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  • Resectable esophageal carcinoma.
  • Barrett esophagus with high-grade dysplasia.
  • Carcinoma of the cardia or proximal stomach.
  • Achalasia.
  • Advanced disease (mega-esophagus).
  • Failed esophagomyotomy.
  • Benign (undilatable) stricture.
  • Recurrent hiatal hernia or reflux esophagitis following multiple hiatal hernia repairs.

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Absolute

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  • Biopsy-proven distant metastatic (stage IV) esophageal cancer.
  • Tracheobronchial invasion by upper or mid-third tumors visualized on bronchoscopy.
  • Aortic invasion demonstrated on MRI, CT scan, or endoscopic ultrasound (EUS).

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Relative

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  • Cardiopulmonary comorbidities.
  • Previous esophageal surgery causing excessive mediastinal adhesions.
  • Previous radiation therapy (more than 6–12 months prior) causing mediastinal and esophageal radiation fibrosis.

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  • In our series of patients, overall mortality is 1%, and more than 70% of patients experience no postoperative complications.

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Expected Benefits

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  • Resection of the intrathoracic esophagus and accessible associated adenopathy for definitive therapy or local management of disease, while restoring normal swallowing and digestive function as much as possible.

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Potential Risks

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  • Cervical esophagogastric anastomotic leak (5–10%).
  • Cervical dysphagia or esophageal stricture requiring early postoperative dilation (50–60%).
  • Postvagotomy dumping symptoms (25–50%).
  • Recurrent laryngeal nerve injury (< 5%).
  • Chylothorax (< 2%).
  • Mediastinal hemorrhage (< 1%).
  • Membranous tracheal injury (< 1%).
  • Gastric tip necrosis (< 1%).
  • Surgical site infections and systemic complications common to any major operation (eg, pneumonia, venous thromboembolism, and cardiovascular events).

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  • A table-mounted "upper hand" retractor facilitates exposure of the operative field.
  • Endoscope for preoperative visualization of the esophageal abnormality and to ensure an adequate normal proximal margin.
  • 14-inch right-angle clamps.
  • Extra-long 16-inch electrocauterizing device.
  • Gastrointestinal anastomosis (GIA) stapler

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Preoperative Planning

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  • Thorough preoperative staging evaluation is essential before performing transhiatal esophagectomy for malignancy.
    • Esophagoscopy and biopsy, to establish the location of the tumor and histology.
    • CT scanning, to demonstrate the local extent of the tumor and presence of distant metastatic disease.
    • EUS, to define the depth of tumor invasion within the esophageal wall and surrounding tissues. EUS can also identify dissemination of tumor into regional lymph nodes and can be combined with fine-needle aspiration for confirmation of malignancy.
    • Positron emission tomography has recently become a standard part of the staging evaluation and determines occult distant metastatic disease.
  • For patients with a history of gastric disease or previous gastric surgery, or patients with esophagogastric junction tumors that may necessitate resection of a major portion of the stomach, a barium enema should be performed to assess the colon as an alternate conduit if the stomach is not suitable.
  • Maximizing the patient's preoperative cardiopulmonary status is paramount to successful recovery.
  • Patients should abstain from cigarette smoking and alcohol use for a minimum of 3 weeks before the operation.
  • Patients should use an incentive spirometer on a regular basis (10 deep breaths three times daily), and walk at least 1–3 miles per day.
  • For patients with severe dysphagia, weight loss, or dehydration, liquid supplementation by either oral or nasogastric routes should be considered.
  • Placement of percutaneous gastrostomy ...

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