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

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208 Section III • The Esophagus

◆ Mobilization of the stomach: The mobilization of the stomach proceeds along the greater

curvature in the direction of the pylorus, with division of the omentum maintaining a 1-cm

margin from the right gastroepiploic artery and vein. Attention should be paid to avoiding

excessive traction on the omental artery arcade. The right gastroepiploic vessels should be

preserved until the extent of dissection is determined. The stomach is retracted to the right

to provide tension on the short gastric vessels. Dissection proceeds cephalad along the

greater curvature until the proximal stomach and distal esophagus are freed (Figure 18-5).

◆ The freed stomach is reﬂ ected to visualize the celiac axis on the posterior aspect. The poste-

rior gastric artery and recurrent branch of the left inferior phrenic artery should be identi-

ﬁ ed, ligated, and divided. Node-bearing tissue is removed from the superior aspect of the

pancreas, around the celiac axis, and along the left gastric artery for en bloc removal with

the specimen. The left gastric artery and vein are ligated.

◆ The lesser sac is examined to determine whether the pancreas or spleen is involved with the

tumor. The lesser omentum is divided and removed from the right side of the esophagus to

the pylorus, with care taken to preserve the right gastric artery and vein.

Liver

Cut edge of diaphragm

Stomach

FIGURE 18 –5

CHAPTER 18 • Esophagogastrectomy 209

3. SELECTION OF PARTIAL OR TOTAL GASTRECTOMY

◆ Proximal esophagogastrectomy with esophagogastrostomy should be undertaken if the tumor

can be adequately resected with a 5-cm margin by removal of the proximal stomach. The

stomach has a blood supply that is less likely to be affected by atherosclerotic disease and

requires only a single anastomosis, as opposed to using an intestinal conduit.

◆ Gastric remnant reconstruction: The margin of resection should be 4 to 6 cm from the

esophagogastric junction, from halfway on the lesser curvature to a medial point on the

fundus. A gastrointestinal anastomosis (GIA) stapler is placed at a right angle and transects

the proximal stomach from the lesser curvature toward the fundus. The staple line is

oversewn with inverting 3-0 suture. Care should be taken to maintain tension along the

stomach to prevent shortening of the lesser curvature. A pyloromyotomy may be necessary

to prevent gastric stasis secondary to division of the vagus nerves (Figure 18-6).

Tumor removed along

with portions of esophagus

and fundus of stomach

FIGURE 18 –6

210 Section III • The Esophagus

◆ The gastric remnant is brought into the thorax through the hiatus and behind the proximal

esophagus. The margin should be at least 10 cm. If the margin is adequate, the posterior

wall of the esophagus is anastomosed to the end of the gastric tube. If the margin is inade-

quate, the gastric tube length should be determined. If the length of stomach is inadequate

to achieve a clear proximal remnant, the left side of the colon can be used as an alternative

between the gastric remnant and the cervical esophagus (Figure 18-7).

Stomach

Esophagus

Left lung

Heart

FIGURE 18 –7

CHAPTER 18 • Esophagogastrectomy 211

◆ Esophagogastric anastomosis: The esophagus is cut at a 45-degree angle with the ante-

rior wall longer than the posterior wall. Stay sutures should be placed with 4-0 Vicryl at

the midpoint of the anterior wall, as well as the posterior wall. A 2-cm gastrotomy is

made between the stapled end of the lesser curvature and the greater curvature. The stay

suture from the posterior esophageal wall is passed through the full thickness of the

cephalad portion of the gastrotomy. A 45-mm endoscopic GIA stapler is placed with the

thick part in the stomach and the narrow part in the esophagus. Two suspension sutures

are tied on each side of the anastomosis, one at the tip and one at the base. The stapler

is ﬁ red to complete the posterior section of the anastomosis (Figure 18-8, A-B).

◆ Care should be paid to ensure that the staple line is adequately clear of the previous staple

line along the lesser curvature. Overlap of the staple lines could result in ischemia and a

subsequent leak.

◆ The anterior portion of the anastomosis is made in two layers: the inner layer with con-

tinuous full-thickness 4-0 inverting polydioxanone structure (PDS) and the outer layer

with interrupted sutures. Particular attention should be given to where the hand-sewn

portion intersects with the stapled portion at the corners. Start the inner layer at the cor-

ner and incorporate at least 5 mm of the staple line (Figure 18-8, C).

◆ Total gastrectomy with Roux-en-Y esophagojejunostomy is undertaken if a proximal

gastrectomy does not allow the tumor to be resected with adequate 5-cm margins on the

stomach.

FIGURE 18 –8

212 Section III • The Esophagus

◆ The right gastroepiploic and right gastric vessels are suture-ligated and divided distal to the

pylorus. The duodenum is divided distal to the pylorus with a linear stapler. The staple line

should be inverted with interrupted 3-0 nonabsorbable sutures and covered with omentum

to prevent duodenal stump blowout (Figures 18-9 and 18-10).

Gastrointestinal

anastomosis stapler

Duodenum

FIGURE 18 –9

Duodenum

FIGURE 18 –10

CHAPTER 18 • Esophagogastrectomy 213

◆ The esophagus is mobilized to the level of the inferior pulmonary vein. A monoﬁ lament

nylon purse-string suture is placed around the circumference of the proximal esophagus.

The esophageal lumen should be distended with a no. 24 Foley catheter and a 20-mL

balloon, which is advanced into the esophagus and gently inﬂ ated (Figure 18-11).

Proximal end

of duodenum

Distal end

of esophagus

FIGURE 18 –11

214 Section III • The Esophagus

◆ A jejunal interposition is created using the Roux-en-Y technique (Figures 18-12 and 18-13).

The jejunum should be mobilized sufﬁ ciently to permit anastomosis with the thoracic

esophagus, necessitating division of several jejunal arteriovenous arcades.

Jejunum divided

with GIA stapler

FIGURE 18 –12

CHAPTER 18 • Esophagogastrectomy 215

GIA stapler

(Roux-en-Y anastomosis)

Duodenum

Jejunum

Proximal end

of jejunum

FIGURE 18 –13

216 Section III • The Esophagus

◆ Loading: An end-to-end anastomosis (EEA) stapler is passed through the jejunum into the

esophagus and ﬁ red. The jejunum is anchored to the proximal esophagus. To minimize

bile reﬂ ux, the surgeon should anastomose the duodenal loop to the jejunum at least

50 cm distal to the esophagojejunal anastomosis. The blind end of the jejunal loop is sta-

pled closed (Figures 18-14 and 18-15).

Distal end of

esophagus

Proximal end of

jejunum

Securing

anastomosis

with interrupted

sutures

FIGURE 18 –14

Jejunum

Esophagus

Descending

colon

Transverse colon

Sigmoid colon

Jejunum

Duodenum

FIGURE 18 –15

CHAPTER 18 • Esophagogastrectomy 217