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An epidural catheter may be placed before induction of anesthesia to facilitate postoperative pain management. Pneumatic intermittent calf compression boots are applied. With the patient in the supine position under general single-lumen tube endotracheal anesthesia, a Foley catheter and a radial arterial line are placed. Central venous access may be obtained via the right side of the neck.
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To confirm the location of the tumor and/or extent of Barrett epithelium, as well as to rule out gastric/duodenal pathology, upper endoscopy may be performed using minimal air insufflation. After removing the endoscope, an 18F Salem sump nasogastric tube is placed, and the stomach is decompressed. A transverse roll is placed beneath the shoulders, and the head is placed on a gel donut and turned to the right. The entire abdomen and left neck are prepared and draped in continuity (Fig. 16-1). An intravenous antibiotic is administered before making the skin incision, and additional doses are given periodically as appropriate throughout the procedure for wound prophylaxis.
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Preparation of the Stomach
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An upper midline laparotomy incision is made. The peritoneal cavity and abdominal viscera are examined for evidence of metastatic disease or other pathology. The xiphoid process is excised with electrocautery. A Buchwalter retractor is placed. A bladder blade is used to retract the lower sternum cephalad, and Richardson blades are used to retract the rectus muscles laterally (Fig. 16-2). The left triangular hepatic ligament is divided with electrocautery (Fig. 16-3). The mobilized left hepatic lobe is retracted rightward with a wide Deaver blade covered with a laparotomy sponge (Fig. 16-4).
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The nasogastric tube is positioned along the greater curvature of the stomach with its tip near the pylorus and is used as a handhold on the stomach. The abdominal esophagus is dissected from its crural attachments with electrocautery, encircled, and elevated on a Penrose drain. Alternatively, for lesions that are possibly directly invading the area of the esophagogastric junction (EGJ), a cuff of diaphragm can be resected with cautery under direct vision. The greater curvature of the stomach is mobilized using a harmonic scalpel, taking great care to avoid injury to the gastroepiploic arcade (Fig. 16-5).
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The gastric fundus is mobilized using a harmonic scalpel to divide the short gastric vessels. Divided branches may be reinforced with ligatures or clips. The posterior gastric vessel, a penultimate branch usually well visualized off the splenic artery, is carefully divided and ligated. The left gastric vessels are dissected, reflecting the left gastric lymph nodes toward the stomach. The left gastric vessels are divided using a roticulating vascular stapler (Fig. 16-6).
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A generous Kocher maneuver is performed. The serosa overlying the anterior wall of the pylorus is incised with electrocautery, avoiding the great pyloric vein of Mayo. A complete pyloromyotomy is performed using straight Mayo scissors or a #15 blade. Alternatively, a formal Heineke-Mikulicz pyloroplasty may be performed (see Chapter 17).
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Mobilization of the Abdominal, Thoracic, and Cervical Esophagus
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Attention is turned to the diaphragmatic hiatus, where the peritoneal reflection and phrenoesophageal ligament are taken with electrocautery dissection, completely mobilizing the esophagus in the hiatus. Transhiatal exposure is achieved by manual retraction using the hooked handles of two narrow Deaver retractors (Fig. 16-7).
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Mobilization of the intrathoracic esophagus proceeds cephalad while maintaining downward traction on the stomach. Blunt manual dissection is performed along the anterior and posterior aspects of the thoracic esophagus in a relatively avascular plane. Lateral attachments containing segmental vascular branches are divided close to the esophagus using electrocautery under direct vision whenever possible (Fig. 16-8). Divided lymphatics are meticulously ligated with surgical clips. Care is taken to avoid injury to the inferior pulmonary veins.
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As mobilization of the esophagus proceeds cephalad, direct visualization becomes impossible. Blunt “blind” manual dissection is undertaken anteriorly and posteriorly using the palpable nasogastric tube within the esophageal lumen as a guide. Care is taken to avoid injury to the membranous wall of the trachea anteriorly and to the aorta and azygos vein posteriorly (Fig. 16-9). Lateral attachments containing segmental vessels are hooked on the surgeon's finger and gently avulsed close to the esophagus using a downward motion using hemaclips and cautery when possible.
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While mobilizing the superior thoracic esophagus, the surgeon's entire hand will be passed through the stretched diaphragmatic hiatus, working into a retrocardiac position. The surgeon must closely monitor the arterial line tracing during this portion of the procedure. If hypotension develops, it may be necessary for the surgeon to remove his or her hand from the chest intermittently to permit the blood pressure to recover. Major vascular injury must be recognized promptly; although repair may be possible through the dilated hiatus, emergency anterolateral thoracotomy is sometimes required.21 The thoracic esophagus is mobilized in this fashion to the level of the thoracic inlet.
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After the entire thoracic esophagus has been completely mobilized, attention is turned to the left neck, where an incision is made along the anterior border of the sternocleidomastoid muscle and deepened through the platysma. This step can often be facilitated by a second surgeon starting on the neck just as the surgeon is starting the periesophageal dissection from below; this can shorten the overall time and make good use of the two surgeons working from opposite ends through the completion of the anastomosis. The omohyoid muscle is divided with electrocautery. The contents of the carotid sheath are reflected posteriorly with the sternocleidomastoid muscle. The middle thyroid vein is divided between surgical ties. Dissection is continued through an areolar plane to the vertebral bodies, reflecting the thyroid, trachea, and esophagus anteromedially. Blunt digital dissection is carried out along the vertebral bodies in a caudal direction until the thoracic inlet is entered. The surgeon's fingers from above and below should be able to touch without difficulty while again observing the blood pressure monitor. The esophagus is encircled in the thoracic inlet using blunt digital dissection. A Penrose drain is passed around the distal cervical esophagus and is used to elevate it into the incision (Fig. 16-10).
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The esophagus is separated from the membranous wall of the cervical trachea with careful blunt dissection aided by electrocautery. Special care is taken to avoid injury to the recurrent laryngeal nerves.
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Resection of the Specimen and Delivery of the Stomach to the Neck
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The tip of the nasogastric tube is pulled back to the top of the cervical esophagus, which is divided well above the thoracic inlet using a GIA stapler. The fenestrated end of a large chest tube is sutured to the distal end of the divided cervical esophagus (Fig. 16-11). With downward traction on the mobilized stomach, the mobilized esophagus and the attached chest tube are pulled inferiorly through the posterior mediastinum until the fenestrated end of the chest tube appears through the diaphragmatic hiatus in the abdomen. The greater curvature of the stomach is fashioned into a long tube using sequential firings of the GIA stapler, taking care to obtain an adequate margin around the lesser curvature of the stomach. The detached esophagogastrectomy specimen is delivered from the operative field.
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The long gastric staple line is oversewn with imbricating seromuscular suture. The newly fashioned gastric tube is placed in a sterile plastic endoscopic camera sleeve. The endoscopic camera sleeve is sutured to the fenestrated (abdominal) end of the chest tube that was passed through the posterior mediastinum (Fig. 16-12). Sheathed in the sterile plastic camera sleeve, the gastric tube is delivered cephalad via the diaphragmatic hiatus into the posterior mediastinum in the surgeon's hand. Simultaneous traction on the cervical end of the posterior mediastinal chest tube is used to pull the sterile plastic camera sleeve upward, delivering the gastric tube atraumatically through the thoracic inlet into the cervical incision.
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Creation of the Anastomosis and Feeding Jejunostomy
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A suitable point on the stomach, away from the long gastric staple line, is selected for the anastomosis. A hand-sewn two-layer anastomosis is fashioned. A row of interrupted seromuscular sutures is placed between the stomach and the cervical esophageal remnant, fashioning the outer layer of the posterior wall of the anastomosis (Fig. 16-13). Care is taken to avoid leaving an excessive length of cervical esophagus. Every effort is made to ensure that the anastomosis remains both tension free and above the level of the thoracic inlet. The esophageal staple line is grasped in a Kocher clamp and excised using a scalpel blade. The stomach is entered with electrocautery and suctioned. The inner layer of the posterior wall of the anastomosis is fashioned with interrupted absorbable suture.
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The nasogastric tube is advanced beyond the anastomosis into the stomach and positioned with its tip at the level of the diaphragmatic hiatus. It is then placed on suction and secured to the skin of the nasal septum with a heavy nonabsorbable monofilament suture. The inner layer of the anterior wall of the anastomosis is completed with running or interrupted absorbable suture. The outer layer of the anterior wall of the anastomosis is completed with a row of interrupted seromuscular sutures. Alternatively, a modified “Orringer” posterior wall stapled anastomosis using an EndoGIA stapler can be performed, then closing the anterior wall in two layers.
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A feeding jejunostomy is created. The tip of an 18F red rubber catheter is trimmed and passed through two concentric seromuscular purse-string sutures of absorbable material placed in the antimesenteric wall of the jejunum 40 cm beyond the ligament of Treitz. The red rubber catheter is imbricated into the antimesenteric wall of the jejunum proximally using a row of interrupted seromuscular absorbable sutures. The feeding tube is brought out through the abdominal wall lateral to the rectus muscle sheath at the level of the umbilicus. The serosal surface of the jejunum is sutured to the parietal peritoneum at the jejunostomy tube site using absorbable sutures at several points to prevent volvulus. The feeding tube is secured to the skin with a heavy silk suture.
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A short 1-inch Penrose drain is secured with a silk suture to the skin at the inferior end of the neck incision and passed behind the esophagogastric anastomosis. Care is taken to avoid passage of the Penrose drain below the thoracic inlet. The neck incision is closed in two layers using a running 3-0 absorbable suture to reconstitute the platysma muscle and a running 4-0 subcuticular suture to reapproximate the skin. The abdomen is closed in two layers using #1 absorbable running suture to reconstitute the linea alba and staples to reapproximate the skin.