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Ростовский Государственный Медицинский Университет

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Книга_1050_Библиотеки_им_академика_М_И_Перельмана

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■ ThegastrotomysiteisresectedwithonetotwoapplicationsoftheEndoGIA stapler(FIG18).Thestaplelineisoversewnwithinterrupted3-0silksutures.

■ Theanastomosisisreinforcedwith3-0silksuturesplacedbetweenthemuscular layeroftheesophagusandtheserosaofthegastricconduit.

■ Apleuralflapisharvestedandusedtowraptheesophagogastricanastomosis. Omentumorintercostalmuscleflapscouldbeusedasalternativesfor coverageoftheesophagogastricanastomosis.

PEARLSANDPITFALLS

Preoperative evaluation

■PreoperativestagingshouldincludeaPET/CTscan

andEUS.Patientswithtransmuraltumorsand nodaldiseasebenefitfrompreoperative chemotherapyandradiation.

■Patientswithahistoryofpreviousgastricsurgery

mayrequiretheuseofacolonicorjejunalconduit.

■Patientsshouldundergopulmonaryfunctiontests

andechocardiographytoassessperioperativerisk.

Mobilizationofthe stomach

■Therightgastroepiploicarteryandveinmustnotbe

injured.Theprimarybloodsupplytogastricconduit isderivedfromthisvasculararcade.

■Thegastricconduitshouldbe4to5cmindiameter.

■Thegastricconduittipcouldbeischemicandshould

beresectedifthereisnecrosisdetected.

Esophagogastric anastomosis

■Theanastomosisshouldbecoveredwitha

vascularizedpedicle,suchasomentum,pleura,or intercostalmuscle.Ananastomoticleakwithinthe thoraxcouldresultinlife-threateningmediastinitis.

■Atwo-layeranastomosisshouldbeperformed

regardlessofthetechnique.

Postoperativecare ■Postoperativebariumesophagramshouldbe

obtained5to7daysaftertheproceduretoevaluate theintegrityoftheesophagogastricanastomosis. Containedleakscanbemanagedwithbowelrest andantibiotics.Largeleakstypicallyrequire operativerepair.

POSTOPERATIVECARE

■

Patientsshouldbeextubatedintheoperatingroomifpossible.Achest radiographisobtainedintherecoveryroomorintensivecareunit(ICU).An epiduralcatheterisusedtoadministerlocalanesthesiaforoptimalpain controlandpulmonarytoilet.

■ Thenasogastrictubeisplacedonlowcontinuoussuctiontoavoidgastricstasis andaspiration.

■ Fluidbalanceshouldbecloselymonitoredtoavoidvolumeoverloadand respiratorycomplications.

■ Enteralnutritioncanbeinitiatedonpostoperativeday3tominimize perioperativemalnutrition.

■ Abariumswallowstudyisobtainedonpostoperativedays5to7toassessthe anastomosisforaleak.Aliquiddietcanbeinitiatedifthebariumstudyis negativeforaleak.Thedietisslowlyadvancedtoasoftmechanicaldiet.

■ Patientsaretypicallydischargedwhentheyaretoleratingasoftdietandareable toambulatewithoutdifficulty.

OUTCOMES

■ InmodernsurgicalseriesforIvorLewisEsophagectomy,theperioperative mortalityratesrangefrom1.4%to4.4%.Theanastomoticleakratesrange from0%to3.5%.Theoverallmorbidityratesrangefrom26.6%to45%.

■ Theoverall5-yearsurvivalrateforpatientsundergoingIvorLewis esophagectomyrangesfromthe25.2%to33.3%.Patientswithpositivenodal diseasehaveaworseprognosiscomparedtopatientswithnegativenodal disease.

COMPLICATIONS

■ Pneumonia

■ Anastomoticleak

■ Thoracicductinjuryandchyleleak

■ Delayedgastricemptying

■ Reflux

■ Aspirationpneumonitis

■ Pulmonaryembolism

■ Acutemyocardialinfarction

SUGGESTEDREADINGS

1.CerfolioRJ,BryantAS,BassCS,etal.FasttrackingafterIvorLewisesopahagogastrectomy.

Chest.2004;126:1187–1194.

2.VisbalAL,AllenMS,MillerDL,etal.IvorLewisesophagogastrectomyforesophagealcancer.

AnnThoracSurg.2001;71:1803–1808.

3.KarlRC,SchreiberR,BoulwareD,etal.Factorsaffectingmorbidity,mortality,andsurvivalin

patientsundergoingIvorLewisesophagogastrectomy.AnnSurg.2000;231:635–643.

4.GulchL,SmithRC,BambachCP,etal.ComparisonofoutcomesfollowingtranshiatalorIvor

Lewisesophagectomyforesophagealcarcinoma.WorldJSurg.1999;23:271–275.

5.GriffinSM,ShawIH,DresenerSM.EarlycomplicationsafterIvorLewissubtotal esophagectomywithtwo-fieldlymphadenectomy:riskfactorsandmanagement.JAmCollSurg. 2002;194:285–297.

6.VanHagenP,HulshofMC,VanLanshotJB,etal.Preoperativechemoradiotherapyfor esophagealorjunctionalcancer.NEnglJMed.2012;366:2074–2084.

7.HulscherJB,VanSandickJW,DeBoerGEM,etal.Extendedtransthoracicresectioncompared withlimitedtranshiatalresectionforadenocarcinomaoftheesophagus.NEnglJMed.2002;347:1662–

1669.

Chapter14

MinimallyInvasive Esophagectomy



BenjaminWeiRobertJ.Cerfolio MaryT.Hawn

DEFINITION

■ Theincidenceofesophagealcancer,especiallyadenocarcinoma,hasincreased dramaticallyoverthepastdecades.Thisphenomenonissecondarytothe increasingincidenceofobesitycontributingtorisingratesofrefluxand Barrett’sesophagusintheUnitedStates.

PATIENTHISTORYANDPHYSICALFINDINGS

■ Patientswithesophagealmalignancypresentwithprogressivedysphagiaand weightloss.Theincidenceishigherinmenandinsmokers.Patientsoften havealong-standinghistoryofgastroesophagealrefluxsymptoms.The physicalexaminationisusuallyunremarkable.

IMAGINGANDOTHERDIAGNOSTICSTUDIES

■ Allpatientswithdysphagiashouldbeevaluatedwithanupperendoscopyand biopsyofsuspiciouslesions.Patientswithbiopsy-provencarcinomaare stagedtodeterminetreatment.Thestagingprocessincludescomputed tomography(CT)ofthechestandabdomen,anintegratedpositronemission

tomography(PET)/CT,andendoscopicultrasound.PatientswithT3orN1 diseasearetreatedwithneoadjuvantchemoradiationandrestagedpriorto resection.

SURGICALMANAGEMENT

PreoperativePlanning

■ Ifthepatientisunabletomaintainadequatenourishmentduringneoadjuvant therapyorismalnourishedandtooweakforresection,weplacea jejunostomytube(J-tube),preferablywithalaparoscopicapproach.This allowsforstagingandtheabilitytoruleoutmetastaticdisease.A percutaneousendoscopicgastrostomytubeshouldbeavoidedinanypatient thatisbeingconsideredforesophagealresection.Additionally,havingtheJtubeplacedupfrontminimizestheabdominalportionoftheesophageal resectionprocedure.

PositioningfortheAbdominalPortion

■ Thepatientispositionedinthesupinepositionwithbotharmstuckedanda Foleycatheterinplace.Wedonotroutinelyuseanarteriallineoracentral line.Anasogastrictube(NGT)isroutinelyplaced.Ifoneisplaced,caremust betakentopullitfarbackintotheesophagusaswellastoremoveall esophagealtemperatureprobesorotherdevicespriortostaplingthestomach. Ifbodyhabitusorotherconcernspreventarmtucking,itisnotanecessity.

TECHNIQUES

PORTPLACEMENT

■ AVeressneedleentrytechniqueisusedtoplacea5-mmtrocarapproximately15 cminferiortothexiphoidand3cmtotheleftofthemidline.Theabdomenis

theninspectedforevidenceofdistantdiseaseandanysuspiciousareasare biopsiedandsentforfrozensection.Fouradditionaltrocarsareplaced:(1) 12-mmtrocarisplaced7cminferiortotherightcostalmarginand3cmfrom themidline,(2)5-mmtrocarisplaced6cmsuperiortothe12-mmtrocarand usuallytotherightofthefalciformligament,(3)5-mmtrocarjustoffmidline totherightandinferiortothebaseofthexiphoidtoretracttheleftlateral segmentoftheliver.A5-mmlockinggrasperpositionedunderneaththeleft lateralsegmentoftheliverandthediaphragmisgraspedanteriorandtothe rightoftheesophagealhiatustakingcaretoavoidthephrenicvein,and(4)5mmtrocar2cmbelowtheleftcostalmarginintheanterioraxillaryline(FIG

1).

■ ThepatientispositionedinmoderatereverseTrendelenburgposition.The surgeonstandsonthepatient’srightsideandusesthetworight-sidedports. Theassistantstandsonthepatient’sleftandusestheleftsubcostalportand cameraport.

CRURALDISSECTIONANDESOPHAGEAL MOBILIZATION

■ Thegastrohepaticligamentisdividedusinganultrasonicdissector.Theright crusofthediaphragmcanthenbeidentifiedattheesophagealhiatus.The phrenoesophagealligamentisdividedanteriorly,takingcaretofollowthe stomachtowardtheangleofHis,lateralandinferiortotheleftesophageal crus.Thecruraaredissectedcircumferentiallyandtheesophagusisisolated.

■ Oncetheretroesophagealwindowiscompleted,aPenrosedrainisplacedaround thegastroesophagealjunction.Thetwotailsaresuturedtogetherwithasingle 2-0Vicrylstitchtouseasahandletoassistinthecruraldissectionandfor intrathoracicpull-upandmanipulationduringthesecondportionofthe procedure(FIG2).Dissectionofthelower5to7cmoftheesophagusisthen performedwhiletheassistantplacesthePenroseontraction.Thiscanmostly beperformedwithbluntdissection.Iftheleftpleuralspaceisentered,we placeachesttubeatthecompletionoftheabdominalportionoftheoperation. Radiationchangescanmakethispartofthedissectionmoredifficult.

GREATERCURVATUREDISSECTION

■ Onthedistalaspectofthegreatercurvatureofthestomachapproximately5cm

proximaltothepylorus,thegreatercurvatureisgraspedandelevated anteriorlybythesurgeon’slefthandandtheassistantplacesthetransverse colonondownwardtraction.Thesurgeondividesthegastrocolicligament wellinferiortotheprojectedcourseoftherightgastroepiploicvessels. Becausetherightgastroepiploicvesselswillserveastheprimaryblood supplyforthegastricconduit,greatcareistakentoavoidinjuringthese vesselsduringgreatercurvaturedissection(FIG3).

■ Thelessersacisenteredatleast1to2cminferiortotherightgastroepiploic vesselsprojectedcourse.Oncethelessersacisentered,theposteriorstomach wallisgraspedandelevatedanteriorlyandtothepatient’srightsidewiththe surgeon’slefthandtoopenthedissectiontensionplane.Thismaneuver positionsthegastroepiploicvesselsanteriorlyandhelpsprotectthemfrom injuryduetoinadvertentgrasping(FIG4).

■ Dissectionisthencarriedproximally,takingcaretostaysuperiortothe

transversecolonasitcoursestowardthesplenicflexure.Thisisaccomplished byliftingtheposteriorstomachwallanteriorlyandtowardthepatient’sright sidewiththesurgeon’slefthandwhiletheassistantretractsthegreater omentuminferiorlyandtothepatient’sleft.Theproximalaspectofthe greatercurvatureismobilizedbydividingallshortgastricvesselsuntilthe leftcrusofthediaphragmisreached.Ifthereisexcessomentumimpedingthe view,wewillplacea“fatstay”usinga2-0VicrylsutureonanMHneedle. Thesutureisplacedthroughthefat,theneedleisremoved,andtheassistant graspsbothendsofthesutureandextractsthemthroughtheleft-sidedtrocar. Thetrocaristhenremovedandreinsertedsothatthesuturecomesthroughthe trackbutnotthetrocar.Tensionisplacedonthesutureuntilthefatis retracted;then,thesutureissecuredwithahemostatattheleveloftheskin.

■ Weleavesomeomentumalongthesuperioraspectofthegreatercurvatureofthe stomachtobeusedtobuttresstheintrathoracicanastomosis.

LESSERSACANDLEFTGASTRICPEDICLEDISSECTION

■ Theposteriorattachmentstothestomacharedivided,exposingtheoriginofthe leftgastricvesselsalongthelessercurvature.Inexposingtheleftgastric artery,theadjacentfatandlymphnodesshouldbeelevatedanteriorlytoallow forresectionwiththespecimen.

■ Theleftgastricvesselsarethenidentifiedonthemedialaspectofthelesser curvature.Oncethesevesselsareskeletonized,awhitevascular(2.5mm) stapleloadisfiredacrosstheleftgastricarteryatitsoriginfromtheceliac axis(FIG5).

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