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Chapter • Abdominothoracic Esophagogastrectomy
Step18
Pull-through procedure
For the substernal reconstruction, a long strong suture is passed from the cervical incision through
the mediastinal tunnel into the abdomen to facilitate the pull-through procedure. e suture is
tied to the oral end of the colonic interposition. e colon is transposed through the substernal
tunnel to the cervical incision under a continuous and gentle pull, and the sternum should be
retracted upward with a sharp retractor during the procedure (
. Fig. 23.12).
. Fig.23.12
Section II • Esophagus, Stomach, and Duodenum
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Step19
Posterior mediastinum
Interposition of the colon through the posterior mediastinum is performed in the bed of the
removed esophagus. e posterior mediastinal route of the interposed colon is favorable to the
substernal or presternal position because of the shorter distance to the neck. In addition, the
posterior mediastinal route prevents kinking of the colon and leads to better functional results.
e interposed colon causes hemostasis in the operation eld (
. Fig. 23.13).
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Step20
. Fig.23.13
End-to-side anastomosis (esophago-colostomy or pharyngocolostonomy)
If possible, the end-to-side anastomosis should be performed with a double-row suture technique.
In case of a dierent lumen diameter, interrupted sutures and a end-to-side anastomosis can
be performed close to the tenia coli (
. Fig. 23.14).
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23
. Fig.23.14
Chapter • Abdominothoracic Esophagogastrectomy
Step21
Side-to-side anastomosis (esophagotomy-colostomy or pharyngocolostomy)
e alternative technique for anastomosis aer colonic interposition is a side-to-side coloesophageal anastomosis performed by a linear stapler (. Fig. 23.15).
. Fig.23.15
Step22
Reconstruction of the intestine (colo-jejunostomy)
Gastrointestinal continuity is achieved by distal colo-jejunostomy and jejunojejunostomy.
A colo-sigmoidostomy completes the reconstruction. e mesenteric defects have been closed.
e operative site aer transposition of the colon and reconstruction is shown (. Fig. 23.16).
. Fig.23.16
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Section II • Esophagus, Stomach, and Duodenum
Combined Transhiatal Transthoracic Esophagectomy
We reported this technique for the rst time in 1980. It uses the concepts acquired in transhiatal
dissection in tumors located more superiorly in the cervicothoracic esophagus or in the middle
third of the thoracic esophagus and avoids a “blunt” dissection performed without visual control,
which increases the possibility of iatrogenic injury to mediastinal structures. However, at present
more and more surgeons favor transhiatal esophagectomy for its technical simplicity and favorable outcome.
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Indication
Contraindication
Step1
Step2
Indications and Contraindications
Esophageal carcinoma in the mid or upper third aer subtotal gastrectomy
-
Extensive local invasion (trachea, vessels)
-
Preoperative Investigations/Preparation for the Procedure
Bronchoscopy
-
Procedure
z Access
See ▶ Chap. 12, “Subtotal Esophagectomy: Abdominothoracic Approach.”
Abdominal exposure
e operation begins with a upper midline laparotomy, and the abdominal viscera and diaphragmatic section are examined (see earlier), which permits access to the posterior mediastinal space.
e mediastinal dissection is done as above, allowing visual control as far as the tracheal branching.
Right anterior thoracotomy
A right anterior thoracotomy is then performed, if possible without transection of the costal
margin. If the rigidity of the thorax so requires, the anterior arch of the costal margin is removed,
and should this prove insucient, the remaining posterior arch of the costal margin is resected
via the anterior thoracic incision.
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Step3
Step4
Step5
Esophageal dissection and mediastinal lymphadenectomy
e ipsilateral mediastinal pleura, which remains in contact with the esophagus, is incised
through the anterior thoracic incision. e arch of the azygos vein is incised, enabling the dissection of the cervicothoracic esophagus. To expand the mediastinal lymphadenectomy, this
incision is used to dissect the intercostal veins. e trunk of the azygos vein is ligated at the
supradiaphragmatic level and resection of the associated thoracic duct is required by the lymphatic involvement.
During esophageal dissection at the high level of the cervical region, tracheobronchial intubation with a Carlens tube can be used to facilitate access to the esophagus, occluding the right
bronchial tube (see
Technique of cervical anastomosis
See . Fig. 23.14 and . Fig. 23.15
Technique of high intrathoracic esophagocolostomy
See . Fig. 23.14 and . Fig. 23.15
▶ Chap. 24, “Abdominothoracic Esophagohemigastrectomy,” Steps1–3).
Chapter • Abdominothoracic Esophagogastrectomy
Standard Postoperative Investigations
See ▶ Chap. 11 “Subtotal Esophagectomy: Transhiatal Approach.”
Postoperative Complications
z Early Postoperative Course
Pulmonary infections
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Septic complications: subphrenic or intra-abdominal abscess; cervical wound infection
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Anastomotic leak
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Necrosis of the interposition
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hydro or pneumothorax
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herniation of bowel into the right pleural cavity
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z Late Postoperative Course
Cicatricial strictures of the cervical esophago- or pharyngeocolostomy, mostly due to anas-
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tomotic leak
Kinking of the interposition
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Mechanical trauma to a subcutaneous gra, which oen needs surgical intervention
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Propulsive disorder
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motor disorder of swallowing and passage of food through colonic segment
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Tricks of the Senior Surgeon
Treatment of anastomotic stenosis is performed by bougienage or balloon dilation. Very
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rarely is surgical intervention indicated.
Reasons for necrosis of the interposition are: decrease of circulation due to kinking or com-
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pression of the main vessels, hypovolemia, and hypercoagulability. Avoidance is by interposi-
tion of a long colonic segment without tension. Optimization of the postoperative hemody-
namic and rheologic parameters is necessary.
Kinking of the interposition is a rare but dangerous complication, which often requires reop-
-
erative intervention, due to clinical symptomatic disturbance of the gastrointestinal passage
by elongation of the interposition. Surgical intervention is performed by shortening of the
graft.
To avoid diaphragmatic paralysis, the phrenic nerves must be preserved.
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To avoid herniation of bowel into the right pleural cavity, the diaphragmatic defect must be
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closed.
Abdominothoracic Esophagohemigastrectomy
Michael F. Nentwich, Dean Bogoevski
e surgical approach toward adenocarcinomas of the esophagogastric junction (AEG) is still
under debate. Siewert and Stein provided a system for classifying the tumors into three types
based on topographical-anatomical criteria; this has been widely accepted in Europe and has
had a direct impact on therapeutic strategies. TypeI AEGs involve the distal esophagus and arise
mostly in the intestinal metaplasia of Barrett’s esophagus, TypeII originate at the anatomical
cardia, and TypeIII are subcardial gastric carcinomas inltrating the esophagogastric junction
and distal esophagus from below.
In Europe patients with an AEG TypeI carcinoma are treated with radical en-bloc esophagectomy and gastric tube reconstruction. In patients with AEG TypeII, an extended gastrectomy or
esophagogastrectomy is indicated. In the United States the standard surgical therapy in patients
with AEG TypesI and II is esophagectomy with hemigastrectomy, whereas the therapy for TypeIII
carcinomas is similar to that in Europe. In some patients a tumor is operated on as an esophageal
cancer, but denitive histology shows a gastric cancer, and vice versa.
In case of a tumor extension involving more than one quarter of the stomach and a 5-cm distal
margin cannot be achieved, a total esophagogastrectomy with colonic interposition is advised.
Indications
Contraindications
Indications and Contraindications
Carcinoma of the distal esophagus (AEG TypeI) with involvement of the proximal stomach
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Locally advanced carcinoma of the cardia (AEG TypeII)
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Adenocarcinoma of the proximal stomach (AEG TypeIII) with inltration of the distal
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esophagus
Active duodenal ulcer
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Severe or irreversible cardiopulmonary insuciency
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Preoperative Investigations/Preparation for the Procedure
Esophagogastroduodenoscopy with histological diagnosis
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Total colonoscopy to exclude second malignancy or diverticula in the transposed colonic
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segment
CT scanning of the thorax and abdomen; some surgeons also suggest a PET-CT scan
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Abdominal sonography
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Esophageal endosonography (if indicated)
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Pulmonary function tests and blood gas analysis
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Echocardiography (if indicated)
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Ergometry and other cardiac investigations (if indicated)
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Entire orthograde bowel preparation
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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_24, © Springer-Verlag Berlin Heidelberg 2016
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Section II • Esophagus, Stomach, and Duodenum
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Procedure
Positioning
Patient in the le lateral position for the thoracic part of the operation
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Right anterolateral thoracotomy through the h intercostal space (ICS)
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Repositioning to the supine position
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Upper transverse incision with median extension
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Alternatively, a modied helical patient position without the need of intraoperative repositioning
can be used
Patient placed on a vacuum-positioning device and positioned in a right thoracoabdominal
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position (
. Fig. 24.1)
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Step1
. Fig.24.1
Shoulders are rotated approximately45°, hips remain less rotated, right arm is elevated
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across the body exposing the axilla
Table rotation for exposure of either abdominal or thoracic parts
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Approach
Upper transverse laparotomy incision with median T-shaped extension
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Insertion of Rochard retractor to elevate costal margin
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Anterolateral thoracotomy through the h ICS
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Laparotomy
e abdomen is entered by a supraumbilical transverse laparotomy with median reverse Tshaped extension. Aer ligation and transection of the ligamentum Teres and aer abdominal
wall adhesions are cleared, a Rochard retractor is inserted to elevate the costal margins on both
sides.
Chapter • Abdominothoracic Esophagohemigastrectomy
Step2
Step3
Step4
Exposure
e peritoneum, omentum and the liver are palpated to exclude metastatic disease. Mobilization
of the le lateral liver lobe is done by ligation of the le falciform ligament and by the dissection of
the lesser sac close to the liver. e greater omentum is then detached from the transverse colon.
Lymphadenectomy
Lymphadenectomy begins at the hepatoduodenal ligament and includes the lymph nodes surrounding the proper and the main hepatic artery and the hepatodoudenal ligament as well as
t
he lymph nodes at the celiac trunk. Attention has to be paid to preserve the right gastroepiploic vessels. Lymphadenectomy is continued along the splenic artery until the splenic hilum
i
s reached.
Mobilization and resection of the proximal stomach
Traction is applied to the stomach toward the right upper abdomen to expose the origin of the
le gastroepiploic artery and the short gastric vessels. ese vessels are transected and ligated
between clamps. Mobilization of the greater curvature of the stomach is performed up to the
gastroesophageal junction. During this step the phrenicogastric ligament has to be transected
with electrocautery.
Mobilization of the lesser curvature of the stomach is performed up to the gastroesophageal
junction, paying special attention to the le gastric artery and the vein. ese are transected and
ligated between clamps.
e resection margins are set in the distal stomach region about 5–7 cm distal to the esophagogastric junction in the mid third of the stomach (
5 cm should be obtained. e stomach is preferably divided with a stapler device; otherwise it
is recommended to make a single-layer closure of the gastric incision with a running suture or
interrupted stitches. In case a stapler device is used, the serosa should be adapted with seromuscular stitches.
. Fig. 24.2). A distal tumor margin of at least
Step5
Step6
. Fig.24.2
Transthoracic esophagectomy
See ▶ Chap. 23 “Abdominothoracic Esophagogastrectomy.”
Preparation of the colonic interposition
See ▶ Chap. 23 “Abdominothoracic Esophagogastrectomy.”
Section II • Esophagus, Stomach, and Duodenum
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Step7
Step8
Reconstruction
e interposition of the colon can be done either by creating a substernal or presternal tunnel
or by using the posterior mediastinum route in the bed of the removed esophagus. is is the
preferred route because it reduces kinking of the colon and the oral colonic end is closer to the
cervical esophagus.
See
▶ Chap. 23 “Abdominothoracic Esophagogastrectomy.”
e anastomosis can be placed either intrathoracically or cervically. Usually the colonic interposition provides excessive length to reach the cervical area. An intrathoracic anastomosis is
performed using a circular stapler, preferably with a large diameter (28 mm) to prevent future
anastomotic strictures and a end-to-side anastomosis is applied. Alternatively, the anastomosis
can be done as a hand-sewn one in a single-layer running suture technique. Attention has to be
paid to the “corner” areas of the anastomosis and additional interrupted sutures may be placed to
ensure a primary sucient anastomosis.
If a cervical anastomosis is favored, it can be performed as described in the
dominothoracic Esophagogastrectomy.”
Intestinal reconstruction
To reconstruct the intestinal continuity, a end-to-side or side-to-side cologastrostomy is performed by either a one- or two-layered anastomosis. e gastric remnant is incised for 3–4 cm
close to the linear stapler line at the anterior gastric wall (
. Fig. 24.3).
▶ Chap. 23 “A b -
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. Fig.24.3
In addition, the colonic continuity is established by a side-to-side colonic anastomosis. Mesenteric
incisions need to be closed to avoid internal herniation.
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Chapter • Abdominothoracic Esophagohemigastrectomy
Postoperative Complications
Early Postoperative Course
Pulmonary infections
-
Septic complications: subphrenic or intra-abdominal abscess; cervical wound infection
-
Anastomotic leakage
-
Necrosis of the colonic interposition
-
Hydro or pneumothorax
-
Herniation of bowel into the right pleural cavity
-
Late Postoperative Course
Cicatricial strictures of the cervical esophagogastrostomy, mostly due to anastomotic leak
-
Kinking of the interposition
-
Mechanical trauma to a subcutaneous colonic interposition, which oen needs surgical
-
intervention
Diculty swallowing or motility disorder
-
Anastomotic ulcers in the area of the colonogastrostomy
-
Tricks of the Senior Surgeon
Treatment of the stenosis is performed by bougienage or balloon dilatation. Very rarely is
-
surgical intervention indicated.
Reasons for necrosis of the colonic interposition are decrease of circulation due to kinking or
-
compression of the main vessels, hypovolemia, and hypercoagulability. It can be avoided by
using a long colonic segment without tension. The postoperative hemodynamic and rheo-
logic parameters need to be optimized.
Kinking of the interposition followed by elongation often requires surgical intervention as it
-
can lead to a disruption of the ow of injested food through the colonic conduit. The conduit
has then to be shortened.
To avoid herniation of bowel into the right pleural space, closure of the diaphragm has to be
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performed.