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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_901_Библиотеки_им_академика_М_И_Перельмана
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138
Esophageal branches of
Phrenoesophageal
Intraabdominal
Phrenoesophageal
Angel of His
Anatomy
Anatomy
Blood supply
Cervical esophagus➔inferior thyroid artery
Thoracic esophagus➔branches of the aorta
Abdominal esophagus➔branches of the left
gastric and phrenic arteries
Venous drainage➔parallels arterial supply
Esophagus
T. Zohourian et al.
inferior thyroid arteries
Esophageal branch
of bronchial artery
Lymphatic drainage of the esophagus is
longitudinal
Proximal one-third➔drain into deep cervical
lymph nodes
Middle third of esophagus➔mediastinal
para-aortic nodes
Distal third of esophagus➔drains to the celiac
lymph nodes
The esophageal wall consists of four layers:
mucosa➔submucosa➔muscularis
propria➔adventitia
There is no serosa in the esophagus➔more prone
to perforation and metastatic spread
Ascending
branches of
left gastric artery
Left
gastric
artery
Aortic
esophageal
arteries
Components of the lower esophageal sphincter:
Intrinsic muscles of the distal esophagus
Flap valve enforced by the angle of his
Crura of the diaphragm
Phrenoesophageal ligament (Laimer membrane)
An intra-abdominal lower esophagus length of at
least 3cm
fat pad
ligament
esophagus
h
Th
5 Esophagus
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Anatomy
Physiologic areas of narrowing of the esophagus:
Include the
139
1. Cervical esophagus (8cm from incisors)
2.Thoracic esophagus at aortic arch (20cm from
incisors)
3. Gastroesophageal junction (40cm from
esophagus)
Esophageal Neoplasm Benign
Benign esophageal neoplasms
Epidemiology
Only 1% of esophageal masses are benign (60% of benign esophageal lesions➔leiomyomas,
20%➔cysts)
Oropharynx
yroid cartilage
Cricopharyngeal
constriction
Trachea
Aortic
constriction
Lower esophageal
sphincter
Cricoid cartilage
Aorta
Left main bronchus
Diaphragm
Stomac
Most common benign esophageal tumor (~75%)
Prevalence: Men>women
Leiomyomas
presentation
Round, rubbery, submucosal lesion (Muscularis propria) in the lower 2/3 of esophagus
Symptoms: Asymptomatic➔found incidentally on EGD and barium swallow performed for other
concerns; dysphagia
Leiomyomas
Esophagogram, EUS, or CT (to rule out cancer)
diagnosis
DO NOT BIOPSY➔Increases likelihood of mucosal perforation during enucleation
Leiomyomas
management
Leiomyoma Preferred approach
<5cm Endoscopic approach (enucleation)
>5cm Video-assisted thoracoscopy, robotic assisted thoracoscopy or laparoscopy
140
T. Zohourian et al.
Esophageal Neoplasm Malignant
Esophageal cancer
Occurs most commonly during the sixth and seventh decades of life
In the USA, adenocarcinoma predominates over squamous cell carcinoma
Prevalence
Squamous cell carcinoma arises mostly in the upper and middle third of the esophagus
Adenocarcinoma arises mostly at the distal esophagus and esophagogastric junction
Risk factors Smoking, alcohol, gastrointestinal reux disease, Barrett esophagus, and obesity,
nitrosamines, ingestion of hot or caustic liquids
Presentation Dysphagia, weight loss, cough, hemoptysis
Diagnosis requires a histologic examination of tumor tissue➔endoscopic biopsy
For locoregional staging➔endoscopic ultrasound (EUS) is the preferred method
Diagnosis
Staging
CT combined with PET is used for evaluation of hypermetabolic areas to rule out
locoregional disease
Evaluation for distant metastases: Contrast-enhanced CT of the neck, chest, and abdomen;
whole-body PET/CT±diagnostic laparoscopy
TNM staging for esophageal cancer
T N M
Tis: High-grade dysplasia N0: No lymph node
metastasis
T1: Tumor invades the lamina
propria, muscularis mucosae, or
submucosa
T2: Tumor invades the muscularis
propria
T3: Tumor invades adventitia N3: Metastasis in 6 or
T4: Tumor invades adjacent structures
N1: Metastasis in 1 or 2
regional lymph nodes
N2: Metastasis in 3 to 6
regional lymph nodes
more regional lymph
nodes
M0: No distant
metastasis
M1: Distant metastasis
5 Esophagus
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Esophageal cancer
141
Stage TNM Management
I T1N0M0 Surgery
IIA T2N0M0 or
Management
Surveillance after
esophagectomy
IIB T1N1M0 or
III T3N1M0 or
I VA Any T, Any N, M1a Chemoradiotherapy
IVB Any T, Any N, M1b Palliative treatment
Case scenarios Management
High-grade dysplasia Endoscopic treatment (radiofrequency ablation or
T1a tumor (disease limited to
mucosa or submucosa)
Routine CT imaging for surveillance is recommended for the rst 2 to 3years and then
annually until year 5
Esophagogastroduodenoscopy is performed if symptoms develop
Research
Reference Findings
Rogers MP, DeSantis AJ, DuCoin CG.Oligometastatic
Adenocarcinoma of the Esophagus: Current
Understanding, Diagnosis, and Therapeutic Strategies.
Cancers (Basel). 2021;13(17):4352. https://doi.
org/10.3390/cancers13174352
Surgery
T3N0M0
Neoadjuvant
T2N1M0
T4, any N, M0
endoscopic mucosal resection)
Endoscopic mucosal resection
The depth of tumor invasion and extent of nodal involvement
are the best predictor of long-term survival and an important
guide for therapeutic approaches
therapy±surgery
Neoadjuvant
therapy±surgery
Saddoughi SA, Reinersman JM, Zhukov YO, etal.
Survival after surgical resection of stage IV
esophageal cancer. Ann Thorac Surg.
2017;103(1):261–6. https://doi.org/10.1016/j.
athoracsur.2016.06.070
van Hagen P, Hulshof JJB, van Lanschot EW, etal.
Preoperative chemoradiotherapy for esophageal or
junctional cancer. N Engl J Med. 2012;366:2074–84
Esophagectomy is not recommended for Stage IV esophageal
cancer due to poor 5-year survival
The Dutch chemotherapy and radiation in esophageal surgery
study (CROSS) trial, which compared neoadjuvant treatment
and surgery to surgery alone. They found out that neoadjuvant
chemoradiotherapy followed by surgical resection in
4–6weeks is superior to surgery alone for overall 5-year
survival in T3 esophageal cancer
142
Esophagectomy
Esophagectomy
T. Zohourian et al.
Transthoracic (Ivor
Approach
Incisions
Indications
Anastomosis Anastomosis resides in chest Anastomosis resides in neck Anastomosis resides in neck
Lewis)
Laparotomy/laparoscopy
Right thoracotomy/
thoracoscopy
Tumors in the middle and distal
third of the esophagus
Tumors in the gastroesophageal
junction
Transhiatal
esophagectomy
Left neck
Laparotomy/laparoscopy
Tumors in the middle and distal
third of the esophagus
Tumors in the gastroesophageal
junction
Three-incision
technique (McKeown)
Right thoracotomy/
thoracoscopy
Left neck
Laparotomy/laparoscopy
Tumors above the
gastroesophageal junction
extending up to the level of
the clavicle
Key steps
Blood supply
to gastric
conduit
Abdominal phase:
• Hiatal and lymph node
dissection
• Gastric mobilization: Stomach
is fully mobilized from all
attachments
• Creation of gastric conduit:
Stomach is tubularized to
create a gastric conduit
• Pyloric drainage procedure
• Jejunostomy feeding tube
Thoracic phase:
• Esophageal mobilization
• Azygous vein division
• Esophagogastric specimen is
stapled and removed
• Construction of
esophagogastric anastomosis
Right gastroepiploic artery Right gastroepiploic artery Right gastroepiploic artery
Abdominal phase:
• Hiatal and lymph node
dissection
• Gastric mobilization: Stomach
is fully mobilized from all
attachments
• Creation of gastric conduit:
Stomach is tubularized to
create a gastric conduit
• Pyloric drainage procedure
• Jejunostomy feeding tube
• Esophageal dissection is
continued through the hiatus
Neck phase:
• Left neck incision
• Esophagus is dissected free
and then divided
• Conduit is pulled up to the
neck
• Construction of
esophagogastric anastomosis
Thoracoscopic phase:
Esophageal mobilization from
the thoracic inlet proximally
and to the hiatus distally
Abdominal phase:
• Hiatal and lymph node
dissection
• Gastric mobilization:
Stomach is fully mobilized
from all attachments
• Creation of gastric conduit:
Stomach is tubularized to
create a gastric conduit
• Pyloric drainage procedure
Jejunostomy feeding tube
Neck phase:
• Left neck incision
• Gastric conduit is brought up
to the neck
• Construction of the
anastomosis
5 Esophagus
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Esophagectomy
143
Transthoracic (Ivor
Approach
Advantages
Disadvantages
Lewis)
Low rate of anastomotic leak
(3–4%)
Lower rate of recurrent
laryngeal nerve injury
Leaks are difcult to control
and have a higher risk of sepsis
and death
Signicant gastric reux
Require single-lung ventilation
Research
Reference Findings
Levy RM, Trivedi D, Luketich
JD.Minimally invasive esophagectomy. Surg
Clin North Am 2012; 92:1265
Transhiatal
esophagectomy
Reduces respiratory
complications and leak rates
from the cervical neck
anastomosis
Extensive lymphadenectomy is
not possible
Higher rate of postoperative
anastomotic strictures
Risk of injury to the great
vessels due to blind transhiatal
dissection
Risk of injury to the
membranous wall of trachea
Cervical anastomosis is associated with a greater risk of anastomotic
leak, stricture, recurrent laryngeal nerve injury, and swallowing
dysfunction
Three-incision
technique (McKeown)
Limited by the inability to
achieve a radical resection
Intrathoracic anastomosis is associated with more cardiopulmonary
complications and direr consequences when the anastomosis leaks
Hagens ERC, van Berge Henegouwen MI,
Cuesta MA, Gisbertz SS.The extent of
lymphadenectomy in esophageal resection
for cancer should be standardized. J Thorac
Dis. 2017;9(suppl 8):S713–23
Orringer MB.Transhiatal esophagectomy:
how I teach it. Ann Thorac Surg.
2016;102(5):1432–37
The extent of lymphadenectomy for esophageal cancer is still
controversial
Transhiatal esophagectomy allows for abdominal lymphadenectomy
but a subcarinal, high paraesophageal, and paratracheal lymph node
dissection is not possible
Ivor Lewis esophagectomy allows for a 2-eld lymphadenectomy
Three-incision approach allows for 3-eld lymphadenectomy
The advantages of a transhiatal esophagectomy: Avoidance of a
thoracotomy and a cervical esophageal anastomosis, where a
postoperative leak would cause an external salivary stula rather than
mediastinitis
Intraoperative Case scenario and their management
Case scenarios Management
Liver lesion found intraoperative for a patient
undergoing esophagectomy for esophageal cancer
Send a frozen biopsy of the lesion before doing
esophagectomy➔if the lesion is positive for
metastasis➔abort esophagectomy
144
Intraoperative Case scenario and their management
Case scenarios Management
T. Zohourian et al.
Right gastroepiploic artery is found to be occluded
while attempting to do an Ivor Lewis procedure
Use another conduit than the stomach to replace
esophagus (colon or jejunum)
Complications after esophagectomy and their management
Complications Characteristics Management
Hypovolemia in patient
with gastric conduit
Atrial brillation Common postoperative complication
Graft ischemia Rare complication Usually prevented by preservation of the
Chylothorax Triglyceride >110mg/dL
Hypotension can lead to gastric tip necrosis
in the conduit
Self-limited
May indicate a leak in the mediastinum
Higher drainage (>800cc in 24h) is
associated with lower rates of resolution by
dietary means alone
Volume resuscitation with uids
If needed vasopressors (gastric conduit
perfusion may be compromised)
Judicious use of uid may aid in
preventing this complication
right gastric and right gastroepiploic
arteries
Nonoperative management (NPO,
TPN)+drainage
Ligation of the thoracic duct and
pleurodesis or radiographic embolization
with a lymphangiogram
Anastomotic leak after
Ivor Lewis
esophagectomy
Anastomotic leak after
transhiatal
esophagectomy
Tachycardia or tachyarrhythmias
Diagnose with CT with oral contrast
Tachycardia or tachyarrhythmias
Diagnose with CT with oral contrast
Contained leak➔broad-spectrum
antibiotics, nutritional supplementation,
and close observation
Uncontained leak➔resection of conduit
and cervical esophagostomy
Broad-spectrum antibiotics, nutritional
supplementation, and close observation
Open the cervical incision and drain it
5 Esophagus
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Hiatal Hernia
Barium esophagogram
Case Characteristics or landmarks Radiology
Gastroesophageal junction: Where gastric folds
terminate
Hiatus: “Pinched” appearance from the gastric folds
Normal barium
esophagogram
traversing through the hiatus
Does not always correlate with diaphragmatic shadow
Distance between GEJ & Hiatus <3cm
AP double-contrast esophagram static
image with oral barium contrast
demonstrates a normal esophagus (e)
and gastroesophageal junction(arrow)
leading into the stomach fundus (s)
145
Paraesophageal
hiatal hernia
Gastric fundus herniates superiorly with a normally
positioned GEJ
AP upper GI series delayed radiograph
demonstrates the stomach fundus and
body(s) above the diaphragm, with a
normally positioned GE junction
(arrow)
146
Barium esophagogram
Case Characteristics or landmarks Radiology
T. Zohourian et al.
Sliding hiatal
hernia
Hiatal hernia
Characteristics
Most common
GEJ migrates superiorly through the hiatus
Right anterior oblique upper GI
static image with oral barium contrast
demonstrates a sliding
hiatal hernia. Note the gastric
mucosa(arrow) superior to the right
hemi-diaphragm (arrowhead). Note the
esophagus (e) and stomach(s)
Protrusion of stomach through the esophageal hiatus and into the thorax
Dened by size >2cm between the gastroesophageal junction and the diaphragmatic hiatus
(herniation <2cm is considered physiological)
Presentation
Asymptomatic
Gastrointestinal symptoms: Dysphagia, regurgitation, early satiety, vomiting, gastroesophageal
reux refractory to medical management, gastrointestinal bleeding (Cameron ulcers)
Respiratory symptoms: Shortness of breath
Borchardt triad (severe epigastric pain, inability to vomit, and inability to pass a nasogastric
tube)➔concern for acute gastric volvulus
5 Esophagus
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Hiatal hernia
147
Paraesophageal hiatal hernia is diagnosed with barium esophagogram and EGD
In addition to that, patients will require manometry before any operative intervention
Diagnosis
Diagnostic
modality
EGD
Barium
esophagogram
Characteristics
Retroex the scope to check if the
diaphragmatic crura are appropriately
tight around the esophagus
Variation in Z-line position
Gastroesophageal junction>2cm
above diaphragmatic indentation
AP upper GI series delayed radiograph
demonstrates the stomach fundus and
body(s) above the diaphragm, with a
normally positioned GE junction
(arrow)
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