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The anesthetic technique must be of the highest standard. All patients undergoing the Ivor Lewis procedure should have an epidural catheter placed whenever possible to obtain satisfactory levels of analgesia postoperatively, thereby facilitating physiotherapy and respiratory function. A double-lumen endotracheal tube permits single-lung ventilation, which is required to obtain proper visualization and radical resection of the area concerned. Arterial and central venous pressure lines are inserted. Urinary output should be monitored with a Foley catheter. A gastric tube is placed to ensure adequate drainage during the procedure. The patient is positioned with the aid of a vacuum beanbag during thoracotomy. Twenty-four-hour antibiotic prophylaxis is instituted before incision.
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The Ivor Lewis esophagectomy is a two-stage procedure consisting of laparotomy for gastric mobilization and tubularization, followed by a right thoracotomy for esophageal resection and reconstruction. A radical lymphadenectomy is performed in the upper abdomen and chest. During the procedure, careful dissection is mandatory to avoid bleeding, limit the need for transfusion, and minimize manipulation of the heart.
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The patient is positioned in a supine manner for laparotomy, and an upper midline incision is performed. Full abdominal exploration ensues with special attention to evidence of tumor dissemination in the form of unforeseen peritoneal or serosal implants, liver metastasis, or both. An abdominal self-retaining retractor is useful. The left lobe of the liver can be retracted cephalad and to the right after dividing the triangular ligament.
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The dissection of the stomach starts by entering the lesser sac at a point well away from the gastroepiploic artery. The greater omentum is divided along the greater curvature by ligating and transecting the branches of the gastroepiploic arteries to the epiploon. During this maneuver, great care is taken to protect the gastroepiploic vessels needed for future vascularization of the stomach. The short gastric vessels are ligated sequentially and divided as close to the spleen as possible to avoid interrupting the epiploic arcade, thus preserving the circulation to the gastric fundus. Injury to the fundus of the stomach is assiduously avoided because this will serve as the site of the future anastomosis. While dissecting the gastrocolic omentum toward the duodenum, the stomach is lifted upward to allow the various adhesions between the stomach and pancreas down to the posterior surface of the first part of the duodenum to be transected. At this point in the operation the right gastroepiploic artery origin or venous communicating branch to the mesocolon is most vulnerable to injury. The duodenum is mobilized generously with a Kocher maneuver, and any loose adhesions between the duodenum and gallbladder fundus are divided.
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Attention is turned to the lesser omentum, which is divided close to the undersurface of the left liver lobe up to the esophageal hiatus. The vagal branches to the liver are transected, and if a left liver lobe artery is found, care is taken to preserve this artery if at all possible. The right gastric vessels are identified, dissected, ligated sequentially, and divided approximately 1 inch proximal to the pylorus. The stomach is lifted up by the assistant, bringing into the surgeon's view a bundle of tissue connecting the lesser curvature to the posterior abdominal wall (i.e., the celiac trunk). Palpation confirms pulsation of the left gastric artery within this tissue. Careful dissection permits the artery and vein to be visualized individually and tied off. The surrounding fat and lymph nodes are also removed during this maneuver. The left gastric artery is divided and ligated close to its origin from the celiac axis. The remaining loose adherent tissue, which contains a few small vessels, is divided, bringing the crura of the diaphragm into view. Gentle posterior pressure between the two pillars permits access to the posterior mediastinum, where loose areolar tissue can be broken down with gentle dissection. The phrenoesophageal ligament is transected around the esophagus to complete the mobilization. During this procedure, a cuff of diaphragmatic muscle can be resected if diaphragmatic invasion is suspected. After opening the diaphragmatic hiatus, access is gained to the fibrofatty and lymphatic tissue that separates the esophagus from the pericardium. This fibrofatty and lymphatic tissue is reflected away from the surrounding structures. In this way, much of the dissection of the lower esophagus can be achieved through the abdomen under direct vision. The gastric tubularization is performed using several linear staplers, starting from the gastric fundus down to the place on the small curvature where the right gastric artery has been ligated. The staple line is placed such that it leaves a gastric tube of 4 to 5 cm in width (Fig. 18-1). The staple line is oversewn in a running fashion, although some surgeons prefer to use interrupted sutures. Thus, by resecting the lesser curvature, all lymphatic tissue in this area is removed. A lymph node dissection along the splenic artery, common hepatic artery, and celiac axis is performed. This also can be done en bloc with the dissection of the left gastric artery. The gastric tube is fixed to this separated lesser curvature by using two stay sutures.
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At the end of the first stage of the procedure, it should be possible to place the pylorus at the hiatus, ensuring sufficient length for the reconstruction. Pyloroplasty is not carried out, but digitoclasy of the pylorus may be useful. The abdomen is closed.
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A lateral thoracotomy (which can be extended anteriorly or posteriorly depending on the surgeon's preference) is performed through the fifth interspace. The serratus muscle is spared if possible.
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The right lung is selectively deflated and retracted anteriorly. First, the azygos vein is dissected, ligated, and transected, as well as the underlying intercostobronchial artery. The mediastinal pleura anterior to the esophagus is opened widely from the azygos vein to the top of the chest. The proximal esophagus is dissected circumferentially and looped with an umbilical tape. The dissection is carried cephalad toward the apex of the chest, separating the esophagus from its tracheal and prevertebral attachments using the tape for traction and countertraction. Great care is taken to avoid injury to the membranous part of the trachea.
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Similar dissection of the esophagus is achieved by encircling it with a tape distally from the distal pole of the tumor. During this dissection, it is important to remove the esophagus en bloc along with the surrounding tissues, including the thoracic duct and azygos vein, to achieve radical resection, especially if transmural extension is suspected. Dissection of the esophagus proceeds inferiorly, encompassing all tissue between the aorta and pericardium, including all periesophageal and subcarinal nodes. Both vagal nerves are transected.
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A further lymph node dissection is performed along the left and right paratracheal spaces, along the aortopulmonary window, and along the right recurrent nerve at the level of the brachiocephalic trunk. To facilitate exposure of the right recurrent nerve, slight traction is exerted on the right vagus nerve, slightly stretching the recurrent nerve. Avoiding electrocautery is mandatory in this region to avoid injury to the nerve. Similarly, the left recurrent nerve is identified, and careful lymph node clearance is performed.
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At this point, the gastric tube can be pulled up into the chest cavity, being careful to avoid axial rotation of the tube during this process (Fig. 18-2). A suitable point at least 5 cm above the tumor is chosen for transecting the esophagus. After transection, a frozen section must be obtained of the proximal resection margin to confirm the absence of tumor extension in the suture line.
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A number of techniques have been described for esophagogastrostomy, including use of a circular stapler or hand-sewn anastomosis.
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For a mechanical anastomosis, the esophagus is transected, and a purse-string suture with, for example, Prolene 4-0 running suture, is placed through the mucosa and muscular layer. The anvil head of the circular stapler (size at least 25) is placed into the esophagus, and the purse-string suture is tied snugly around the shaft of the anvil head. An incision is made at the top of the gastric tube to insert the gun of the circular stapler. The site where the gun will perforate the gastric wall is chosen carefully on the posterior aspect of the gastric tube, away from previous staple lines and the greater curvature vessels. One also must verify that once the anastomosis is performed, it will not be under tension because this can lead to postoperative complications. After penetrating the gastric wall, the pointed shaft of the gun is detached, and the gun is connected to the anvil head. The gun then is fired in the customary manner, and the doughnuts are inspected to ensure the integrity and completeness of the anastomosis. Several nonabsorbable stitches can be placed between the muscular layer of the esophagus and the seromuscular lining of the stomach to strengthen and protect the anastomosis. The nasogastric tube then is advanced through the anastomosis into the gastric tube. The redundant part of the gastric tube including the opening used to insert the gun is then transected with a linear stapler, and the staple line is inverted with a running suture.
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Hand-Sewn Anastomosis
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For a hand-crafted anastomosis (Fig. 18-3), the posterior seromuscular aspect of the anastomosis is performed using separated nonabsorbable suture, for example, Ticron 3-0 stitches. The esophagus and gastric tubes then are incised along this suture line using electrocautery. The posterior layer comprising the full thickness of both the esophagus and gastric wall then is performed with separated absorbable suture, for example, Maxon 3-0 stitches. The gastric tube is advanced across the anastomosis. The anterior part of the esophageal wall is transected. The anastomosis is finalized using separated absorbable suture, for example, Maxon 3-0 for the anterior layer, and separated nonabsorbable suture, for example, Ticron 3-0 for the outer seromuscular layer. Some authors use a running suture, whereas others prefer a single-layer anastomosis.
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In most cases we use a pleural flap to cover the anastomosis to protect the chest cavity from anastomotic leakage. The thoracic cavity is usually drained using a 36F chest drain placed in the paraspinous position. The chest wall is closed in layers.