Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult

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198 Section III • The Esophagus

◆ The stomach, which has been previously mobilized, should be gently elevated into the

chest (Figure 17-5).

◆ An endoscopic gastrointestinal anastomosis (GIA) stapling device is used to resect the cardia

and proximal fundus along the lesser curve with at least a 5-cm margin. This staple line can

be oversewn with interrupted 3-0 silk Lembert stitches (Figure 17-6).

Liver

Cut edge of diaphragm

Stomach

FIGURE 17 –5

FIGURE 17 –6

CHAPTER 17 • Esophagectomy—Transthoracic (Ivor Lewis) 199

◆ The stomach is placed as high in the chest cavity as possible to avoid undue tension at the

anastomotic site. A stapled anastomosis using an end-to-end anastomosis (EEA) stapling

device can be used via a 1.0- to 1.5-cm gastrotomy or, alternatively, a hand-sewn

anastomosis can be performed. The hand-sewn anastomosis is performed in two layers.

First, the posterior row of interrupted 3-0 silk stitches is placed between the posterior wall

of the esophagus, approximately 0.5 to 1.0 cm proximal to the cut end of the esophagus

and the fundus of the stomach (Figures 17-7 and 17-8).

Tumor removed along

with portions of esophagus

and fundus of stomach

FIGURE 17 –7

FIGURE 17 –8

200 Section III • The Esophagus

◆ At this point, the anesthesiologist places a nasogastric tube as the surgeon guides it from the

esophagus, through the gastrotomy, and into the stomach. A running 4-0 absorbable suture

is used to perform the mucosa-mucosa anastomosis. An anterior row of interrupted 3-0 silk

Lembert stitches completes the anastomosis (Figure 17-9).

◆ The stomach should be tacked to the prevertebral fascia and esophageal hiatus with inter-

rupted 3-0 silk stitches once the anastomosis is complete. A 36F chest tube is placed into

the right side of the chest and exited through a separate stab incision below the thoracotomy.

FIGURE 17 –9

CHAPTER 17 • Esophagectomy—Transthoracic (Ivor Lewis) 201

3. CLOSING

◆ The abdominal incision is closed according to surgeon preference. The fascia is usually

closed with a no. 0 or no. 1 interrupted or running absorbable monoﬁ lament suture, and

skin is closed with staples. The thoracotomy is closed with interrupted no. 1 or no. 2

Vicryl ﬁ gure-of-eight stitches. Muscle layers are individually reapproximated with running

2-0 Vicryl suture, and the skin is closed with staples or running 4-0 absorbable suture.

Sterile dressings are applied (Figure 17-10).

Stomach

Esophagus

Left lung

Heart

FIGURE 17 –10

202 Section III • The Esophagus

STEP 4: POSTOPERATIVE CARE

◆ Routine intensive care unit monitoring is not mandatory following transthoracic esophagec-

tomy, but the decision is made for each individual based on length of operation, surgeon

preference, patient comorbidities, and blood loss. On postoperative day 4 or 5, a contrast

esophageal swallow study is performed to evaluate the anastomosis for leak. If no leak is

present, a diet is initiated and output from the chest tube is monitored. Assuming no

increase in output with feeding and a fully expanded lung and drained right hemithorax,

the chest tube can be removed. Ambulation and chest physiotherapy should be initiated on

postoperative day 1 and continued until discharge.

STEP 5: PEARLS AND PITFALLS

◆ Identify and preserve the right gastric and right gastroepiploic arteries when mobilizing the

stomach.

◆ Test the esophagogastric anastomosis under water before closing to ensure no gross anasto-

motic dehiscence is present.

◆ Avoid injury to the posterior membranous trachea during esophageal mobilization.

◆ Act quickly to ensure adequate drainage of the thorax and mediastinum if signs of anasto-

motic leak occur in the postoperative period.

SELECTED REFERENCES

1. Junginger T, Gockel I, Heckhoff S: A comparison of transhiatal and transthoracic resections on the prog-

nosis in patients with squamous cell carcinoma of the esophagus. Eur J Surg Oncol 2006;32:749-755.

2. Hulscher JB, van Sandick JW, de Boer AG, et al: Extended transthoracic resection compared with limited

transhiatal resection for adenocarcinoma of the esophagus. N Engl J Med 2002;347:1662-1669.

203

CHAPTER

Esophagogastrectomy

Joseph B. Zwischenberger and Edward Y. H. Chan

STEP 1: SURGICAL ANATOMY

◆ A comprehensive understanding of the anatomy of the thorax, esophagus, stomach, and

abdomen is critical before undertaking surgical procedures on the esophagus and stomach.

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Indications: Indications for esophagogastrectomy include malignant tumor of the lower

esophagus or esophagogastric junction, which precludes a clear tumor margin to allow use

of the stomach for esophageal reconstruction. Malignancies of the esophagogastric junction

are most commonly adenocarcinomas of gastric origin (Figure 18-1).

◆ A left thoracoabdominal approach is indicated if the tumor location necessitates resection

of the distal esophagus and proximal stomach and when a Roux-en-

Y anastomosis is to be

used to reconstruct the resected stomach. If removal of the proximal stomach only is re-

quired to obtain adequate surgical margins, an anastomosis may be made between the

distal stomach and the esophagus in the chest. However, this reconstructive approach

may be associated with reﬂ ux esophagitis and dysphagia. Some surgeons prefer the alter-

native of a total resection of the stomach and distal esophagus with a Roux-en-

Y jejunal

interposition with an end-to-end anastomosis with the remaining esophagus. For a total

esophagogastrectomy, a colon interposition is required. A double-contrast barium enema

and colonoscopy will aid selection of the right (preferred), transverse, or left colon.

During the procedure, length and blood supply also inﬂ uence colon selection.

◆ Preoperative planning: Informed consent is obtained and the patient is made nothing-by-

mouth status at least 8 hours before the procedure. A bowel preparation is necessary the

day before the procedure in case the colon is needed as a reconstruction conduit. In the

operating room, a radial artery catheter should be used for continuous blood pressure

monitoring. Central venous access is not routinely necessary; however, if access is needed,

the right neck veins should be used to allow the surgeon complete access to the left side of

the neck during operation. A double-lumen endotracheal tube is used to deﬂ ate and retract

either lung to facilitate dissection. If a colonic interposition is planned, mesenteric angiography

should be performed on patients with risk factors for atherosclerotic disease.

204 Section III • The Esophagus

◆ Anesthesia: General endotracheal anesthesia is mandatory for this procedure.

◆ Position: The patient is placed in the right lateral (left thoracoabdominal) position.

◆ Operative preparation: The skin over the entire neck, chest, and abdomen should be

prepped with povidone-iodine (Betadine).

Tumor in

distal esophagus

Incision

FIGURE 18 –1

CHAPTER 18 • Esophagogastrectomy 205

STEP 3: OPERATIVE STEPS

1. INCISION

◆ Incision and exposure: A left thoracotomy is performed between the sixth and seventh

ribs. The serratus anterior muscle is separated to expose the intercostal muscles, which are

removed from the superior aspect of the seventh rib to enter the chest (Figure 18-2).

◆ A thoracoabdominal incision may provide greater exposure. However, this approach leads

to longer operative time and may result in an unstable costal arch, chondritis, or persistent

pain. A separate midline abdominal incision is often better tolerated (see Figure 18-1).

Incision

FIGURE 18 –2

206 Section III • The Esophagus

2. DISSECTION

◆ Diaphragm incision: The left thorax is entered and a semilunar incision is made in the

diaphragm near the costal arch, 2 cm from the costal margin. Retraction of the cut edge

of the diaphragm exposes the left lobe of the liver and the left upper abdomen. Radial

incisions may be made to expose and resect the adjacent diaphragm to achieve tumor-free

margins when the tumor invades the crus. Crural resection has a greater risk of diaphrag-

matic paralysis postoperatively (Figures 18-3 and 18-4).

◆ The abdomen should be carefully examined for peritoneal or hepatic metastases. The cardia

of the stomach should be palpated through the lesser sac, and the mobility of the tumor

should be assessed. If there are metastases or the tumor is ﬁ xed to the aorta or spine, the

tumor is not resectable.

◆ Esophageal mobilization: The pleura of the mediastinum is opened with visualization

of the esophagus and the esophageal tumor. Mobilization of the esophagus from the aorta is

achieved and the esophagus proximal to the tumor is encircled by a Penrose drain. The

surgeon must identify the anterior vagus nerve and the left bronchus and pulmonary vein.

The esophageal vessels should be dissected, ligated, and divided. To provide local clearance

of the tumor, the surgeon should take 1 cm of the crura in continuity with the

tumor (see Figure 18-4).

CHAPTER 18 • Esophagogastrectomy 207

Tumor in

distal esophagus

Esophageal tumor

Left lung

Heart

FIGURE 18 –3

Incision in diaphragm

Anterior vagus nerve

Left bronchus and

pulmonary vein

FIGURE 18 –4