- Resectable esophageal carcinoma.
- Barrett esophagus with high-grade dysplasia.
- Carcinoma of the cardia or proximal stomach.
- Advanced disease (mega-esophagus).
- Failed esophagomyotomy.
- Benign (undilatable) stricture.
- Recurrent hiatal hernia or reflux esophagitis following multiple hiatal hernia repairs.
- 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).
- Cardiopulmonary comorbidities.
- Previous esophageal surgery causing excessive mediastinal adhesions.
- Previous radiation therapy (more than 6–12 months prior) causing mediastinal and esophageal radiation fibrosis.
- In our series of patients, overall mortality is 1%, and more than 70% of patients experience no postoperative complications.
- 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.
- 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).
- 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
- 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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