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Chapter • Cervical Esophagectomy
Step 4
Vascular Anastomoses
e venous and arterial anastomoses are now performed. First the vein is anastomosed. Preferably
a conuens of the major mesenteric vein with a smaller contributing vein is used on the side of
the gra and the internal jugular vein on the other side. e incision in the internal jugular vein
should be at least 3 to 4 mm long. e anastomosis is performed under a magnication of at least
× 4, preferably with a microscope. Running sutures with non-resorbable, monolament material,
8-0 or 9-0, are used. Before closure, the anastomosis is rinsed with heparinized saline.
e vein should be anastomosed before the artery only if an expedient progression of the
operation is evident. Should delays occur (e. g., diculties during the preparation or unforeseen
anesthesiological circumstances in conjunction with unstable cardiovascular parameters), the
artery should be anastomosed prior to the vein, allowing a perfusion of the intestinal ap with
nutrient-rich blood until peristalsis returns. If the nature of the delay prevents the anastomoses,
the harvested intestinal ap should be stored in moist dressings. If desired, the metabolic rate
of the temporary non-perfused ap can be decreased by cooling the ap. Routinely, there is no
necessity for the use of organ preservation solutions.
e same technique is used for the artery. e anastomosis can be performed on the superior
thyroid artery, the thyrocervical trunk, or the common carotid artery directly. Rarely other cervical
branches like the lingual or facial artery are used.
It is extremely important to avoid kinking and compression especially on the vein during
placement of the gra into the neck, and during closure of the neck.
If the vascular reconstruction fails, either a second loop can be harvested or a gastric tube can
be fashioned (
. Fig. 9.4).
. Fig.9.4
Section II • Esophagus, Stomach, and Duodenum
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3
4
5
6
7
8
9
10
Step 5
Esophagojejunal Anastomoses
Aer reperfusion an adequate ow is conrmed. en the lower and nally the upper esophagojejunal anastomoses are performed end-to-end or end-to-side aer shortening the gra to
an adequate length. ese anastomoses are performed using 3-0 or 4-0 absorbable sutures in a
single layer. It is important to grasp the entire thickness of the pharynx or esophagus, whereas the
stitches in the jejunum are extramucosal. If the anatomy is demanding (e. g., a very low intrathoracic anastomosis), the suture can be performed in an interrupted fashion. e nasogastric tube
is then placed through the gra into the stomach.
It is important to implant the gra in an isoperistaltic fashion to facilitate swallowing. Even
under optimal conditions, it can take weeks before the gra gains normal transplant function
(. Fig. 9.5).
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. Fig.9.5
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Chapter • Cervical Esophagectomy
Step 6
Final Aspects
e neck is drained suciently from both sides with at least one so easy-ow drain on each side.
e neck is closed by loose interrupted subcutaneous and skin stitches.
For the postoperative follow-up, it is advantageous to ensure that parts of the jejunal gra are
clinically visible. is can be achieved either by placing a few sutures in a manner such as to allow
a division of the covering tissue or by conguring the ap so as to leave parts of the ap uncovered,
serving as a “monitor” during the postoperative surveillance. Verication of the blood ow can be
performed using Doppler ultrasound. As an adjunct, various tissue probes are available, facilitating
the measurement of the oxygen partial pressure.
Standard Postoperative Investigations
Anticoagulation (PTT 60–70s)
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Controlled systolic arterial blood pressure
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Monitoring of microcirculation and improved rheology
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Daily Doppler ultrasound
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Regular inspection of the ap on postoperative day1 every hour
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Postoperative Complications
Venous thrombosis (reoperate immediately)
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Arterial thrombosis (reoperate immediately)
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Necrosis of the transplant (excise and drain by pharyngostomy or reconstruct with gastric
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tube or colon)
Salivary leak (drain adequately)
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Lymphatic leak
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Recurrent laryngeal nerve injury
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Esophageal stenosis (dilate by endoscopy) (long term)
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Poor swallowing function (long term)
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Major bleeding
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Tricks of the Senior Surgeon
Be aggressive to reoperate if vascular status is questionable.
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Avoid kinking of the vein by keeping it short.
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Keep central venous pressure high and perform adequate heparinization to avoid vascular
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problems.
Leave the neck open if the jejunum is congested after reperfusion but cover the vessels with
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tissue.
If the exposure for vascular reconstruction becomes dicult, perform a hemithyroidectomy.
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Occasionally a partial sternotomy may enable a safer inferior esophageal anastomosis.
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Lymphatic leak can be managed conservatively; only rarely the lymphatic duct must be
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ligated.
Exposure can be facilitated by division of the medial head of the sternocleidomastoid muscle.
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Previous surgery with resection of the internal jugular vein necessitates dissection down to
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the subclavian vein.
Early tracheotomy.
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Avoid compression bandages, tapes around the neck or tracheal strips with extrinsic com-
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pression of the vascular pedicle.
Left Thoracoabdominal Approach for Carcinoma
of the Lower Esophagus and Gastric Cardia
Shoji Natsugoe, Takashi Aikou
Introduction
Tumors located aborally to the carina, i. e., Barrett’s carcinoma or carcinoma of the esophagogastric
junction, may be approached by a le-sided thoracotomy instead of the more usual right-sided
access combined with an abdominal approach. e extent of lymphadenectomy is limited to the
middle and lower mediastinum.
Indications and Contraindications
Indications
Contraindications
Tumors of the infracarinal esophagus
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Tumors of the esophagogastric junction
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See
▶ Chap. 11 on “Subtotal Esophagectomy: Transhiatal Approach”
High-risk patients
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Preoperative Investigation/Preparation for the Procedure
See chapter on “Subtotal Esophagectomy: Transhiatal Approach”
Procedure
z Access
Spiral positioning of the patient with 45°elevation of the le thorax
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Rotating the operating table for the thoracic part/abdominal part
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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_10, © Springer-Verlag Berlin Heidelberg 2016
Section II • Esophagus, Stomach, and Duodenum
1
2
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5
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Step 1
Thoracotomy
e skin incision is made obliquely from the epigastrium toward the sixth or seventh intercostal
space, and a good exposure of the mediastinum or abdomen can be achieved by rotating the operating table. Aer 1 cm of costal cartilage is resected, the le side of the chest is opened. Distant
and peritoneal metastases should be excluded prior to thoracotomy (
. Fig. 10.1).
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. Fig.10.1
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Chapter • Left Thoracoabdominal Approach for Carcinoma of the Lower Esophagus and Gastric Cardia
Step 2
Incision of diaphragm and mobilization of the colon
Para-aortic lymphadenectomy is performed by delivering the splenic exure into the chest through
a circumferential incision in the periphery of the diaphragm. e descending colon is then mobilized down the le paracolic gutter to the base of the sigmoid colon mesentery. Aer mobilization
of the le kidney from the retroperitoneum as well as pancreas and spleen, the le renal vein is
identied (
. Fig. 10.2).
. Fig.10.2
Section II • Esophagus, Stomach, and Duodenum
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3
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Step 3
Para-aortic lymph node removal
e para-aortic lymph nodes in the le lateral region are then dissected, and the right lateral paraaortic lymph nodes are removed aer performing an extended Kocher maneuver (. Fig. 10.3).
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Step 4
. Fig.10.3
Lymph node removal of the upper abdomen
Lymph nodes of the hepatoduodenal ligament and around the common hepatic artery, le gastric
artery and celiac trunk are dissected (. Fig. 10.4).
Mobilization of the stomach and transection of the duodenum follows (see chapter “Total
Gastrectomy with Conventional Lymphadenectomy”)
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23
. Fig.10.4
Chapter • Left Thoracoabdominal Approach for Carcinoma of the Lower Esophagus and Gastric Cardia
Step 5
Lower mediastinal lymph node removal
Regarding the le intrathoracic approach, the le pulmonary ligament is divided and the mediastinal pleura is opened. e pleura covering the lower thoracic esophagus is incised, allowing the
clearance of loose connective tissue together with the lower thoracic paraesophageal, supradiaphragmatic, posterior mediastinal and intradiaphragmatic lymph nodes (
. Fig. 10.5).
. Fig.10.5
Section II • Esophagus, Stomach, and Duodenum
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3
4
5
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7
8
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Step 6
Reconstruction
ere are several methods of reconstruction according to the tumor location and extension. RouxY reconstruction by using an EEA stapler introduced through the end of the Roux limb (see
▶ Chap. 13, . Fig. 13.5) or a hand sewn end to side anastomosis, as shown here, is an option for
performing the esophago-jejunostomy (
See
▶ Chap. 11 on “Subtotal Esophagectomy: Transhiatal Approach” for standard postoperative
investigations and complications.
. Fig. 10.6).
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. Fig.10.6
Chapter • Left Thoracoabdominal Approach for Carcinoma of the Lower Esophagus and Gastric Cardia
Tricks of the Senior Surgeon
Kinking of the Roux limb: this is a rare but dangerous complication, due to clinical symptoms
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of diculty passage due to relative obstruction of injested content through the Roux limb
secondary to elongation, which requires surgical intervention and is performed by shortening of the Roux limb.
If the trachea is injured, use direct suture and pericardial ap.
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