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The basic principle underlying en bloc esophagectomy is resection of the tumor-bearing esophagus within a wide envelope of periesophageal tissue, which includes both pleural surfaces laterally, a patch of pericardium anteriorly, and the thoracic duct posteriorly, along with the mediastinal lymph nodes from the tracheal bifurcation to the hiatus (Fig. 19-1).
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An upper abdominal lymphadenectomy is also performed, including the celiac, common hepatic, left gastric, parahiatal, lesser curvature, and retroperitoneal lymph nodes. A “third field” nodal dissection can be incorporated by extending the lymphadenectomy to include the superior mediastinal and cervical lymph nodes (Fig. 19-2). The procedure is almost always carried out through three incisions: a right thoracotomy, followed by a laparotomy and collar neck incision. More recently, the thoracic and abdominal portions of the dissection are accomplished by a minimally invasive approach.
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A right fifth interspace thoracotomy is performed regardless of the location of the tumor within the esophagus (Fig. 19-3, inset). The “first field” comprises the middle and lower mediastinum and is bound superiorly by the tracheal bifurcation, inferiorly by the esophageal hiatus, anteriorly by the hilum of the lung and pericardium, and posteriorly by the descending thoracic aorta and the spine. Dissection of the middle and lower mediastinum begins by incising the mediastinal pleura over the anterior aspect of the azygos vein from the level of the azygos arch superiorly to the aortic hiatus inferiorly. The dissection proceeds leftward anterior to the aorta and across the mediastinum to the opposite pleura, which is entered along the entire length of the incision. The thoracic duct thus is mobilized anteriorly toward the specimen and is ligated inferiorly at the aortic hiatus and superiorly as it crosses to the left side of the mediastinum (Fig. 19-3). All lymphatic channels are clipped or ligated between the thoracic duct and the spine to minimize the probability of a chylothorax. The arch of the azygos vein, but not its main trunk, is resected en bloc with the specimen. The anterior dissection is commenced by dividing the azygos vein at its caval junction and by carrying the dissection along the right main bronchus and the posterior aspect of the hilum of the right lung. The hilar and subcarinal nodes are cleared, and a patch of pericardium is resected en bloc with the tumor-bearing esophagus for all but submucosal tumors (T1) of the middle and lower thirds of the esophagus. Division of both pulmonary ligaments (left and right) completes the esophageal mobilization (Fig. 19-4). For tumors traversing the hiatus, a 1-in cuff of diaphragm is excised circumferentially en bloc with the specimen using electrocautery. The completed dissection clears all nodal tissue in the middle and lower mediastinum, including the right and left paraesophageal, parahiatal, paraaortic, subcarinal, bilateral hilar, and aortopulmonary lymph nodes.
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Dissection of the third field begins during the thoracic portion of the procedure and is later completed through a collar neck incision. Dissection of the nodes in the superior mediastinum includes the nodes along the right and left recurrent laryngeal nerves throughout their mediastinal course. The paratracheal retrocaval compartment is not disturbed. The left recurrent nerve is dissected using a “no touch” technique, and nodes along its anterior aspect are carefully excised. Notably, there is a paucity of nodal tissue along the left nerve in nearly all Caucasians. The right recurrent nerve is carefully exposed near its origin at the base of the right subclavian artery (Fig. 19-5). The right vagus nerve serves as a good guide to locate the right recurrent nerve. The right recurrent nodal chain begins at that level and forms a continuous package that extends through the thoracic inlet to the neck. Again, the nerve is dissected using a strict no touch technique. Through the cervical incision, the remainders of the recurrent nodes are dissected, as are the lower deep cervical nodes located posterior and lateral to the carotid sheath. Thus the third field includes a continuous anatomically inseparable chain of nodes that extends from the superior mediastinum to the lower neck. These nodes should be appropriately labeled cervicothoracic nodes rather than cervical nodes.
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The abdomen is entered through a midline incision (Fig. 19-6, inset). The omentum is separated from the colon in the avascular plane, and the lesser sac is entered. After dividing the short gastric vessels, the retroperitoneum is incised along the superior border of the pancreas (Fig. 19-6). The retroperitoneal lymphatic and areolar tissues are swept superiorly toward the esophageal hiatus and medially along the splenic artery to the celiac trifurcation. The left gastric artery is divided flush with its celiac origin, and the nodes along the common hepatic artery are dissected toward the specimen. This retroperitoneal dissection is bound by the dissected esophageal hiatus superiorly, the hilum of the spleen laterally, and the common hepatic artery and inferior vena cava medially. Finally, the lesser curvature and left gastric nodes are included with the specimen as the gastric tube is prepared. The omentum is resected as a separate specimen at least 1 in outside the gastroepiploic arcade.
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A generous low collar incision is performed, and subplatysmal flaps are raised inferiorly and superiorly (Fig. 19-7). The strap muscles and the medial heads of the sternocleidomastoid are divided. The esophagus (previously fully mobilized from the thorax) is retrieved from the prevertebral space. The esophagus is divided distally, and the specimen is retrieved in the abdomen. The previously dissected recurrent nerves are easy to visualize (especially the right recurrent nerve), and any residual nodal tissue is excised. Next, the nodes posterior and lateral to the carotid sheath are removed, along with the supraclavicular nodes, particularly for tumors of the middle and upper esophagus. The dissection is limited superiorly by the inferior belly of the omohyoid. Within the abdomen, the gastric tube is prepared and the specimen is removed (Fig. 19-8). Gastrointestinal continuity is restored by a cervical esophagogastrostomy. A feeding jejunostomy tube is placed for early postoperative enteral feeding.
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