Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1050_Библиотеки_им_академика_М_И_Перельмана

■ THEismostcommonlyusedintreatmentofesophagealcancer.Inparticular, adenocarcinomasoflowerthirdoftheesophagusandSiewerttypesIandII GEjunctionadenocarcinoma(FIG1;Table1)areoptimallysuitedforthis approach.

■ Squamouscellcarcinomas(SCCs)ofthelowerthirdoftheesophagusmayalso beapproachedviaTHE,whereastumorsofthemiddleandupperthirdofthe esophagususuallyrequiretransthoracicesophagectomy(TTE)toallowfor directvisualizationofthedissectionoftheinvolvedesophagus.

■ Allpatientsshouldundergoacomprehensivemedicalhistorywithemphasisnot onlyonclinicalhistorypertinenttotheprimaryindicationforconsiderationof THEbutalsothepertinentcomorbidconditionsthatwouldinfluence treatmentplanning.Includedinthishistoryisacomprehensivepastsurgical history.Priorfundoplicationwillmakedissectionoftheesophagealhiatus moredifficult.Patientswithapriorhistoryofgastricresection,forexample, maynotbecandidatesforuseofthestomachasaconduitforreconstruction becauseofinadequatelengthorbloodsupply.Finally,ifthecolonistobe consideredforuseforreconstruction,theinfluenceofpriorcolectomyon anatomyandbloodsupplyshouldbeverycarefullyconsidered.

■ InpatientswithadenocarcinomaoftheesophagusandGEjunction,ahistoryof GErefluxdiseaseshouldbeelicitedaswellasacarefulhistoryofprior endoscopicandradiographicevaluations.InpatientswithSCC,apriorand currenthistoryoftobaccoandalcoholuseshouldbeelicited.

■ Acomprehensivephysicalexaminationshouldbeperformedwithspecial attentiontothecervicalandsupraclavicularareasforenlargedlymphnodes, chestexamforpossibleeffusions,andabdominalexamforpalpablemasses andperiumbilicallymphnodes(SisterMaryJosephnodule).

■ Allpatientspresentingwithdysphagiashouldundergouppergastrointestinal endoscopyandbiopsywiththegoalofmakingadiagnosisandlocalizingthe

■ Onceadiagnosisofcancerismade,acomputedtomography(CT)ofthechest andabdomenwithoralandintravenouscontrastisdone.

■ Tumorlocation,locoregionalinvolvementorinvasion,regionaland extraregionallymphnodeinvolvement,andmetastaticdiseaseshouldbe evaluatedandrecorded.

■ InpatientswhomastandardCTofthechestandabdomenisunremarkable,a positronemissiontomography–computedtomography(PET-CT)shouldbe performedagaintoconfirmprimarytumorlocationandextent,evaluate regionalandextraregionalnodalinvolvement,andexcludeoccultmetastases.

■ Inpatientswithoutmetastaticdisease(stage4),anendoscopicultrasoundisdone todocumentdepthofinvasionofthetumor(Tstage)andevaluatemediastinal andperigastric/celiaclymphnodeinvolvement(Nstage).Biopsyof suspiciouslymphnodesisindicated.

■ AllpatientsshouldthenbeassignedapretreatmentTNMstagetoguide treatmentplanningdiscussions,preferablyunderthedirectionofa multidisciplinarytreatmentplanningconferenceattendedbysurgical, medical,andradiationoncology.1TheNationalComprehensiveCancer Network(NCCN)definesoptimaltreatmentplanningalgorithms.

■ AsTHEisatechnicallycomplexoperationwithahighdegreeofassociated morbidityandmortality,thisoperationshouldbedonebysurgicalteams experiencedintheperioperativemanagementofthesepatients.

■ Patientsshouldundergopreoperativeevaluationbythesurgicalandanesthesia teamforpurposesofmitigatingperioperativerisksintheareaofcardiac, pulmonary,andrenalcomorbidities.

■ Adiscussionshouldbedonewiththepatientastohowpainwillbemeasured

■ Perioperativeantibioticsshouldbeadministeredwithin60minutesofskin incisionandredosedinatimelymannerduringtheoperation.Cefazolin, dosedtoweightspecificationsandredosedevery4hours,isrecommended. Cefoxitincanalsobeusedandredosedevery3hours.Forpatientswitha beta-lactamallergy,clindamycinorvancomycinandaminoglycosideor aztreonamorfluoroquinoloneareused.Allprophylacticantibioticsarenot necessarybeyondsurgerycompletion.

■ Appropriatedeepvenousthrombosisprophylaxisisrequired.Intermittent sequentialcompressiondevicesshouldbeplacedpriortoinductionof anesthesiaandcontinuedaftersurgery.Chemicalprophylaxisshouldbe institutedpostoperativelyonceclinicallyindicated.

■ Urinarycathetersareplacedfollowinginductionofanesthesiaanddiscontinued within24hoursofsurgery.

■ PatientsundergoingTHEarepositionedsupineontheoperatingroomtable (FIG4).

■ Botharmsaretuckedandpressurepointspaddedtopreventinjuryduringthe courseoftheoperation.

■ Atowelormediumgelrollisplacedbehindtheshoulderstoallowformild extensionoftheneck.Thisisofparticularimportanceinobese,short-necked patients.