Teknik Operasi Esofagus

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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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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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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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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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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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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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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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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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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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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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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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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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(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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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.


19/19


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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3. Akiyama H, Tsurumaru M, Udagawa H, Kajiyama Y. Radical

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