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Chapter • Transhiatal Esophagohemigastrectomy
Step16
Preparation of a substernal tunnel
A blunt opening is made in the substernal cavity by spreading the scissors, while retracting the
xiphoid ventrally with a sharp retractor (
Aer opening the substernal cavity, a substernal tunnel is constructed with an atraumatic
clamp.
e sternum has to be retracted anteriorly, and the endothoracic membrane is to be separated
from the sternum. A longitudinal incision along the anterior border of the le sternocleidomastoid
muscle is made to expose the cervical esophagus. Blunt preparation with the hand through the
substernal tunnel usually leads to rupture of the mediastinal pleura (
. Fig. 25.12a).
. Fig. 25.12b,c).
. Fig.25.12
Section II • Esophagus, Stomach, and Duodenum
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Step17
Completed preparation of the retrosternal tunnel
In case of tight adhesions to the sternum, these adhesions are dissected sharply with scissors.
Between the corpus and the manubrium sterni the substernal fascia is very tightly connected
to the sternum. Furthermore, the visceral and parietal pleura are tightly connected in this region.
For this reason, very careful, stepwise preparation with a long atraumatic clamp has to be performed, and the preparation should be manually controlled by the substernally introduced nger
of the surgeon (
. Fig. 25.13).
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. Fig.25.13
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Chapter • Transhiatal Esophagohemigastrectomy
Step18
Pull-through procedure
For the substernal reconstruction, a long strong suture is passed from the cervical incision through
the mediastinal tunnel and 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 in the substernal tunnel to the cervical incision under a continuous and gentle pull, and the sternum should be pulled
upward with a sharp retractor during the procedure (
. Fig. 25.14).
. Fig.25.14
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 colonic interposition 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 operative eld (
. Fig. 25.15).
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Step20
. Fig.25.15
End-to-side anastomosis
If possible, the esophago-colonic or pharyngo-colonic end-to-side anastomosis should be performed in a double-row suture technique.
In case of a dierent lumen diameter, interrupted stitches and a end-to-side anastomosis can
be performed close to the tenia coli (
. Fig.25.16
. Fig. 25.16).
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Chapter • Transhiatal Esophagohemigastrectomy
Step21
Side-to-side anastomosis
e alternative technique for anastomosis aer colonic interposition is a side-to-side coloesophageal anastomosis performed by a linear stapler (. Fig. 25.17).
. Fig.25.17
Section II • Esophagus, Stomach, and Duodenum
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Step22
Reconstruction of the intestine
Gastrointestinal continuity is achieved by cologastrostomy.
A colosigmoidoscopy completes the reconstruction. e mesenteric incisions have to be closed.
e operative site aer transposition of the colon and reconstruction is shown (. Fig. 25.18).
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. Fig.25.18
Standard Postoperative Investigations
See ▶
Chap. 24
Esophagectomy: Transhiatal Approach”.
Postoperative Complications
Early Postoperative Course
Pulmonary infections
-
Septic complications: subphrenic or intra-abdominal abscess; cervical wound infection
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Anastomotic leak
-
Necrosis of the colonic interposition
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Hydro or pneumothorax
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Herniation of bowel into the right pleural cavity
“Abdominothoracic Esophagohemigastrectomy” and also ▶
Chap. 11
-
“Subtotal
Chapter • Transhiatal Esophagohemigastrectomy
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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Diculty swallowing or a motility disorder
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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 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 surgi-
-
cal intervention, due to clinical symptomatic diculty with emptying of the colonic conduit
by elongation of the interposition. Surgical intervention is performed by shortening of the
graft.
To avoid herniation of bowel into the pleural cavity, the diaphragmatic hiatus has to be
-
closed.
Extended Gastrectomy
Asad Kutup, Jakob R. Izbicki
Clinical TNM staging and an evaluation according to the adenocarcinoma of the esophagogastric
junction (AEG) classication in TypeI (esophagus), Type II (cardia), and TypeIII (subcardia)
form the basis for an individualized surgical treatment of AEG. Endoscopic resection is only
appropriate for the infrequent mucosal carcinomas whereas the majority of the junctional carcinomas are treated by surgical resection. A TypeI carcinoma is removed by radical transthoracic
en-bloc esophagectomy with high intrathoracic esophagogastrostomy or by the transhiatal esophagectomy. In case of TypeII or III carcinomas, a transhiatal extended gastrectomy including distal
esophageal resection is performed with reconstruction by Roux-en-Y esophagojejunostomy in the
lower mediastinum. However, some advanced TypeII carcinomas, which cannot be resected R0 at
the esophagus, need a total esophago-(hemi-)gastrectomy with colon interposition. is surgical
strategy is justied by the topography of the lesion and the corresponding lymphatic drainage.
Neoadjuvant treatment should be considered in cT3 and cT4tumors.
Indications
Contraindications
Step1 to Step7
Step8
Indications and contraindications
AEG TypesII and III tumors (cT1sm1–cT3; cT4 if resectable)
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Aer incomplete endoscopic resection of cT1tumors
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Peritoneal carcinomatosis
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Child-Pugh C cirrhosis with severe portal hypertension
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Preoperative Investigation/Preparation for the Procedure
See ▶ Chaps. 21 and 23 “Total Gastrectomy” and “Transhiatal Esophagectomy.”
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Consider bowel preparation in case of colonic interposition.
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Procedure
z Access
Upper transverse incision with median extension or, alternatively, midline incision
See “Total Gastrectomy
Exposure of the esophagogastric junction
Aer lymphadenectomy of the celiac trunk, the lymphatic dissection is continued along the celiac trunk to the upper para-aortic region. Lymphatic tissue thus remains adherent en bloc with
the lesser curvature and is later resected en bloc with the specimen. e abdominal esophagus
is mobilized and caudal traction is applied with a so rubber tubing like a Penrose drain. For
better exposure of the esophageal hiatus and the para-aortic region, the diaphragmatic crura are
incised and the stumps are ligated. During this maneuver connective tissue between esophagus,
the diaphragmatic crura, and the abdominal aorta must be removed carefully. us the diaphrag-
▶ Chaps. 21 and 22.
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_26, © Springer-Verlag Berlin Heidelberg 2016
Section II • Esophagus, Stomach, and Duodenum
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Step8 (continued)
matic crura become exposed to the le and right side of the esophagus and both are resected en
bloc with the specimen. A wide and sharp transection of the phrenoesophageal ligament and the
gastrophrenic ligament at the esophagogastric angle of His is undertaken (
. Fig. 26.1).
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Step9
. Fig.26.1
Exposure of the distal esophagus
For a better exposure of the distal esophagus, the diaphragm is incised up to the inferior le
phrenic vein. Transection and suture ligation of the le phrenic inferior vein are performed. Incision of the diaphragm up to the central portion is done (. Fig. 26.2)
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23
. Fig.26.2
Chapter • Extended Gastrectomy
Step10
Mobilization of the distal esophagus
Insert Mikulicz retractors, which are pulled upward to the le and right. Dissection starts with
sharp dissection at the anterior esophageal surface to separate the diaphragm and pericardium
from the esophagus (
To the right and le, the pleural cavity is incised and the parietal pleura are removed en bloc
with the specimen. e esophagus is pulled caudally and the lateral esophageal ligaments consisting of branches of the vagal nerves, pulmonary ligaments, and esophageal branches are transected
carefully between clamps or clips. Some surgeons prefer to use an energy device to ligate these
connections. (
Mobilization of the region posterior to the esophagus including paraesophageal lymphatic
tissue from the aorta and paravertebral fascia up to the tracheal bifurcation is done sharply and
under vision (
. Fig. 26.3a).
. Fig. 26.3b).
. Fig. 26.3c).
. Fig.26.3