Step 1: Surgical Anatomy
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Patients with bulky mid-esophageal tumors, especially those who have undergone neoadjuvant chemoradiation, are best treated with a transthoracic approach.
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The transhiatal approach is useful for patients with poor lung function (FEV 1 <1 liter or <50% predicted).
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Fewer lymph nodes are harvested with a transhiatal approach, on average, than with a transthoracic approach, although it is not clear whether this confers any survival advantage.
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Patients with mid-esophageal tumors (above 32 cm from the incisors) are most easily approached through the chest.
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Patients with end-stage achalasia have an enlarged, tortuous esophagus with enlarged, periesophageal vessels. Transhiatal esophagectomy in this setting is challenging, and transthoracic dissection may be easier.
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Neoadjuvant chemoradiation of gastroesophageal (GE) junction tumors is not a contraindication to this approach as this area is well visualized from the abdomen.
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Patients with poor cardiac function or significant aortic stenosis are best resected with a transthoracic approach in order to avoid perioperative hypotension.
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The transhiatal approach is generally used to reestablish gastrointestinal continuity in patients undergoing cervical exenteration.
Step 2: Preoperative Considerations
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See Chapter 1 for general preoperative considerations.
Step 3: Operative Steps
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The patient is placed in the supine position with both arms to the side. A small transverse bump is placed under the shoulder blades and the head is turned to the right. The abdomen, both anterior chests, and left neck are prepped. A midline laparotomy is performed as described in Chapter 1 .
1.
Dissection of Esophagus and Cervical Incision
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After mobilization of the gastric conduit as described in Chapter 1 , the hiatus is approached. For T2 tumors or smaller, it is acceptable to dissect the crura away from the esophagus. Dissection usually begins on the right and proceeds anteriorly over the left side of the esophagus, which is actually the left limb of the right crus.
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For bulky or T3 tumors, the hiatus should be incised 1 cm away from the tumor and a rim of diaphragm should be incorporated onto the specimen. The phrenic vein, which runs anteriorly, should be ligated. On the right side, the vena cava is located several centimeters away from the esophagus.
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An ultrasonic scalpel may be used to divide all attachments visible from the abdomen. Large arterial branches from the aorta should be clipped. Deaver retractors are useful in gaining exposure. As one proceeds cranially, the Deaver retractors are used to the retract the crus in one direction and a long, large right-angle or Harken #1 clamp can be used to distract the esophagus in the other direction as the assistant uses an ultrasonic scalpel to divide attachments up to the level of the carina.
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At this point an incision is made in the left neck as described in Chapter 1 , Tri-Incisional Esophagectomy, with the exception that dissection of the esophagus away from the trachea and recurrent nerves has not already been performed in the chest. ( Figure 4-1 )
Figure 4-1 Related posts:
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