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Ростовский Государственный Медицинский Университет

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Книга_1050_Библиотеки_им_академика_М_И_Перельмана

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■ Lengthoftheconduitisinspectedbydeliveringtheconduitoverthepatient’s torso(FIG15).Theapexshouldreachtothesternalnotchtobeofsufficient lengthtoreachintothecervicalincisiononcebroughtthrutheesophageal bed.

■ Theconduitshouldbeinspectedforviability.Iftheviabilityisinquestion, removalofsomeoftheapexofthestomachmayresultininsufficientlength forcingconversiontoatransthoracicapproachwheregastricconduitlengthis lessofaconcern.

GastricDrainageProcedure

■ Asthevagusnerveswillbedivided,agastricdrainageisusuallynecessary eitherintheformofapyloromyotomyorpyloroplasty.Withtubularizationof gastricconduit,somehaveomittedthisstepasunnecessary.7Inthesepatients, delayedgastricemptyingcanbemanagedpostoperativelybyendoscopic balloondilationorbotulinumtoxininjectionintothepylorus.

■ Forpyloromyotomy,anincisionmeasuring1.5cmalongthestomachextending 1cmalongtheanteriorsurfaceoftheduodenumacrossthepylorusismade usingtheneedletipcautery.Withafinemosquitoclamp,thepyloricmuscle fibersaredivided.Anomentalpatchcanbeusedtopatchtheexposed submucosausingaGrahampatchtechnique.

■

Forpyloroplasty,a4-cmfull-thicknesslongitudinalincisionismadebeginning2 cmproximaltothepylorusontheanteriorstomach.Thisfull-thickness incisionisthenclosedtransverselywithinterruptedfull-thickness3–0silk suture(FIG16).

Esophagogastrostomy

■ TheapexofthegastricconduitisthensuturedtotheendofthePenrosedrain. ThePenroseisthendrawnupandoutthecervicalincisiondeliveringthe stomachintotheneck.Typically,thestomachreacheswithexcesslength permittingtrimmingoffurtherstomachofftheapexoftheconduit.Similarly, theesophaguscanbefurthertrimmedandbothadditionalspecimensmarked andsentforfinalproximalanddistalmarginanalysis.

■ Thecervicalanastomosiscanbeaccomplishedeitherbyahand-sewnorstapled approach.

8,9

■ Forhand-sewn,two-layeranastomosisisperformedwithanouterlayerof interrupted3-0silksutureinaseromuscularfashionandinnerlayerof runningfull-thicknessmonofilamentabsorbablesuture.Othershavedescribed asingle-layeranastomosisusingmonofilamentabsorbablerunningsuture.

■ Forastapledanastomosis,astaysutureof2-0silkisplacedatthe6o’clock

positionofthecervicalesophagus.A2-cmlonglongitudinalgastrotomyis madeontheanteriorsurfaceofthegastricconduitclosetothegreater curvature.The2-0silkisthenplacedattheapexofthisgastrostomyandtied toserveasstaysutureholdingorientationofcervicalesophagusandgastric conduitforapplicationofthestapler.A45-mmstaplerisadvancedwithone armintheesophagusandtheotherinthestomach.Thestaplerisdirected towardtherightearwiththeanastomosisplacedalongthegreatercurvature ofthestomach.Theremainingcommonenterotomyisclosedintwolayers withaninnerlayerofrunningfull-thickness,3-0monofilamentsutureandan outerlaterofinterrupted3-0silksutureinaseromuscularfashion(FIG17).

■ Aftercompletionoftheanastomosis,carefulcaudaltractionofthestomachat thehiatusisappliedastheanastomosisisdeliveredbackintotheneckbehind thetracheaandexcessredundancyoftheconduitinthechestisstraightened out.

■

Eitheranasojejunalfeedingtubeisplacedorsurgicaljejunostomytubeplaced forpostoperativenutrition.

■ Thegastricconduitisanchoredtothearchofthehiatuswithinterrupted3-0silk suturetopreventherniation.

■ Thesoftclosedsuctiondrainisplacedthruthethoracicinletanddeliveredout ontothechestwall.Theneckwoundisclosedbyapproximatingtheplatysma musclewithinterruptedsutureandclosingtheskinwitharunning subcuticularsutureof3-0monofilamentabsorbablesuture.Theabdominal woundisclosedperroutine.

RECONSTRUCTION:COLONCONDUIT

MobilizationoftheColon

■ WhenperformingacoloninterpositionforreconstructionfollowingTHE,the stomachispreservedotherthantheportionremovedtoassureadequatedistal margins.Thiswouldincludepreservationoftheleftgastricartery.To facilitateuseofthecolon,however,completegastricmobilizationas discussedearlierisnecessaryasthepreferredrouteforthecolonis retrogastrictodecreasetensionontheconduitandbloodsupply.

■ Completecolonicmobilizationisrequiredincludingmobilizationofboththe splenicandhepaticflexures.Thisoftenentailsextensionofthesurgical incisionbelowtheumbilicus.

■ Oncemobilizationiscomplete,verificationofadequacyofbloodsupplyforthe subsequentconduitisneededeveninthesettingofpreoperativeangiography. Thiscanbeaccomplishedbyserialligationoftheileocolicartery,thenright colicartery,and,ifnecessary,middlecolicarterieswithBulldogclamps(FIG

3).

■ Angiographicarterialanatomyrequirementsforasuccessfulleftcolic–based

coloninterpositionreconstructionincludeapatentinferiormesenteric artery,patentascendingbranchoftheleftcolicartery,intactmarginal arteryanastomosisbetweentheleftcolic(inferiormesenteric)andmiddle colic(superiormesenteric)arteries,singlemiddlecolictrunkpriorto bifurcationintoarightandleftbranch,andseparateoriginoftheright colicartery.

■ Toreachtotheneck,aconduitbasedontheleftcolicarterybranchofthe inferiormesentericarteryand,ifpossible,middlecolicarteriesisneeded. Thisentailsdeliveringthecoloninanisoperistalticfashiontotheneckwith thececumorproximalrightcolonservingastheproximalendofthecolon conduit(FIG18)

■ Ifthebloodsupplyisadequateforaleftcolicvascularbasedconduit,the ileocolicarteryisligatedaslowinthemesenteryaspossible,asistheright colicartery.Themesenteryoftheascendingcolonislikewisedividedtothe

levelofthemiddlecolicarteries.

■ Theterminalileumisdividedwithasurgicalstapler.

■ Thececumisrotateduptothenecktoverifyadequateconduitlength.Ifnot,the middlecolicbranchescanbedividedaswell(FIG19).

DeliveryofColon

■ Oncethecolonismobilized,thecolonisdeliveredthruthehiatusinafashion similartothegastricconduitasdiscussedearlier.Todecreasedemandson conduitlength,itisoptimaltodeliverthecolontothehiatusbehindthe stomachinaretrogastricposition.Alternatively,thecoloncanbedelivered thruaretrosternalpathwayiftheposteriormediastinumisnolongeraviable

option.Thedisadvantageofthisrouteisincreaseddemandonconduitand bloodsupplylength.

■ Asthereistypicallyadequatelengthtothecolonconduit,theproximalendof thecoloncanbeamputatedback,usuallyremovingthececum.Thishasthe advantageofdecreasingthesizedifferentialbetweenthecervicalesophagus andcolonasthecolonnarrowsinluminaldiameterandbecomesthickerand moremuscular.Also,asonemovesdistallyonthecolon,therelianceon mesentericarcadesforbloodsupplydecreases.

Anastomoses

■ Theesophagus-to-colonanastomosisisaccomplishedinasimilarfashionas describedinthesectionontheuseofthestomachasaconduitfor reconstruction.Thiscanbestapledusingalinearstaplerorhandsewnin eitheraone-ortwo-layertechnique.Althoughcircularstaplerscanbeused, conduitlengthisofteninadequate,makingthisawkward(FIG20).

■ Thecervicalanastomosisisdrawnbackintheneckbycarefulcaudaltractionon thecolonatthehiatus.

■ Thecolonisthendividedatapointalongtheposteriorstomachtopermita subsequentcolon-to-stomachanastomosis.Thisisoptimallydoneusinga linearstaplerjoiningthecolonandstomachinaside-to-sidefashionand closingthecommonenterotomywithanadditionalstaplerloadorhand-sewn closure.

■ Inmanipulatingthecolonforthisanastomosis,itisimperativetonotdisturbthe mesenteryofthecolonoutofconcernfordisruptingthemesentericvessels.

■ Entericcontinuityisrestoredbycompletingthesmallbowel-to-colon anastomosisusingsurgicalstaplersinastandardfashion.

■

Ajejunostomyfeedingtubeisplacedfornutritionalsupportasisacervical closedsuctiondrain.

■ Agastricdrainageprocedureisdoneifvagotomywasperformedduringthe courseofesophagealresection.

PEARLSANDPITFALLS

Indications ■THEshouldonlybeperformedforcurativeintent

whentreatingmalignancy.

■NCCNguidelinesshouldbefollowedasto

preoperativeevaluation,staging,andtreatment algorithms.

Approach ■THEshouldonlybeconsideredforpatientswith

appropriatepathology(middle,lowerthirdofthe esophagus,andGEjunctiontumors).

■Inpatientswithunfavorablepriorsurgicalhistory

(priorgastricsurgeryrenderingthegastricconduit inadequate)orlocallyadvancedtumorsthatrequire adirectvisualizationofmediastinaldissection,a THEiscontraindicatedinfavorofatransthoracic approach.

Gastricmobilization ■Avoidanytractionordirecttraumatotheright

gastroepiploicandrightgastricarterypediclessoas toavoiddisruptingthesevesselsorcausingvenous injurywithresultantthrombosisasthiswillleadto graftfailure.

■Useofanelectrosurgicaldevicegreatlyimproves

efficiencyandeffectivenessofgastricmobilization.

Esophagealdissection ■Ifexcessiveadhesionsareencounteredsecondaryto

tumorextensionortreatmenteffectorexcessive bleedingisencounteredwithbluntdissectionofthe esophagus,aTTEshouldbeperformed.

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