Transcript
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Techniques of Esop hageal Resection 139
accepted component of preoperative clinical stag-
ing; in addition to being complementary to CT, it
allows the sampling of regional lymphadenopathy.
Endoscopic ultrasonography is especially useful for
stratifying patients being treated in clinical trials.
Pretreatment thoracoscopy and laparoscopy can pro-vide accurate staging information, but this author
does not routinely perform them before initiating
preoperative chemoradiotherapy. All patients who
are considered to be candidates for curative resec-
tion undergo laparoscopy at the time of the intended
resection, to spare patients with distant disease from
a potentially morbid procedure. In the absence of
symptoms, a bone scan is not obtained, and bron-
choscopy is reserved for those patients with lesions
in the middle or upper esophagus. Positron emission
tomography (PET) has great promise as a stagingtool, but further investigation is required before its
routine use can be advocated.
Therapeutic Approach
Due to the dismal results of resection alone, com-
bined-modality therapy continues to be explored in
an attempt to improve outcomes. Therefore, resection
frequently follows chemotherapy, radiation therapy,
or chemoradiotherapy as a component of a multi-
modality approach to patients with esophageal can-cer. Although conclusive evidence regarding the ben-
efit of induction therapy prior to resection is lacking,
there is also little to suggest that the technique of
esophageal resection should be altered following
neoadjuvant therapy, and conflicting data exist
regarding increased morbidity and mortality associ-
ated with resection in the setting of a combined-
modality approach. These issues are addressed in
Chapters 5, 6, and 8 and will not be discussed here.
PREOPERATIVE AND
PERIOPERATIVE MANAGEMENT
All patients who are to undergo esophagectomy ben-
efit from a comprehensive preoperative teaching pro-
gram not only to prepare them for the intended
surgery but also to educate them in regard to what to
anticipate in the immediate postoperative period and
in regard to the short- and long-term effects of the
procedure. At this authors center, dedicated nursing
personnel instruct the patients in pre- and postopera-
tive pulmonary exercise, and patients are informed of
the potential need for postoperative ventilatory sup-
port and possible supplemental enteral nutrition and
are acquainted with the alterations in their dietary
habits that may be necessitated by esophageal
replacement. All patients undergo mechanical bowel
preparation, and if colon interposition is entertained
as a reconstructive option (albeit an unusual occur-
rence), oral antibiotics are also administered. In
patients treated with esophagectomy without preoper-
ative chemoradiotherapy, there is no demonstrable
benefit from preresection parenteral or enteral nutri-
tional support, which is therefore not routinely rec-
ommended. Patients receiving induction chemoradio-
therapy prior to esophagectomy and who are unable tomaintain nutritional status because of dysphagia may
well benefit from either enteral or parenteral nutri-
tional support during the preoperative phase of their
treatment. All patients have an enteral feeding tube
placed during surgery in case they are unable to sus-
tain adequate oral intake during the initial postopera-
tive period. Patients do not routinely require enteral
nutritional support following esophagectomy.
Perioperative antibiotic prophylaxis against oral
and gastrointestinal flora is routinely administered,
and sequential compression stockings are placed toprevent deep venous thrombosis.
This author prefers that a thoracic epidural
catheter be placed for optimal postoperative analge-
sia. A double-lumen endotracheal tube is not neces-
sary. The right neck is the preferred site for the place-
ment of a central venous access catheter. The right
arm is left out at 90 for venous and arterial access.
OPERATIVE TECHNIQUE
Transhiatal Esophagectomy
With the patient placed supine on the operating
table, the left arm is tucked to the side once all
boney prominences have been padded. The head is
turned to the right, extended, and stabilized with an
O-ring padded foam protector. The skin is prepped
with Betadine solution, from the left ear to the pubis
and laterally to the midaxillary lines.
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140 CANCER OF THE UPPER GASTROINTESTINAL TRACT
An upper midline incision is made from the
xiphoid process to the umbilicus (Figure 71),and
wide exposure is provided with a self-retaining
table-fixed retractor with the retractors hugging the
right and left costal margins, lifting cephalad and
toward their respective shoulders (Figure 72).The
abdomen is thoroughly explored, and biopsies are
performed on all suspicious nodules; the specimens
are sent for frozen-section analysis as any evidence
of metastatic disease will abort the intended proce-
dure. The ligamentum teres is ligated and divided,
both the falciform and left triangular ligaments are
divided, and the left lateral segment of the liver is
retracted upward and to the right. Attention is then
directed to the greater curvature of the stomach,
where division of the greater omentum outside the
right gastroepiploic artery (which must be identifiedand protected throughout the procedure) is com-
menced. Injury to the right gastroepiploic vessels is
avoided by maintaining a safe distance of at least 2
cm inferior to the vessels until the termination of the
right gastroepiploic artery. The left gastroepiploic
vessels and short gastric vessels are then encoun-
tered and may be ligated just outside the border ofFigure 71. Transhiatal esophagectomy is performed through an
upper midline incision and a left cervical incision.
Figure 72. Exposure to the upper abdomen is obtained with a self-retaining retractor secured to
the operating table, with retraction under both costal margins.A Penrose drain is in view at the gas-
troesophageal junction.
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142 CANCER OF THE UPPER GASTROINTESTINAL TRACT
nal lymph node dissection that could incorporate the
periesophageal soft tissue, pleura, and pericardium if
such is the surgeons preference. All attachments are
circumferentially divided with the cautery between
hemoclips up to the level of the carina.
The cervical component of the procedure is
begun by making an incision approximately 6 to 7
cm long at the anterior border of the sternocleido-
mastoid muscle from just above the suprasternal
notch (Figure 75). Following the division of theplatysma muscle with the cautery, the dissection is
carried down along the medial border of the stern-
ocleidomastoid muscle, and the omohyoid muscle is
incised. The dissection is continued medial to the
left carotid artery and left internal jugular vein,
dividing the middle thyroid vein to gain entrance to
the prevertebral space. Blunt self-retaining Wheit-
lander retractors are then used to retract the stern-
ocleidomastoid muscle, carotid artery, and internal
jugular vein laterally and the thyroid and trachea
medially. The cervical esophagus is then encircledwith careful blunt and sharp dissection, maintaining
Figure 75. The cervical incision along the anterior border of the sternocleidomastoid
muscle provides exposure to the cervical esophagus. Dissection is carried along the medial
aspect of the internal jugular vein and carotid artery to the prevertebral space.
Figure 74. Dissection of the distal esophagus is initiated under direct vision, with all
periesophageal tissue and mediastinal lymph nodes swept with the specimen up to the carina.
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Techniques of Esop hageal Resection 143
the dissection on the adventitia of the esophagus to
avoid injury to the recurrent laryngeal nerve in the
tracheoesophageal grove (Figure 76).With upward
and superior traction on the Penrose drain, blunt dis-
section is continued circumferentially almost to the
level of the carina (Figure 77).
The mediastinal component of the procedure is
now addressed. With caudal traction on umbilical
tape that has been secured to the gastroesophageal
junction, a hand is placed through the open hiatus,
posteriorly between the esophagus and the aorta, and
the esophagus is bluntly freed from its posterior
attachments. This maneuver is continued until the cer-
vical portion of the dissection is reached by confirm-
ing that a finger placed through the cervical wound
into the posterior mediastinum is able to be palpated
by the other hand placed through the diaphragmatichiatus and into the posterior mediastinum. Anteriorly,
the hand placed through the transabdominal incision
must hug the anterior wall of the esophagus, slip
under the carina, and carefully free the esophagus
from the membranous trachea until the cervical dis-
section is encountered. During this maneuver, periods
of extreme hypotension can occur that respond well to
volume resuscitation and limiting compression of the
heart that may require the dissection to be stopped for
short periods of time. The lateral attachments to the
esophagus are then usually hooked with the index fin-ger and, with the use of a long sweetheart retractor
placed into the mediastinum, divided between large
hemoclips with the cautery (Figure 78).The most
superior of these attachments are often divided
blindly by finger dissection circumferentially and
by a combination of a pushing and pulling of the final
periesophageal attachments.
Now that the entire esophagus is free from its
attachments, the cervical and upper mediastinal
esophagus is mobilized into the cervical wound. A
long 1-inch Penrose drain is placed on the esophagus,
and both are divided, with the GIA stapler effectively
securing the Penrose drain to the distal divided esoph-
agus. The stomach, with the attached esophagus, is
now brought through the abdominal wound, to lie on
a moist lap pad (Figure 79). The attached Penrose
drain has been drawn through the posterior medi-
astinum and will be used to help transpose the gastrictube through the mediastinum to the cervical incision.
Selecting the highest point of the stomach (Figure
710),a gastric tube is formed by multiple firing of
the GIA stapler (Figure 711),preserving the greater
curvature and its blood supply and opening the lesser
curvature angle to provide the greatest length possible
(Figure 712).In so doing, the specimen will consist
of the esophagus and its contained tumor and a con-
siderable portion of the fundus cardia and lesser cur-
vature (with the appropriate lymphadenectomy speci-
men), securing an adequate margin beyond the tumoredge (Figure 713).The right gastric vessels are pre-
Figure 76. The cervical esophagus is encircled with a 1/4-inch Penrose drain, avoid-
ing dissection in the tracheoesophageal groove where the recurrent laryngeal nerve
resides (forceps).
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144 CANCER OF THE UPPER GASTROINTESTINAL TRACT
served, and care is taken not to oversew the staple line
(Figure 714). The abdominal end of the Penrosedrain is now secured to the posterior wall of the stom-
ach with 3-0 silk sutures. The lesser-curvature suture
is left long, and the suture along the greater curvature
(the short gastric vessel side) is cut short so that the
orientation of the transposed gastric tube can be eas-
ily identified and maintained. With very gentle trac-
tion on the cervical end of the Penrose drain, the gas-
tric tube is placed through the esophageal hiatus by
hand and gingerly pushed upward through the poste-
rior mediastinum to the cervical incision. In doing so,
a good 6 to 8 cm of stomach wall will be easily mobi-lized into the cervical field. The Penrose-drain sutures
to the posterior wall of the stomach are now inspected
to ensure proper orientation and to confirm that thereis no twisting of the gastric conduit. The sutures are
then cut, and the Penrose drain is removed.
Figure 78. With the crus of the diaphragm divided anteriorly,
wide exposure to the mid- and upper mediastinum can be obtained
with the use of long Harrington retractors; however, the area just
posterior and superior to the carina requires blunt dissection without
direct visualization.
Figure 79. The cervical esophagus is divided, and the esopha-
gus and stomach are delivered through the abdominal wound. The
tumor can be seen bulging in the distal esophagus.
Figure 77. A, Traction on the cervical esophagus allows for blunt dissection almost to B, the level of the tracheal bifurcation.
A B
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Techniques of Esop hageal Resection 145
An automatic purse-string suture applier is then
placed on the cervical esophagus, and the excess cer-
vical esophagus is excised (Figure 715). Either a
28- or 25-mm EEA circular stapling device anvil is
placed in the cervical esophagus, and the purse-
string suture is tied (Figure 716).Through an ante-
rior gastrotomy, the shaft of the EEA circular sta-
pling device is inserted into the gastric tube, and the
trocar is brought through the posterior gastric wall.
The circular stapling device is then attached to theanvil, and the device is closed and fired, forming an
esophagogastrostomy. The stapling device is
removed, and the anvil is checked for two complete
donuts of tissue; the proximal esophageal donut is
sent to pathology as the final proximal margin.
Through the anterior gastrotomy, the anastomosis
can be inspected for bleeding and completeness. The
excess gastric tube proximal to the anastomosis
including the anterior gastrotomy is then excised
with a linear stapling device (TA-60 with 4.8-mm
staples). An endoscope is then passed transorallythrough the cricopharygeus to the anastomosis, and
air is insufflated, with the anastomosis submerged
under saline to detect any air leaks that need to be
secured with 3-0 silk sutures. The gastric tube is also
inspected for viability and to ensure that there has
been no unrecognized twisting of the transposed
stomach. Two 3-0 silk sutures are used to secure the
gastric tube to the surrounding available tissue (but
not to the prevertebral fascia). A nasogastric (NG)
tube is passed through the anastomosis, to lie just
above the esophageal hiatus. The platysma is closed
with a series of interrupted 3-0 absorbable sutures,
and the skin is closed with skin staples (Figure 717).
No drain is placed in the cervical field.
Figure 710. The highest point on the stomach is identified and
will serve as the most superior tip of the gastric tube.
Figure 711. A, B, and C, The linear stapler is used to lengthen the
lesser-curvature side of the gastric tube and to complete the resection.
A
B
C
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146 CANCER OF THE UPPER GASTROINTESTINAL TRACT
Shifting attention to the abdominal compartment,
the surgeon secures the stomach to the diaphrag-
matic hiatus with two 3-0 silk sutures. A needle
catheter feeding jejunostomy is placed, and the
abdominal wound is closed.
Transthoracic Esophagectomy
The standard transthoracic approacha combined
midline laparotomy and right thoracotomy (Ivor
Lewis esophagectomy)is described here (Figure
Figure 712. The gastric tube will serve as the reconstructive
conduit.
Figure 713. The specimen, with the tumor protrud-
ing through the gastroesophageal junction, is shown
with an adequate proximal and distal margin.
Figure 714. The gastric conduit provides adequate length to the cervical incision through the posterior mediastinum for a tension-free
anastomosis. A, The gastric conduit on the anterior chest wall. B, Relationship to the cervical esophagus.
A B
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Techniques of Esop hageal Resection 147
718).The abdominal component of the transthoracic
esophagectomy is identical to the abdominal phase of
the transhiatal esophagectomy described above.
Mobilization of the distal esophagus and stomach,
lymphadenectomy, pyloromyotomy, and needle
catheter feeding jejunostomy are performed, and the
abdominal wound is closed prior to repositioning the
patient for the mediastinal dissection. The patient is
placed in a left lateral decubitus position, and a right
lateral thoracotomy is performed, the thoracic cavitybeing entered through the fifth or sixth intercostal
space. As opposed to the transhiatal approach, a dou-
ble-lumen endotracheal tube allows single-lung venti-
lation and provides ideal exposure to the esophagus
and surrounding mediastinal structures. The azygos
vein is divided with the endo-GIA vascular stapler (2
mm). The mediastinal pleura is incised along the
entire length of the esophagus; the esophagus is
encircled, and traction is applied as the dissection
proceeds (Figure 719). The lymphadenectomy
should include mediastinal lymph nodes from sta-
tions 2 and 4 (upper and lower paratracheal nodes
from the intersection of the caudal margin of the
innominate artery to the azygos vein), 3 (posterior
mediastinal nodes above the tracheal bifurcation), 7
(subcarinal lymph nodes), and 8 (middle and lower
periesophageal nodes from the tracheal bifurcation to
the inferior pulmonary vein and extending inferiorlyto the gastroesophageal junction to meet the abdom-
inal dissection). The proximal esophagus is divided
as far superior to the tumor edge as is possible
(preferably with a 5-cm margin) with the GIA sta-
pler. The gastroesophageal junction and stomach are
then pulled through the esophageal hiatus and into
the chest, ensuring that there is no twisting of the
stomach that is to serve as the reconstructive conduit.
The stomach is then divided with the GIA stapler,
incorporating the lesser-curvature lymph nodes. The
specimen is sent to pathology to confirm negativeproximal and distal margins. If a stapled anastomosis
Figure 715. The automatic purse-string device is applied to the
cervical esophagus.
Figure 716. The 25-mm EEA anvil in the cervical esophagus,
with purse-string suture tied.
Figure 717. The cervical incision is closed with a skin-stapling
device.
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148 CANCER OF THE UPPER GASTROINTESTINAL TRACT
is preferred, the technique described in the previous
section on the transhiatal technique is applicable as
outlined. Alternatively, a hand-sewn anastomosis can
be performed in an end-to-side fashion in two layers
or (as this author prefers) with a single layer of inter-rupted 3-0 silk sutures. A nasogastric tube is then
passed beyond the anastomosis, to lie in the distal
stomach. An angled and straight 28F chest tube is
placed, and the thoracotomy is closed.
If there is concern regarding an adequate proxi-
mal margin or if there is aversion to an intrathoracic
anastomosis, the anastomosis can be performed in
the cervical region, as previously described. If this
decision is made prior to operation, one would start
with a thoracotomy first and then reposition the
patient for the abdominal and cervical portion of the
procedure. If this decision is made intraoperatively
following closure of the thoracotomy, the patient is
repositioned for the cervical dissection.
Three-Field Lymphadenectomy
For those who adhere to the advantages of the radi-
cal esophagectomy, three-field lymph node dissec-tion has been described and advocated by some
authors because 30 percent of patients with mides-
ophageal and lower esophageal cancers may have
cervical lymph node involvement.3 Whether this
represents systemic disease or locoregional spread
that can be addressed by a more radical procedure is
not discussed here. Instead, the technique of the cer-
vical component of lymph node dissection is briefly
described. (The abdominal and mediastinal compo-
nents have already been described.)
A U-shaped incision just above the suprasternalnotch provides exposure to the bilateral lymph node
stations to be dissected (Figure 720).The plane just
Figure 718. The thoracic and upper abdominal incisions for the
Ivor Lewis esophagectomy.
Figure 719. Transthoracic view of the mediastinal dissec-
tion, demonstrating traction on the thoracic esophagus as the
periesophageal soft tissue and mediastinal lymph nodes are
resected with the esophageal specimen.
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Techniques of Esop hageal Resection 149
recurrent laryngeal nerve is an extension of the
level-two lymph nodes previously dissected during
the thoracic component of the radical lymphadenec-
tomy procedure.
Minimally Invasive Esophagectomy
A number of approaches to achieving a minimally
invasive esophagectomy have been described,
including combined thoracoscopic and laparoscopic
esophagectomy, thoracoscopic esophagectomy with
open gastric mobilization, laparoscopic gastric
mobilization with minithoracotomy, laparoscopic
transhiatal esophagectomy, and hand-assisted lap-
aroscopic transhiatal esophagectomy. The largest
experience to date has been reported for the com-
bined thoracoscopic and laparoscopic approach,which are described in detail elsewhere.4 This
authors center has adopted the hand-assisted laparo-
scopic transhiatal esophagectomy, which is describ-
ed below. The actual and theoretic advantages of this
approach are that (1) there is no need for reposition-
ing, (2) there is no need for single-lung ventilation,
(3) tumor palpation achieves adequate distal mar-
gins, and (4) there is a shallow learning curve, and
the procedure therefore has wide applicability to the
surgical community.
The patient is placed in the supine position, withthe left arm at the patients side and the right arm at
90 as described for the open transhiatal approach.
Although lithotomy is often used in laparoscopic
approaches to foregut surgery, this author does not
feel it is necessary in this situation. The patient is
prepped and draped in a routine fashion (Figure
721).A periumbilical trocar is placed to the left of
the linea alba, through the rectus muscle just cephalad
(approximately 2 cm) to the umbilicus (Figure 722).
A 30 laparoscope is passed through the periumbili-
cal port. Next, three additional trocars are placed inthe right hemiabdomen. The liver retractor port is
placed as close to and as lateral to the costal margin
as possible. This position allows the fulcrum of the
retractor to elevate the left lobe of the liver while
remaining outside the operative field. The next two
trocars are placed in position to facilitate dissection
along the greater curvature of the stomach. These are
the working hands of the surgeon; they should be
deep to the platysma muscle is entered, and a flap is
raised superiorly (as is done in a thyroid or parathy-
roid procedure). The boundaries of the dissection are
superior to the middle thyroid vein, inferior to the
pleura, and lateral to the spinal accessory nerve. The
sternocleidomastoid muscle will be retracted eithermedially or laterally, depending on the point of dis-
section, and the division of the clavicular head usu-
ally facilitates this maneuver. The strap muscles are
divided inferiorly as necessary to improve access to
the lymph node basins to be dissected. The omohy-
oid muscle is divided with a cautery, and the deep
external and lateral cervical lymph node basins are
dissected from the pleura, from the posterior scalene
muscles, and along the lateral border of the internal
jugular vein. The thyrocervical trunk and its
branches (as well as the phrenic, vagus, and spinalaccessory nerves) are all preserved. The thoracic
duct is divided at its proximal point of drainage into
the venous system. Attention is then directed to the
deep internal cervical lymph nodes around the inter-
nal jugular vein and medial to the common carotid
artery. The recurrent laryngeal nerve must be identi-
fied and preserved. The dissection of the deep inter-
nal cervical nodes that run along the course of the
Figure 720. The cervical, thoracic, and abdominal incisions
required for radical three-field lymphadenectomy.
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150 CANCER OF THE UPPER GASTROINTESTINAL TRACT
placed low enough to facilitate access to the duodenal
sweep, to accomplish a wide Kocher maneuver. The
trocar closest to the midline should not obscure the
camera view into the mediastinum. The site of the
incision through which the hand will be introduced
into the peritoneal cavity is then selected in the left
hemiabdomen, with the abdomen insufflated (Figure723).The incision should be placed 2 to 3 cm below
the costal margin, with its center in the projection of
the lateral border of the rectus abdominus muscle. A
5- to 6-cm transverse incision is made and then
extended into the anterior rectus sheath, and the rec-
tus abdominus muscle is retracted medially. Next, a
vertical incision is made in the posterior rectus sheath
underneath the rectus muscle, and the peritoneum is
entered. A number of devices have been designed to
allow the introduction of the surgeons hand into the
Figure 721. A,
Intraoperative photograph of port placement sitesand left upper quadrant incision for hand-assisted laparoscopic
transhiatal esophagectomy.B, Drawing of the port sites and left
upper quadrant incision.
Figure 722. Placement of a periumbilical port.
Figure 723. With the abdomen insufflated and the port sites in
place, the base of the Pneumo-sleeve is placed prior to the left
upper quadrant incision.
A
B
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Techniques of Esop hageal Resection 151
peritoneal cavity while allowing for retraction of the
abdominal wound and maintenance of the pneu-
moperitoneum. These devices include the Pneumo-
sleeve, which requires a sterile sleeve apparatus over
the routine gown and gloving, and the Gelport, which
requires no additional sleeve apparatus (Figure 724).
The beauty of the hand-assisted laparoscopic transhi-
atal esophagectomy is that it exactly mimics the open
technique and thus almost completely eliminates the
learning curve and requires no extraordinary laparo-
scopic expertise (but it does require the prerequisite
expertise in esophageal resection). Following visual
identification and palpation of the right gastroepi-
ploic artery, the gastrocolic omentum is divided with
a harmonic scalpel. The gastrohepatic ligament is
likewise divided (with the harmonic scalpel) up to
the crus of the diaphragm and inferiorly to the rightgastric artery, which is preserved. A wide Kocher
maneuver is then performed, and the hepatic flexure
is taken down, ensuring easy identification and
preservation of the takeoff of the right gastroepiploic
artery from the gastroduodenal artery. The stomach
is then retracted cephalad and anteriorly, to divide
any posterior attachments between the pancreas and
the stomach, and the left gastric vessels are isolated
(Figure 725).These vessels are then divided with
the endo-GIA vascular stapler. All lymphatic and
nodal tissue is swept up with the specimen. The peri-toneum overlying the gastroesophageal junction is
then divided, and the esophageal hiatus is opened
with the harmonic scalpel. A Penrose drain is then
doubly looped around the gastroesophageal junction
and is secured tightly with a 2-0 endostitch. This is
then brought through the abdominal wall inferiorly to
provide caudal traction for the mediastinal dissection
(Figure 726).The hand-facilitated mediastinal dis-
section is undertaken (with the harmonic scalpel) up
to the level of the carina (Figure 727).An attempt is
made to perform a pyloromyotomy, which is facili-
tated with the placement of a lighted bougie intro-
duced transorally through the esophagus and the
stomach and into the duodenum through the pylorus.
This author and colleagues have found this to be a
technically difficult exercise and frequently have
converted to a pyloroplasty, performed in the usual
manner by making a longitudinal incision from the
duodenum and through the pyloric muscle to thestomach and then closing the incision transversely
with interrupted 3-0 endostitches. The cervical com-
ponent of the dissection is an exact duplicate of that
described for the open technique. The remainder of
the mediastinal attachments are then bluntly divided
by finger dissection, with a hand introduced through
the abdominal port. The cervical esophagus is
divided as described previously, and the specimen is
brought through the left upper abdominal incision.
The gastric tube is formed exactly as described for
the open technique, allowing palpation of the tumorfor an adequate margin. The Penrose drain from the
cervical incision to the abdominal incision is then
Figure 724. A, External view of the hand being placed through the left upper quadrant incision for hand-assisted laparoscopic transhiatal
esophagectomy. B, Intra-abdominal view of the hand within the peritoneal cavity.
A B
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Techniques of Esop hageal Resection 153
author prefers the transverse colon and the technique
described by Akiyama.6
POSTOPERATIVE CARE
Although not mandatory at this authors center,
mechanical ventilatory support is routinely continued
until the first postoperative morning, when the patient
is usually extubated with ease. Deep venous throm-
bosis prophylaxis with sequential compression stock-
ings is continued until the patient is fully ambulatory.Early ambulation and pulmonary toilet is encouraged
as with any major surgical procedure. The NG tube
that was placed during the operation is secured and
adjusted to low continuous suction until bowel func-
tion returns; it is then removed, and metoclopramide
is initiated. A contrast study to examine anastomotic
competency following cervical anastomosis is not
routinely done since developing leaks will declare
themselves at the cervical incision site and are easily
managed by opening the cervical wound and admin-
istering local conservative wound care. If patients
have an intrathoracic anastomosis, a contrast study is
obtained, usually with dilute barium to avoid the cat-
astrophic complications of meglumine diatrizoate
Figure 727. A, Laparascopic view of the carina. B, View of the
carina, with periesophageal lymph nodes dissected with the specimen.
Figure 728. A, Closure of the abdominal incisions. The feeding
jejunostomy is in place. B, View of the abdominal incisions 6 weeks
after hand-assisted laparoscopic esophagectomy.C, Blue ink high-
lights the incisions.
A
B
C
A
B
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154 CANCER OF THE UPPER GASTROINTESTINAL TRACT
(Gastrografin) aspiration. If the patient develops an
anastomotic leak or if there is any concern regarding
the patients ability to maintain adequate nutrition via
oral intake, jejunostomy feedings are begun and are
maintained until the patient no longer requires nutri-
tional supplementation. The patient is instructed in a
postgastrectomy diet (six small meals per day) and is
advised to maintain an upright position during meals
and for 1 hour following meals. The patient shouldhave his or her head elevated above the feet when in
the recumbent position.
Postoperative Complications
As with any major surgical procedure, intraoperative
or postoperative hemorrhage can occur. However,
since most of the mediastinal dissection during trans-
hiatal esophagectomy is done under direct vision,
blood loss during the procedure now averages
between 500 and 700 cc. This authors center has
had one injury to the azygous vein, which required
an anteriolateral thoracotomy to repair. Although
experience is limited at present, blood loss during a
hand-assisted laparoscopic transhiatal esophagec-
tomy is between 100 and 200 cc. A number of com-
plications commonly associated with esophagec-
tomy should be discussed. It should be noted that
there are no large randomized trials of transhiatal
versus transthoracic esophagectomy although a
compilation of published series comparing the two
procedures7 does provide some insight into the rela-
tive rates of morbidity and mortality associated with
the two procedures (Table 71).
Recurrent Laryngeal Nerve Paresis/Palsy
Recurrent laryngeal nerve paresis occurs in approx-
imately 10 percent of patients undergoing transhiatal
esophagectomy. The complication can be minimized
by avoiding sustained mechanical retraction and
minimizing dissection in the tracheoesophageal
Figure 730. Sites for test occlusion of the vascular pedicle to
determine the most viable segment of colon to be used as an
esophageal substitute during colon interposition. (Rt. = right.)
Figure 729. The resected specimen after radical
transhiatal esophagectomy, demonstrating pleura and
normal tissue enveloping the tumor mass.
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Techniques of Esop hageal Resection 155
the drainage from the cervical wound is copious,
this author does not hesitate to perform endoscopy
and dilatation of the anastomosis or the pylorus to
facilitate antegrade drainage and gastric emptying
to facilitate closure. Oral intake is not discouraged,
even with a cervical anastomotic leak. An intratho-racic anastomotic leak is a much more serious
event that requires adequate chest drainage, antibi-
otics, and prolonged parenteral or enteral nutri-
tional support.
One devastating complication is necrosis of the
proximal gastric tube, which is heralded by foul-
smelling cervical drainage and requires takedown of
the anastomosis, creation of a cervical esophageal
fistula, and placement of a gastrostomy tube into the
remaining gastric stump. If the patient survives this
extreme insult, gastrointestinal continuity can bereconstituted with either a colonic interposition or a
small-bowel free flap.
Anastomotic Stricture
Anastomotic stricture is a relatively common com-
plication following transhiatal esophagectomy and is
more likely if an anastomotic leak occurs. Single or
(more likely) multiple dilatations may be required to
eliminate symptoms of dysphagia. This author nor-
mally uses progressive savary dilatations under flu-oroscopic control.
Chylothorax
Injury to the thoracic duct can occur, especially with
a locally advanced tumor of the distal esophagus.
Excessive or increased chest tube drainage (as
opposed to a decrease in chest tube output) following
the 2nd postoperative day should alert the surgeon to
this potential complication. Triglyceride levels can
be obtained from the fluid draining from the chesttube; high-fat jejunostomy feedings will yield a
milky fluid from the chest tube, which is diagnostic.
Although conservative measures such as total par-
enteral nutrition can lead to closure of a chylous leak,
it is much more expeditious to proceed with ligation
of the divided thoracic duct, either via thoracoscopy
or by a minithoracotomy. Early closure of a chylous
leak may avoid prolonged nutritional depletion.
groove. At this authors center, blunt self-sustaining
retractors are placed into the substance of the thy-roid medially to avoid injury to the recurrent laryn-
geal nerve, and all retraction in the area of the tra-
cheoesophageal groove is done with either a finger
or a soft Kittner sponge on a Kelly clamp. It is cru-
cial to maintain the dissection directly on the adven-
titia of the esophagus when encircling it to also
avoid injury to the contralateral (right) recurrent
laryngeal nerve. Most injuries to the nerve result in
hoarseness, are temporary, and resolve without any
intervention. However, dysphagia and aspiration can
be troublesome, even if temporarily; therefore,avoidance of the injury is the best treatment. Per-
manent palsy may require surgical correction.
Anastomotic Leaks
Anastomotic leaks occur in approximately 10 to 15
percent of patients. The rate of anastomotic leaks
following cervical anastomosis is higher than with
an intrathoracic anastomoses because of the poten-
tially compromised blood supply to (and impeded
venous outflow from) the top of the gastric tube. Inaddition, despite all efforts to avoid trauma to the
cephalad portion of the gastric tube, trauma can
and does occur. In this authors experience, the use
of stapled anastomoses appears to have decreased
the rate of anastomotic leaks. Almost all cervical
anastomotic leaks can be managed with conserva-
tive care that includes opening the wound at the
bedside and changing the dressing twice daily. If
Table 71. MORBIDITY AND MORTALITY
OF TRANSHIATAL VERSUS TRANSTHORACIC
ESOPHAGECTOMY FOR ESOPHAGEAL CANCER*
THE (n = 2,675) TTE (n = 2,808)
Morbidity/Mortality (%) (%)
Postoperative morbidity
Pulmonary 24.0 25.0Cardiovascular 12.4 10.5
Wound infection 8.8 6.2
Anastomotic leak 16.0 10.0
Anastomotic stricture 28.0 16.0
RLN injury 11.2 4.8
Postoperative mortality 6.3 9.5
*From 14 published series, 1986 to 1996.
THE = transhiatal esophagectomy; TTE = transthoracic esophagectomy;
RLN = recurrent laryngeal nerve; n = sample size.
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156 CANCER OF THE UPPER GASTROINTESTINAL TRACT
Postresection Follow-Up
The vast majority of recurrences will occur in the
first 2 years post resection, and therefore, this author
schedules office visits for esophagectomy patients
every 3 months for the 1st 2 years and then every 6
months thereafter. A focused history and examina-
tion are performed at each visit, but no routine blood
work is obtained. Computed tomography of the
chest, abdomen, and pelvis and upper endoscopy
can be obtained on a yearly basis, or imaging and
invasive studies can be dictated by symptoms or by
physical findings. Since the treatment of recurrence
or metastatic disease is unlikely to prolong life, there
is negligible gain in performing routine diagnostic
studies (unless the patient is on a clinical trial) to
detect an early recurrence prior to the develop-
ment of symptoms.
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