OVERVIEW OF THE OPERATION
Figure 1 shows the incisions in the midline abdomen and the left cervical area. Figure 2 shows the relevant anatomy and arterial supply of the stomach and the anticipated line of transection form removal of the proximal stomach and esophagus.
ABDOMINAL PORTION OF THE OPERATION
The initial portion of the operation is performed through a midline laparotomy extending from the xiphoid to the umbilicus. The abdomen is inspected for metastatic disease and other pathology. Suspicious lesions outside the field of resection should be biopsied and sent for frozen section analysis. A self-retaining retractor aids in exposure of the upper abdomen and mediastinum. The round and falciform ligaments are divided; and the left lobe of the liver is dissected free from its diaphragmatic attachments and retracted to the right to expose the esophageal hiatus.
Following the assessment of the stomach as a suitable conduit for esophageal replacement, the lesser sac is entered by incising the gastrocolic ligament at the level of the inferior pole of the spleen. The gastrocolic ligament is sequentially divided with energy (bipolar or ultrasonic), or between clamps and ligated (figure 3). Care is taken to preserve the right gastroepiploic artery which is traced to its origin, and the pancreaticogastric attachments are divided using electrocautery. The gastrosplenic ligament is sequentially divided with energy (bipolar or ultrasonic), or between clamps and ligated and the posterior gastric attachments are divided to completely mobilize the gastric fundus (figure 4).
The pars flaccida of the lesser omentum is divided to expose the right crus and the phrenoesophageal ligament is divided, taking care not to injure the esophagus or GE junction (figure 5). The crura are dissected and the distal esophagus is mobilized and encircled with a Penrose drain (figure 6). In order to allow free movement of the pylorus to the level of the esophageal hiatus without tension, the hepatic flexure of the colon is mobilized and retracted inferiorly and the duodenum is mobilized from its retroperitoneal attachments by performing a Kocher maneuver (figure 7). The dotted lines in figure 7 show the course of the division of the gastrohepatic omentum and the gastrocolic omentum. The left gastric artery and a coronary vein are identified and divided near their origin using a linear cutting stapler, with care taken to maintain as much lymph node–bearing soft tissues as possible with the specimen (figure 8).
With the gastric mobilization, Kocher maneuver, and distal esophageal dissection complete, attention is turned to the cervical esophageal dissection. An incision is made along the anterior border of the left sternocleidomastoid muscle extending from the sternal notch to just above the cricoid cartilage (figure 9). The platysma muscle and fascia along the anterior border of the sternocleidomastoid muscle are incised and the omohyoid muscle is identified and divided. The omohyoid fascia is incised and the carotid sheath is retracted laterally to allow access to the tracheoesophageal groove. The middle thyroid vein may be divided to facilitate this exposure. The prevertebral space is entered by blunt finger dissection (figure 10). The anterior strap muscles are divided and the tracheoesophageal groove is dissected to allow anterior esophageal dissection. Care is taken to avoid the recurrent laryngeal nerve, but no specific attempt is made to visualize it. By careful finger dissection, the esophagus is circumferentially mobilized and encircled with a Penrose drain (figure 11). Cephalad retraction of the rubber drain allows blunt dissection of the esophagus from the superior mediastinum.
Following completion of the cervical esophageal dissection, caudal traction is placed on the rubber drain around the gastroesophageal junction, and the surgeon’s hand is passed into the posterior mediastinum along the prevertebral fascia, posterior to the esophagus (figure 12).
As the blunt dissection is extended to cephalad, a finger passed from the cervical incision can be palpated, and the posterior dissection completed (figure 13). Care must be taken to closely monitor the patient’s blood pressure throughout this portion of the operation. The anterior esophageal dissection is similarly performed by inserting the hand into the posterior mediastinum along the anterior surface of the esophagus with the palm facing posteriorly. Two fingers are gently advanced cephalad, with care taken to avoid injury to the pericardium or membranous trachea, until the dissection is complete in the superior mediastinum (figure 14). Upon completion of the anterior and posterior dissection, cephalad retraction from the cervical incision allows blunt mobilization of the lateral attachments along the superior portion of the esophagus. Following this, a hand is reinserted via the diaphragmatic hiatus to complete the lateral dissection by pressing the esophagus against the spine and using a posterior raking motion with the fingers.
Filmy attachments are divided bluntly, and thicker tissues and the vagal trunks are retracted toward the esophageal hiatus and divided sharply between the clips.
When the mediastinal dissection is complete, the nasogastric tube is withdrawn into the proximal esophagus and the cervical esophagus is divided using a TA stapler, with care taken to preserve adequate esophageal length to perform a tension-free anastomosis. A rubber drain is sutured to the specimen to maintain the posterior mediastinal tunnel as the esophagus is delivered into the abdomen (figures 15 and 16).
Vasculature along the lesser curvature of the stomach is then divided with the linear stapling device approximately 6 cm proximal to the pylorus to mark the extent of gastric division for creation of the conduit. Branches of the right gastric artery will provide some blood flow to the distal lesser curvature and should be preserved. The stomach is divided from the fundus to the lesser curve using serial firings of the GIA 80–4.5 stapler to create a gastric tube approximately 5 cm wide (figure 17). The esophagus and proximal stomach are assessed to ensure adequate margins of resection. With the gastric staple line facing the patient’s right side, the stomach is sutured to the Penrose drain and pushed upward through the posterior mediastinum and grasped with surgeon’s left hand or a Babcock clamp via the cervical incision (figure 18). Approximately 4 to 5 cm of gastric tube are delivered into the cervical incision for creation of the anastomosis (figure 19).
The cervical esophagogastrostomy may be created using a two-layer hand-sewn or linear stapled technique. A stapled cervical esophagogastrostomy is created by orienting the gastric conduit along the posterior cervical esophagus (figure 20). A longitudinal gastrotomy is created and two stay sutures of 3-0 silk are placed (figure 20). The esophagogastrostomy is created using a linear stapler (3.5 mm staples) (figure 21). Before releasing the stapler, two 3-0 silk sutures are placed between the stomach and esophagus on each side to buttress the anastomosis. The resulting common opening is closed in two layers, with an inner layer of 3-0 running absorbable suture and an outer layer of interrupted 3-0 silk sutures. Alternatively, this can be closed with a TA stapler as shown in figure 22.
The nasogastric tube is advanced past the anastomosis so that its tip is located in the distal stomach below the diaphragm. A 14-Fr feeding jejunostomy tube is then placed in a limb of proximal jejunum and brought out through a separate stab incision. We do not routinely perform a pyloroplasty due to the low incidence of delayed gastric emptying following this procedure. The abdominal and cervical incisions are closed in layers, and a Penrose drain is placed adjacent to the anastomosis and brought out through the inferior aspect of the cervical incision.
The patient is transferred to the intensive care unit postoperatively. Early extubation is preferred, and aggressive pulmonary toilet is begun immediately. A portable chest x-ray should be obtained in order to confirm placement of life support devices and to rule out pneumo- or hemothorax. Epidural analgesia is usually not required as adequate pain control can be achieved with intermittent opioid pain medications. The patient is maintained on intravenous fluids until adequate oral or enteral nutrition is achieved, usually for several days. Intravenous beta-blockers should be administered as prophylaxis for supraventricular arrhythmias. Typically, the nasogastric tube is removed on postoperative day number three; a thick liquid diet started on day number four; and a mechanical soft diet started on day number five. An esophagram is obtained when there is clinical suspicion of possible anastomotic disruption. Jejunostomy feeds are reserved for patients who are unable to tolerate adequate oral intake due to concern for tube feeding-induced small bowel necrosis in patients who are hemodynamically and catabolically stressed. Barring complications, patients are discharged when they achieve adequate oral intake, typically within 7 to 10 days.