Multiple revision antireux surgery
i. In the setting of esophageal injury or inadequate esophageal length
d. Caustic ingestion
i. Failed dilation therapy
e. Esophageal perforation
i. If not amenable to primary reconstruction
ii. Patient must be stable
iii. Oen a delayed approach
1. Anatomical
a. Need for en-bloc resection of other organs
i. Direct palpation of the lesion is oen necessary to determine resection plane
b. Concern for airway or major vascular injury or malignant involvement
i. Determination of resectability
ii. Evaluation and repair of injury
c. Consideration of a non-gastric conduit (colon, jejunum)
i. In order to preserve the vascular pedicle without tension
ii. To facilitate a timely progression of the operation
d. Locally advanced malignancy-unresectable disease
e. Metastasis
2. Technical
a. Inability to tolerate insuation of the abdomen
b. Hemodynamic instability
c. Inability to tolerate single lung ventilation
d. Prior gastric or mediastinal surgery (relative)
14
15
16
17
18
19
20
21
22
23
Preoperative Investigation and Preparation for Procedure
History and physical examination
Focus on cancer risk factors, smoking history, dysphagia symptoms
-
Laboratory studies
Complete blood count (CBC), electrolytes, coagulation studies, nutritional studies (albumin
-
and prealbumin)
Upper endoscopy
Direct evaluation of the extent of the tumor (or other pathology)
-
Biopsies of the lesion for histopathological evaluation
-
Assessment of the length of preserved proximal esophagus to allow for planning of the loca-
-
tion of the proximal resection margin/anastomotic site.
Assessment of the extent of gastric involvement and determination of the suitability of the
-
stomach for use as a conduit in reconstruction.
Chapter • Minimally Invasive Esophagectomy
Barium esophagram
Delineation of tumor anatomy
-
Assessment of the degree of obstruction
-
Endoscopic ultrasound (EUS)
Determination of ultrasonographic depth of invasion and more accurate T staging
-
Visualization of periesophageal lymph nodes with the potential for biopsy of suspicious
-
nodes to more accurately stage disease preoperatively
May be unable to pass the scope in patients with larger tumors
-
Computed tomography-positron emission tomography (CT-PET)
Evaluation for metastatic disease, especially useful in evaluation of celiac and perigastric
-
lymph nodes not seen by EUS
Assessment of direct tumor invasion of surrounding structures
-
Magnetic resonance imaging (MRI) of the brain
Not routinely performed unless patients present with specic neurological symptoms
-
Pulmonary function testing
Assessment of the suitability of the patient for thoracoscopy and the ability to tolerate single
-
lung ventilation
Cardiac evaluation
Electrocardiogram (ECG) and physician risk assessment in most patients
-
Cardiology referral and formal stress testing for those patients with ECG abnormalities or
-
identied risk factors for cardiac disease.
Echocardiogram may be considered to evaluate for undiagnosed pulmonary hypertension
-
(decision guided by history and physical).
Bronchoscopy
Useful to rule out the presence of airway involvement prior to proceeding to surgery in
-
patients with upper esophageal tumors, especially squamous carcinomas
Laparoscopic staging
Comprises the initial step in the operation for all patients; however, it can also be performed
-
as a stand-alone procedure in patients with a concern for an advanced (i. e., inoperable)
disease state on the basis of preoperative imaging or endoscopic evaluation.
Two- to three-port technique allows for direct visualization of the peritoneum and liver
-
capsule and biopsy of nodal stations that may be inaccessible by EUS.
May divide the le gastric artery with minimal dissection for ischemic preconditioning of
-
the gastric conduit.
1
2
3
4
5
6
7
8
9
Section II • Esophagus, Stomach, and Duodenum
Surgical Technique
Anesthetic Considerations
Anesthetic management during MIE poses specic challenges. Whereas all patients receive an arterial blood pressure monitoring line, central venous catheter placement is not routine. A doublelumen endotracheal tube is placed initially in anticipation of the thoracoscopic phase. In patients
with midthoracic or upper thoracic tumors, a single-lumen endotracheal tube is initially placed
for preoperative bronchoscopy to evaluate airway involvement.
Patients generally require signicant volume loading during the laparoscopic phase secondary
to the pneumoperitoneum and steep reverse Trendelenburg positioning. Given the high ow of
CO2required, the patient can develop signicant hypercarbia and acidosis. e surgeon must also
be mindful of vasopressors administered by the anesthesiologist because these agents directly affect the viability of the newly created gastric conduit. Simple measures can be undertaken to help
correct these problems. Maneuvers to increase preload include lowering the insuation pressure,
decreasing the degree of the reverse Trendelenburg position, and increasing volume loading. In
addition to changes in the ventilator settings, hypercarbia can oen be corrected by reversing the
pneumoperitoneum, allowing the patient time to compensate and clear the excess CO2. ere
must be clear and ongoing communication throughout the procedure between the surgeon and
the anesthesiologist.
10
11
12
13
14
15
16
17
18
19
Endoscopic Evaluation
e operation begins with a careful esophagogastroduodenoscopy (EGD). e location of the
tumor is conrmed along with precise measurements of the proximal and distal extent of the
lesion. e surrounding esophagus is examined for evidence of Barrett changes proximal to the
intended resection margin, with four-quadrant biopsies taken in areas of clinical concern. Careful endoscopic examination of the stomach is also imperative to assess its suitability for use as a
conduit in esophageal reconstruction. Air insuation should be kept to a minimum during the
examination to reduce the degree of small bowel distention which may signicantly decrease
domain and heighten the diculty of laparoscopy.
20
21
22
23