Step 1: Surgical Anatomy
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The normal stomach will reach the neck when placed in situ in virtually every patient. If a patient has had prior gastric surgery, then it may not reach the neck.
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The upper and mid esophagus are most easily accessed via right-side thoracotomy, as the esophagus deviates to the right and there is no intervening aortic arch.
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The azygous vein crosses the esophagus at approximately the junction of the first third and second third of the esophagus. If the azygous vein is unusually large, it should be preserved. The azygous is infrequently a continuation of an interrupted inferior vena cava.
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The left recurrent nerve loops around the aortic arch and ascends in the tracheoesophageal groove in the chest. The right recurrent nerve loops around the right subclavian artery and ascends in the tracheoesophageal groove. Both nerves are best avoided by keeping dissection inside the vagus nerves above the level of the azygous vein.
Step 2: Preoperative Considerations
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A mechanical bowel prep is wise if there is a possibility of requiring a colon interposition instead of a gastric conduit.
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Preoperative intravenous antibiotics are administered. Although many prefer broad spectrum IV antibiotics, there is no data to show that these are superior to preoperative antibiotics directed only at gram-positive organisms.
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All patients undergoing esophagectomy are at high risk of deep vein thrombosis and pulmonary embolism, and they should receive perioperative subcutaneous heparin and sequential compression devices.
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Patients with limited exercise capacity and risk factors for coronary artery disease (CAD) should undergo cardiac testing prior to operation. Patients with a recent change in cardiac symptoms, change in their EKG, possible aortic stenosis, or signs or symptoms of heart failure should also undergo cardiac evaluation.
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Many factors, including location of tumor, extent of dysplasia, surgeon experience, lung and cardiac function, and patient anatomy factor into the route and method of esophagectomy.
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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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Patients with very poor pulmonary function (i.e., FEV 1 <40% predicted) may be better served with a thoracoscopic dissection or transhiatal approach.
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Bronchoscopy with full visualization of the membranous trachea and left main bronchus should be performed by the surgeon for all tumors of the mid and upper esophagus.
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Esophagogastroduodenoscopy must be performed by the surgeon prior to incision.
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A thoracic-level epidural is very useful in managing perioperative pain and minimizing the incidence of pulmonary complications after a thoracotomy.
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The advantages of the tri-incisional esophagectomy include: the complete removal of the esophagus; safe dissection of bulky tumors in the chest under direct vision; and an anastomosis out of the chest.
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Disadvantages include the need for a chest incision, and the higher incidence of recurrent nerve injury with a neck anastomosis.
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Patients with tumors at or above the level of the carina generally require a tri-incisional approach with an anastomosis in the neck.
Step 3: Operative Steps
1.
Right Thoracotomy
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The patient is placed in the left lateral decubitus position with an approximate 30-degree forward tilt.
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An abbreviated right posterolateral thoracotomy is performed, starting beneath the tip of the scapula and extending posteriorly 10 cm—typically just long enough to allow introduction of the surgeon’s hand.
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The latissimus is divided and the serratus muscle is spared and retracted anteriorly. Entry into the chest is on top of the sixth rib, in the fifth interspace. A 2-cm-long portion of the posterior sixth rib is removed to facilitate spreading of the ribs. The lung is retracted anteriorly and the inferior pulmonary ligament is divided with cautery.
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Starting at a region in the esophagus away from the tumor, the pleura is incised just anterior to the azygous vein. Posterior dissection is performed with a large, blunt right-angle or Harken #1 clamp. Medially, the pleural reflection is taken off the pericardium and dissection proceeds posteriorly. Dissection continues with cautery until a finger can encircle the esophagus, followed by a Penrose drain. All tissue lateral to the pericardium is included in the specimen. ( Figure 1-1 )
Figure 1-1
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For tumors at the GE junction, one may choose first to perform dissection in a cranial direction. To the right of the esophagus, all tissue medial to the azygous vein is included in the specimen—branches from the aorta are clipped on the aortic side, and cauterized on the esophageal side. All tissue is dissected off the pericardium and included in the specimen. The Penrose drain is used to distract the specimen away from surrounding tissue.
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On the left, the esophagus is dissected off the pericardium, and then away from the left main bronchus. On the right and posteriorly the esophagus is dissected off the aorta, clipping all large branches.
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The anterior vagus nerve is divided at this level, and dissection proceeds in between the vagus nerve and esophagus. ( Figure 1-2 )
Figure 1-2
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The posterior (left) vagus nerve is also identified and dissected away from the esophagus.
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The azygous vein is divided with an endovascular 2.5-mm stapler.
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Using low cautery settings, the esophagus is dissected away from the carina and trachea. Some of the dissection may be done using blunt finger dissection.
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The apical portion of mediastinal pleura is preserved in order to minimize the risk of contamination from a cervical leak.
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Dissection at the thoracic inlet is performed bluntly with the fingertip, preserving the apical pleura.
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The Penrose drain is knotted and placed along the cervical spine for retrieval during the cervical phase of the operation.
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Another Penrose drain is placed around the esophagus, and dissection proceeds in a caudal direction.
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Medial dissection removes the esophagus and periesophageal tissue off the pericardium.
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The esophagus is dissected laterally away from the aorta and azygous vein. Large arterial feeders should be clipped on the aortic side.
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Extensive dissection to the right and posterior to the esophagus enters the region of the thoracic duct, but must be performed for bulky tumors.
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For GE-junction tumors, a rim of diaphragm is included in the specimen. The rim is elevated away from intraabdominal structures using a large right-angle clamp.
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Mass ligation of the thoracic duct is performed at the level of the esophageal hiatus.
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The pleura overlying the vertebral body lateral to the aorta is incised.
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A blunt-tipped right-angle is used to encircle all tissue anterior to the vertebral body and aorta.
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A #1 silk ligature is used to tie the tissue; take care not to tie too tightly, which could tear through the duct. ( Figure 1-3 )
Figure 1-3
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A suture ligature can be performed, but there may be a higher risk of lacerating the duct.
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The Penrose is knotted and placed into the abdomen for retrieval during the abdominal phase of the operation.
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An examination of the esophageal bed is made for bleeding or for leakage of clear fluid, which may be an indication of a thoracic duct tear in the unfed patient.
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A 28 straight chest tube is placed to the right apex with an additional hole cut to drain fluid from the right pleural base.
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The chest is closed with #1 or #2 Vicryl paracostal sutures.
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Latissimus is reapproximated with a running 0 Vicryl suture.
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The subdermal layer is closed with a running 2-0 Vicryl suture.
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The subcuticular layer is closed with a running 3-0 monocryl or Vicryl suture.
2.
Laparotomy
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A midline upper laparotomy is performed from the base of the xiphoid process to 2 cm above the umbilicus. If the xiphoid process is excessively large, it can be excised.
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The omentum, liver, and serosal surfaces of the abdomen are explored for metastatic disease. If preoperative suspicion of abdominal metastatic disease is high, as in patients with celiac adenopathy, minimal response to neoadjuvant therapy, or signet cell pathology, a laparoscopy should be performed as the initial step. The right gastroepiploic artery is palpated—the pulse should be strong.
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An upper hand retractor is placed at about the level of the nipples. A Balfour retractor is used in addition to the upper hand retractor. Alternatively an Omni-type retractor can be used as the sole retractor. The patient is placed in a reverse Trendelenburg position.
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The attachments between the left lobe of the liver and the diaphragm are divided, taking care not to injure the left hepatic vein. The left lobe of the liver can be folded downward and retracted if the lobe is thin, taking care not to lacerate the surface of the liver. If the left lobe of the liver is thick, then it should be elevated anteriorly.
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Cautery is used to enter and divide the clear areas of the gastrohepatic ligament. An ultrasonic scalpel can be used for thicker areas of the ligament. Dissection proceeds up to the right crus.
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If a Penrose drain has been placed during the thoracic phase of the operation, it is now located and grasped. If not, a rim of diaphragm is included with the esophagus at the hiatus, with care to suture ligate the phrenic vein, which crosses anteriorly.
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At approximately the midpoint of greater curvature, entry is made into the lesser sac, several centimeters away from the gastroepiploic artery. Cranial dissection proceeds with cautery through clear areas, and with ultrasonic scalpel or with clamping and ligation through areas with thicker tissue. The surgeon to the patient’s right side grasps the greater curvature of the stomach (with care not to compress or manipulate the right gastroepiploic artery) and retracts medially. The surgeon to the patient’s left side uses one hand to keep abdominal contents away from the area of dissection and the other hand to distract tissue laterally.
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Dissection proceeds along the greater curvature with care to stay at least 2 cm away from the gastroepiploic artery. The artery eventually ends, and the lateral arcades supplying the stomach become short gastric arteries.
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The anterior and posterior leafs of the short gastrics may be divided with the ultrasonic scalpel, or may be divided with sequential firings of the endoscopic stapler (2.0-mm-thick staples). Often the highest short gastrics enter the cardia of the stomach immediately adjacent to the left crus. Dissection into the splenic artery or pancreas must be avoided. Dense adhesions in this area may make dissection difficult.
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Typically there are loose adhesions between the posterior aspects of the stomach and pancreas, which are divided with cautery.
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The stomach is retracted anteriorly, and the pedicle of the left gastric artery is identified. Sharp dissection with blunt-tip scissors or with cautery is used to dissect all nodes at the origin of the left gastric artery and sweep them onto the specimen. Celiac nodes can also be dissected in this fashion. ( Figure 1-4 ) The base of the left gastric artery is clamped with an endovascular stapler that is 45 mm in length and 2.5 mm in height. The right gastroepiploic artery should be palpated at this point to insure that the celiac axis has not been clamped and the stapler is fired. ( Figure 1-5 )
