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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_832_Библиотеки_им_академика_М_И_Перельмана
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can be different globally and institutionally, but generally chemoradiotherapy is
recommended [9, 17]. Patients treated with neoadjuvant therapy are typically
restaged with a CT or PET-CT approximately 4weeks after completion of therapy
to assess treatment effect and to rule out distant metastatic disease that would preclude resection. Nutritional status should be assessed by history and laboratory data
(albumin, prealbumin) prior to treatment. If adequate caloric intake cannot be maintained, a feeding jejunostomy tube should be considered preoperatively (or prior to
neoadjuvant therapy) and surgery delayed until the patient has been nutritionally
optimized. Bronchoscopy is recommended for mid-esophageal squamous cell cancers, which are notorious for invasion into the airway (and therefore unresectable).
Diagnostic laparoscopy or thoracoscopy should be considered in cases where there
is a question of resectability. Patients with evidence of unresectable malignant disease or those who are unable to tolerate surgical resection should be referred for
denitive chemoradiation therapy.
M. Jureller et al.
4 Operative Approach
A variety of esophagectomy surgical techniques have been described over the last
century, all of which remain in use today. Each technique uses a different combination of approaches to the esophagus in order to accomplish the main steps of esophagectomy: esophageal and gastric mobilization, lymphadenectomy (in the case of
malignant disease), resection of the esophagus and proximal stomach, reestablishment of gastrointestinal continuity (reconstruction), and adjuvant procedures (i.e.
pyloric emptying procedure, feeding tube placement). The details of the most common techniques (i.e. Ivor Lewis, McKeown, Transhiatal, Sweet) as well as colon
interposition esophagectomy are reviewed later in this chapter, along with the
advantages and disadvantages of each. We will mostly review the minimally invasive aspects of the various techniques, as those have become mainstay in practice.
The open exposure techniques typically mimic the minimally invasive methods.
The operation can be separated into stages based on the approach (neck, chest, or
abdomen). The basic steps performed in each stage are similar, regardless of the
technique used.
5 Abdomen
The abdominal portion is required for any esophagectomy, regardless of technique,
and the basic steps are similar. These steps can be accomplished via an upper midline laparotomy, paramedian laparotomy (as part of a thoracoabdominal incision),
or by laparoscopy. First, the abdomen is explored to rule out metastatic disease with
careful attention paid to the liver, omentum, and peritoneum. Diagnostic laparoscopy may be performed rst to avoid an unnecessary laparotomy should distant
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Fig. 1 Division of the
gastrohepatic ligament (A
caudate lobe, B right crus,
C divided gastrohepatic
ligament, D esophageal
hiatus)
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metastatic disease be encountered. The left lobe of the liver is retracted to expose
the esophageal hiatus. The gastrohepatic ligament is opened to expose the right crus
(Fig.1), taking care to preserve a replaced left hepatic artery if present; an accessory
left hepatic artery may be divided. The phrenoesophageal ligament is opened and
the esophagus is mobilized circumferentially from the hiatus. The intrathoracic
esophagus is mobilized, sweeping all periesophageal tissue toward the esophagus
(Fig.2). Borders of this dissection include the pericardium anteriorly, the aorta posteriorly, and the right and left pleura laterally. The short gastric vessels are then
divided to mobilize the greater curve of the stomach. Care must be taken to identify
and preserve the right gastroepiploic arcade, which will be the sole blood supply of
the gastric conduit (Fig.3). The gastrocolic attachments are divided from left to
right beyond the pylorus, maintaining a distance of at least 1–2cm from the right
gastroepiploic vascular arcade. The stomach is retracted anteriorly and the posterior
gastric attachments are divided, avoiding injury to the pancreas and splenic artery.
The left gastric pedicle is then divided at its origin, making sure to mobilize all fatty
and lymphatic tissue toward the specimen before division (Fig.4). The right gastric
artery may be preserved. Lymphatic tissue is also dissected off the superior aspect
of the splenic artery and swept toward the specimen to obtain an adequate celiac
lymphadenectomy. After the stomach has been completely mobilized, the pylorus
should easily reach the right crus. If this is not the case, a Kocher maneuver is performed to gain additional mobilization/length. If desired, a gastric-emptying procedure is then performed (i.e. pyloromyotomy or pyloroplasty). Next, the gastric
conduit is fashioned. The staple line is typically started at the third branch of the
right gastric artery (Fig.5). A linear stapler with a vascular load is placed across the
lesser omentum, directed toward the lesser curve of the stomach, and deployed. The
gastric tube is then created by orienting the stapler parallel to the greater curve and
marching proximally with serially rings of the stapler, ending to the left of the
esophagus (Fig. 6). Width of the conduit is varies by surgeon preference. This
authoring group does not tubularize the stomach and does routinely perform a pyloroplasty. A feeding jejunostomy tube is then placed, if desired (Fig.7). Drains are
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M. Jureller et al.
Fig. 2 Esophageal
mobilization from the
abdomen. (a) demonstrates
dissection along the
pericardial plane anteriorly
(A right crus, B
pericardium, C distal
esophagus) and (b)
demonstrates dissection
along the aortic plane
posteriorly (D aortic plane,
E left crus)
a
b
Fig. 3 Right
gastroepiploic arcade
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241
Fig. 4 Division of the left
gastric pedicle. (a) (A left
gastric pedicle) (b) (B
divided left gastric pedicle,
C esophageal hiatus)
a
b
Fig. 5 Branches of the
right gastric artery along
the lesser curve of the
stomach
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Fig. 6 Creation of the
gastric conduit (A gastric
conduit, B specimen
including proximal
stomach and distal
esophagus)
M. Jureller et al.
Fig. 7 Laparoscopic
jejunostomy tube
placement. (a)
demonstrates a loop of
jejunum approximately
40cm distal to the
ligament of Treitz tacked
up to the abdominal wall.
A jejunostomy feeding
tube is passed into the
distal limb. (b)
demonstrates completion
of the jejunostomy tube
with an anti-torsion stitch
placed 3cm from the tube
entry site
a
b
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typically not needed after completing the abdominal stage. If a cervical anastomosis
is to be performed, the abdomen is left open and the neck dissection is begun. If an
intrathoracic anastomosis is chosen, the conduit it secured to the specimen for later
retrieval in the chest and the abdomen is closed.
6 Chest
A transthoracic approach is used for the Ivor Lewis, McKeown, and Minimally
Invasive Esophagectomy (MIE) techniques. The basic principles for safe dissection
are the same whether performed via thoracotomy, thoracoscopy or robotically.
Esophageal mobilization and creation of an intrathoracic anastomosis is typically
performed through the right chest. After the right lung has been isolated, the inferior
pulmonary ligament is divided and the lung is retracted away. Esophageal mobilization is begun by opening the mediastinal pleura at the junction of the pleura and the
lung, anterior to the esophagus, from the diaphragm proximally to the azygous vein.
Periesophageal tissue is then swept off the avascular plane along the pericardium
toward the esophagus (Fig.8). Dissection is carried superiorly from the inferior
pulmonary vein, keeping dissection on the posterior aspect of the pericardium, until
the bronchus intermedius is encountered. The airway is then traced back to the right
main stem bronchus and subcarinal lymph node packet, which is harvested en bloc.
The left main stem bronchus should then come into view. Care must be taken to
avoid excess use of energy in this area to minimize the risk of thermal injury to the
airway; therefore bronchial arterial branches should be clipped and divided rather
than cauterized. The vagus nerve is encountered as dissection is carried proximally,
which is divided close the esophagus to avoid traction injury to the right recurrent
laryngeal nerve (RLN). The azygous vein is divided as it crosses over the esophagus
to empty into the superior vena cava (Fig. 9) to facilitate mobilization of the
Fig. 8 Mobilization of the
intrathoracic esophagus
along the pericardial plane
(A esophagus, B
periesophageal fat and
lymph nodes, C
pericardium)
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Fig. 9 Division of the
azygous vein as it arches
over the esophagus (A
esophagus, B azygous vein,
C lung)
Fig. 10 Mobilization of
the intrathoracic esophagus
up to the thoracic inlet (A
esophagus, B divided
azygous vein, C left main
stem bronchus, D right
main stem bronchus, E
lung)
M. Jureller et al.
esophagus up to the thoracic inlet (Fig.10). The mediastinal pleura overlying the
posterior aspect of the esophagus is then opened from diaphragm to thoracic inlet.
Posterior mobilization is carried out until the anterior/medial plane of dissection is
met. Lymphatic and aortoesophageal branches along the posterior aspect of the
esophagus should be clipped and divided. The posterior dissection should stay close
to the esophagus to avoid injury to the main thoracic duct that lies within the fat
posteriorly. Once the esophagus has been circumferentially mobilized, the conduit
is retrieved from the abdomen and brought up into the chest. The esophagus is then
transected proximal to the tumor to achieve appropriate margins. Intraoperative
endoscopy may be performed to conrm the appropriate point of transection. The
specimen is then removed and margins are checked by frozen section (Fig.11). The
esophagogastric intrathoracic anastomosis is then performed (discussed below).
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Fig. 11 Esophagogastrectomy specimen opened on
the back table to check
gross margins prior to
being sent for frozen
section (A esophageal
mucosa, B tumor, C gastric
mucosa)
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Drains and/or chest tubes are placed. If a cervical anastomosis is planned, the
esophagus is not transected and only mobilization of the esophagus is carried out.
The patient is then repositioned to perform the abdominal and cervical stages of the
procedure.
7 Neck
A cervical approach is used for the Transhiatal, Sweet, and McKeown techniques.
The MIE may also be performed with a cervical anastomosis. The left neck is preferred because of the more reliable, vertical course of the left RLN and because the
esophagus is slightly deviated to the left in the neck. Injury to the RLN occurs primarily by excessive traction or thermal injury from excessive electrocautery use. It
is this authoring group’s preference to use this technique. A 5–6cm incision is made
along the medial border of sternocleidomastoid muscle (SCM). The platysma is rst
divided and aps are raised, followed by mobilization of the SCM laterally. Strap
muscles are retracted medially. The anterior belly of the omohyoid muscle is typically divided. Dissection is continued medial to the internal jugular and carotid
artery, retracting the vessels laterally with the SCM.The middle thyroid vein and
inferior thyroid artery may be divided if needed for exposure. The thyroid and trachea are retracted medially and dissection is continued posteriorly down to the
spine. A nasogastric tube helps with identication of the cervical esophagus as it is
mobilized from the prevertebral fascia with blunt nger dissection until the esophagus can be hooked and secured with a Penrose drain (Fig.12). The anterior aspect
of the esophagus is carefully dissected away from the trachea, keeping dissection
directly on the esophagus to avoid injury to the RLN in the tracheoesophageal
groove. Circumferential mobilization of the esophagus is carried distally into the
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Fig. 12 Left neck incision
demonstrating exposure of
the proximal esophagus
M. Jureller et al.
thoracic inlet until the distal plane of dissection performed from the chest or abdomen is met. The esophagus can then be transected and the specimen removed
through the abdominal or neck wound. Once the conduit has been passed up from
below, the anastomosis can then be created (discussed below). The neck is closed in
layers and a closed suction drain is placed next to the anastomosis.
8 Esophagogastric Anastomosis
Numerous techniques have been described for creation of the esophagogastric anastomosis, including hand-sewn, stapled, and combined techniques. If the proximal
extent of disease is above 25cm, a cervical anastomosis is recommended to assure
adequate margins. Either a cervical or intrathoracic anastomosis can be performed
for disease distal to 25cm. The gastric conduit must pull up easily into the neck or
chest to reach the transected esophagus without tension. However, pulling up excessive conduit can result in a redundant conduit that empties poorly.
9 Hand-sewn Anastomosis
A hand-sewn technique may be used for either a cervical or intrathoracic anastomosis. Most favor a two-layered anastomosis when the hand-sewn technique is used.
The tip of the gastric conduit is opened anteriorly approximately 2cm from the
stapled edge. Full-thickness corner stitches are placed at 3 and 9 o’clock to approximate the transected esophagus and gastrotomy. The anastomosis is then started with
interrupted 3-0 or 4-0 absorbable suture, taking seromuscular bites on the stomach
side and muscularis propria (longitudinal and circular layers) on the esophageal side
to create the outer layer back row. The inner layer is then constructed by placing
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interrupted simple sutures around the entire circumference with full-thickness bites
on the stomach side and only mucosa on the esophageal side. The anterior, outer
layer is then performed to complete the anastomosis. The anastomosis may also be
done with a continuous, running technique.
10 Linear Stapled Anastomosis
A side-to-side linear-stapled technique may also be used to create either a cervical
or intrathoracic anastomosis. The conduit must have 4–5cm of overlap with the
proximal esophagus. A gastrotomy is made on the anterior aspect of the conduit,
approximately 5cm from the tip. The esophagus is transected at either an oblique or
right angle (the oblique angulature makes an intrathoracic anastomosis more ergonomic). The esophagus is overlapped with the gastric conduit (esophagus anterior to
the conduit). Stay sutures are placed at the anterior corner of the esophagus and
another from the posterior corner of the esophagus to the superior corner of the
gastrotomy. A 3cm linear stapler is positioned with one jaw in the esophagus and
the other in the conduit with the tip of the stapler directed cephalad, then red. The
remaining open portion is closed with full-thickness sutures.
11 EEA/End-to-Side Stapled Anastomosis
An end-to-side stapled technique may be used for creation of an intrathoracic anastomosis [18]. The esophagus is divided at the desired level, typically superior to the
divided azygous vein, with a linear stapler (Fig.13). Typically used is a 25-mm
Fig. 13 Division of the
proximal esophagus above
the azygous vein to
complete the esophageal
resection
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