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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_794_Библиотеки_им_академика_М_И_Перельмана.pdf
Transhiatal Esophagohemigastrectomy
Dean Bogoevski, Jakob R. Izbicki
Introduction
Carcinomas of the cardia are still not classied as a separate entity and were staged like gastric
carcinomas until January 2010. ere is a discordance concerning the classication of carcinomas
within this area owing to the topographical borderland between the esophagus and the stomach.
Siewert and Stein provided a system for classifying the tumors into three types based on topographical-anatomical criteria. TypeI adenocarcinomas of the esophagogastric junction (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.
Dierent tumor entities at the esophagogastric junction (EGJ) should be treated by dierent
surgical approaches. In patients with potentially resectable carcinoma of the cardia (AEG TypesI
and II), this can be achieved by a total or a hemigastrectomy with transhiatal resection of the distal
esophagus and en-bloc removal of the lymphatic drainage in the lower posterior mediastinum
and upper abdomen.
Indications
Contraindications
Indications and Contraindications
Carcinoma of the distal esophagus where preoperatively inltration of the gastric cardia
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cannot be excluded
Adenocarcinoma of the EGJ TypesI and II
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Distal esophageal carcinoma aer subtotal gastrectomy
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Esophageal carcinoma of the mid or upper third aer subtotal gastrectomy (abdominotho-
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racic esophagogastrectomy with cervical or high intrathoracic anastomosis)
Caustic ingestions
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Active duodenal ulcer
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Preoperative Investigations/Preparation for the Procedure
Esophagogastroduodenoscopy with histological diagnosis
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Total colonoscopy to exclude second neoplasm or diverticula in the transposed colon seg-
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ment
CT scanning of the thorax and abdomen; some surgeons also suggest a CR-PET scan
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Abdominal sonography
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Esophageal endosonography
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Pulmonary function tests and blood gas analysis
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Echocardiography
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Ergometry and other cardiac investigations if necessary
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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_25, © Springer-Verlag Berlin Heidelberg 2016
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Step1
Section II • Esophagus, Stomach, and Duodenum
Procedure
z Positioning
Supine position with hyperlordosis
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z Approach
Upper transverse incision with median reversed T-shaped laparotomy
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Insertion of Rochard retractor to elevate costal margin
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Laparotomy
See ▶ Chap. 11 “Subtotal Esophagectomy: Transhiatal Approach.”
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Step2
Step3
Step4
Step5
Step6
Exposure
Aer mobilization of the le lateral liver lobe and dissection of the lesser sac close to the liver, the
greater omentum is detached from the transverse colon. Lymphadenectomy begins at the base
of the right gastroepiploic vessels. e peritoneal sheath is incised above the right gastroepiploic
vessels. e lymph nodes around the origin of the right gastroepiploic artery are dissected, and
special attention is paid not to injure the vessels, since the blood supply for the gastric remnant
will be granted through these vessels.
Lymphadenectomy
Dissection of the lymph nodes surrounding the stomach. For better exposure of these nodes, the
stomach is held upward by ventral traction. e lymph nodes at the upper margin of the pancreas
are dissected. Injury of the serosa of the duodenum and of the pancreatic capsule has to be avoided.
e lymphadenectomy in the hepatoduodenal ligament is performed. In addition, the lymph
nodes around the origin of the right gastric artery are dissected and special attention is paid not
to injure the vessels, since the blood supply for the gastric remnant will be granted through these
vessels.
Completion of the lymphadenectomy
e upper margin of the pancreas is now exposed by applying upward traction to the distal
stomach. Lymphadenectomy continues from the hepatoduodenal ligament along the common
hepatic artery down to the celiac trunk. Lymphadenectomy at the splenic artery, the celiac trunk
and the para-aortal space is performed (see
Lymphadenectomy,” STEP6).
Total gastrectomy (see ▶ Chap. 21, “Total Gastrectomy”)
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; some surgeons prefer to use an energy device for much of this procedure. 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 at the EGJ and then about 7 cm distal to the EGJ in the mid third
of the stomach. e stomach is divided with the stapler device. It is also 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 approximated with seromuscular stitches.
Transhiatal esophageal resection
See ▶ Chap. 11, “Subtotal Esophagectomy: Transhiatal Approach.”
▶ Chap. 21, “Total Gastrectomy with Conventional
Chapter • Transhiatal Esophagohemigastrectomy
Step7
Mobilization of the left colonic flexure
e le lateral peritoneal reection is nally mobilized by dissection of the peritoneum in the
cranial direction. e splenocolic ligament and the phrenicocolic ligament are ligated and divided
using cautery or scissors or an energy device. us the whole splenic exure of the colon is mobilized (
. Fig. 25.1).
. Fig.25.1
Section II • Esophagus, Stomach, and Duodenum
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Step8
Mobilization of the sigmoid colon
Mobilization of the sigmoid colon is facilitated by performing mediocranial traction to expose
the embryonic adhesions between the colon and the retroperitoneum. Further dissection is done
between the mesosigmoid and the retroperitoneal fat, taking care of the le ureter and gonadal
vessels (
. Fig. 25.2).
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Step9
. Fig.25.2
Determination of the essential length
A colonic segment is selected suitable for interposition. e essential length is determined by the
following procedure: elevation of the colon in front of the abdominal wall, and measurement of
the distance between the abdomen and the angle of the mandible by a suture, xed at the root of
the vessel of the colonic mesentery on which the vascular supply to the colonic interposition will
be based (
margin is marked.
. Fig. 25.3). e length of the suture is nally transferred to the colon and the resection
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. Fig.25.3
Chapter • Transhiatal Esophagohemigastrectomy
e black bars show alternative lines for transection of the colon. Resection of bluish margins on
the right exure of the transverse colon between the middle and the right colic artery should be
performed aer preservation of the paracolic arcades. Following this procedure, a better mobilization of the colonic segment can be obtained. To perform the pharyngocolostomy in carcinomas
of the upper third of the esophagus, a long colonic segment is required. erefore parts of the
sigmoid colon have to be used and the rst (and probably the second) sigmoid artery has to be ligated close to the inferior mesenteric artery. Prior to dissection of the vessels, an atraumatic clamp
is provisionally applied to prove the suciency of the vascular supply to the proposed colonic
segment to be used. Dark arrows point to the vascular resection margins. e arcade between the
right and the middle colic artery should be preserved for a better vascular supply of the colonic
segment chosen for interposition (
Advantages of using the le colonic segment are the following:
e more predictably longer length and the smaller diameter of the le colon
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Adequacy of the vascular pattern due to arteries with larger diameter, instead of vascular
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supply via several arcades as in the right colon
Using an antiperistaltic colonic segment has no clinical relevance because the injested food
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is transported through the colonic interposition by gravity
e essential advantage of the le colon is the opportunity to obtain a longer colonic segment.
. Fig. 25.4).
. Fig.25.4
Section II • Esophagus, Stomach, and Duodenum
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Step10
Standard procedure: isoperistaltic reconstruction
e middle colic artery is divided and the vascular supply is through the le colic artery, if a sufcient Riolan arcade exists.
is approach ensures an isoperistaltic reconstruction (standard procedure). Care has to be
taken not to injure the le colic vessels. erefore preparation has to be done carefully and close
to the wall of the colon, and transection of the descending colon is always done without extensive
dissection of the colon using a linear stapler device. e right and middle colic vessels are dissected close to their origin. A prophylactic appendectomy aer total mobilization of the colon is
recommended.
An antiperistaltic colon interposition supplied by the le colic artery can be performed, if
the Riolan anastomosis is either not present or insucient due to previous surgical procedures
(
. Fig. 25.5).
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. Fig.25.5
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Chapter • Transhiatal Esophagohemigastrectomy
Step11
Antiperistaltic reconstruction (not standard)
Preparation of an antiperistaltic (not standard) colonic segment begins with incision of the peritoneum of the le mesocolon far from the colon and stepwise preparation of the mesocolon
maintaining the paracolic arcades and the middle and le colic vessels. An atraumatic vascular
clamp is provisionally applied across the le colic artery and the sigmoid artery to assure adequate
blood supply to the colonic segment to be used for the conduit based on a sucient arcade of
Riolan. If no ischemia occurs aer 3min, the colon interposition can be performed (
. Fig. 25.6).
Step12
. Fig.25.6
Inadequate vascular supply
In case of an inadequate vascular supply by the le and middle colic artery, reconstruction of an
isoperistaltic colon interposition supplied by the sigmoid artery is possible (
. Fig. 25.7).
. Fig.25.7
Section II • Esophagus, Stomach, and Duodenum
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Step13
Inadequate vascular supply
In very rare cases no anastomosis is found between the le colic artery and the rst sigmoid artery.
In those cases the main branch of the inferior mesenteric artery can be used as an anastomosis
between the two areas of blood supply. is can only be accomplished when the distal parts of
the sigmoid colon are adequately perfused by the medial and inferior rectal artery. is has to be
checked by temporary vascular clamping (
. Fig. 25.8).
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Step14
. Fig.25.8
Rare situations
Even aer right hemicolectomy (e. g., following unsuccessful right colonic interposition), construction of an antiperistaltic interposition is possible if the middle colic artery has been spared during
the rst operation. e le colic artery and the rst sigmoid artery are dissected (. Fig. 25.9a).
Vascular supply of the colonic interposition comes from the middle colic artery. Reconstruction
is performed with an ileosigmoidostomy.
Alternatively, a colonic interposition aer right hemicolectomy and aer former transection
of the middle colic artery can be performed using the le colon. e blood supply comes from the
le colic artery. e entire sigmoid colon is needed for the purpose of achieving sucient length
for the interposition and all sigmoid arteries have to be dissected (.
colon segment with poor vascular supply is resected.
If impossible to use the le hemicolon for interposition, the right hemicolon can be used to
perform the colonic interposition.
Fig. 25.9b
). e proximal
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Chapter • Transhiatal Esophagohemigastrectomy
Step14 (continued)
. Fig.25.9
Scheme of construction of an isoperistaltic colonic interposition using the right hemicolon and
the terminal part of the ileum is illustrated here (
the middle colic artery.
Using the right hemicolon for interposition is burdened by frequent complications leading to
poorer postoperative functional results.
. Fig. 25.10). e vascular supply comes from
. Fig.25.10
Section II • Esophagus, Stomach, and Duodenum
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Step15
Vascular supply of the colonic interposition from the ileocolic artery
Also shown is the preparation of an antiperistaltic colonic interposition using the right hemicolon,
with vascular supply from the ileocolic artery (. Fig. 25.11a).
Adequate length of the right hemicolon enables construction of an isoperistaltic interposition
without using the ileocolic portion of the intestine (. Fig. 25.11b). is technique oers several
advantages:
Omission of the terminal ileum, which is prone to necrosis
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Omission of the ileocecal region, which is prone to poor functional results
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. Fig.25.11
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