It is suggested that all esophageal procedures, including thoracoabdominal esophagectomy, begin with endoscopy in the operating room. Repeat endoscopy provides confirmation of the location of the tumor and evaluation of the esophagus for a second lesion or extension into the stomach. With tumors of the middle and upper thirds of the esophagus, bronchoscopy also should be performed. A double-lumen endotracheal tube is placed, permitting deflation of the left lung during the thoracic dissection, and broad-spectrum antibiotics are given before surgical incision and may need redosing during the procedure. We encourage the liberal use of an epidural catheter in the management of postoperative pain, given the extend of the incision.
The patient is positioned in the right lateral decubitus position, which permits access to both the left side of the chest and the upper abdomen. The initial step is an exploration of the abdomen through the medial portion of the incision. A valuable landmark in planning the abdominal portion of the incision is to aim the medial aspect at a point halfway between the xiphoid and umbilicus. The abdominal portion of the incision permits inspection of the liver, palpation of the celiac nodes, and further evaluation of the stomach. With no metastatic disease identified, the incision is carried into the chest over the seventh or eighth rib (Fig. 21-1). The higher the interspace, the easier it is to perform the anastomosis. As the diaphragm is divided, it should be clearly marked with stitches to allow reapproximation at the conclusion of the case.
The incision is carried into the chest over the seventh rib. The higher the interspace, the easier it is to perform the anastomosis. As the diaphragm is divided, it should be clearly marked with stitches to allow reapproximation at the close of the procedure.
Thoracic exploration begins with an inspection of the left lung, diaphragm, pericardium, and pleural space. Opening of the mediastinal pleura permits further inspection of the extent of the tumor, evaluation of possible invasion of the aorta or lung, and determination of metastases to the paraesophageal and paraaortic lymph nodes.
Dissection begins in the chest, freeing the esophagus and harvesting all adjacent lymph nodes. The descending aorta is completely bared by division of the aortoesophageal branches. Aortic involvement precludes resection. The esophagus is encircled after the dissection is carried medially along the posterior aspect of the mediastinum up to the level of the left main stem bronchus, away from the proximal tumor margin. Gentle traction on the esophagus facilitates dissection of the paraesophageal nodes and fat. The thoracic duct is rarely seen with the left thoracoabdominal approach and is not routinely ligated.
It may be necessary to mobilize the esophagus superior to the level of the aortic arch. Division of aortic intercostal vessels is necessary to gain adequate mobilization of the arch. With mobilization of the arch, the left recurrent nerve must be carefully preserved. In addition, it is at this point that the thoracic duct is most vulnerable to injury, and the left main stem bronchus also must be examined for injury to the membranous wall.
Mobilization of the stomach begins with the division of the greater omentum. This is performed outside the gastroepiploic arcade formed by the left gastroepiploic artery arising from the splenic artery and the right gastroepiploic artery arising from the gastroduodenal artery at the pylorus. Use of the stomach to replace the esophagus hinges on the patency of the right gastroepiploic artery and to a lesser degree, the right gastric artery. The transverse colon is placed on stretch, and the lesser sac is entered at the thinnest portion of the omentum. The dissection is carried toward the pylorus, dividing the small omental branches of the epiploic artery. Cautery coagulation is used sparingly for fear of damaging the gastroepiploic arcade. Dissection then is carried toward the spleen, where the left gastroepiploic artery is ligated at the upper end of the arcade as it arises from the splenic artery. Management of the short gastric arteries deserves special attention, and it must be ensured that the ties on the stomach are secure because they can slip with distention of the stomach within the thorax. Alternative methods for controlling the short gastric vessels include use of the Harmonic Scalpel (Ethicon-Endosurgery, Inc.) or the LDS (US Surgical, Norwalk, CT) stapling device.
At the level of the esophagogastric junction, the reflection of the peritoneum is divided, and the esophagus is encircled. Passage of a Penrose drain allows for upward traction on the abdominal esophagus and dissection of the lesser curve. The thin avascular gastrohepatic ligament is divided, and placement of a second thin Penrose drain around the stomach at the level of the incisura can further assist with dissection of the lesser curve. The gastrohepatic ligament should be inspected for an accessory branch of the left hepatic artery. If one is identified, it should be occluded temporarily with a bulldog clamp and the liver assessed for viability. If concern exists about the vascular supply of the liver, the accessory branch must be preserved. This can be done by skeletonizing the accessory branch to its origin from the left gastric artery and preserving these vessels.
Management of the left gastric artery is best accomplished by exposing it with the greater curve rotated to the right, often with the assistance of the Penrose drains. The filmy retrogastric adhesions can be taken down sharply to the level of the pylorus, and the celiac axis can be identified by palpation. With further dissection, the left gastric artery is exposed, doubly tied, and suture ligated at its origin with 2-0 silk suture. The left gastric vein is also suture ligated and divided. At this point in the operation, the stomach is free except for the pylorus/duodenum and right gastroepiploic artery arising from the gastroduodenal artery.
Transection of the Stomach
For a distal esophagectomy performed for cancer, the celiac axis nodes and the nodes along the left gastric artery should have been swept up with the specimen. The stomach should be transected from a point on the greater curvature opposite the emergence of the left gastroepiploic artery to a point on the lesser curvature below the lowest branch of the left gastric artery. The fundus should be preserved to maximize the length of the gastric tube, and it is important not to assume adequate gastric length and amputate the conduit prematurely (Fig. 21-2). After the stapler is fired and the stomach is divided, the staple line is turned in with 4-0 silk Lembert stitches (Fig. 21-3).
The fundus should be preserved (A, solid line) to maximize gastric length, which permits extension of the gastric tube to the neck (a, solid line) if necessary. For a distal lesion where only a portion of the esophagus needs to be resected (b, dashed line), more of the gastric fundus may be taken in creating the gastric conduit (B, dashed line). It is important not to assume adequate gastric length and amputate the conduit prematurely. The circles marked A′ and B′ indicate the proposed esophagogastric site.
The staple line of the gastric conduit is turned in with interrupted Lembert sutures before completing the anastomosis.
If required, further mobilization of the stomach is performed via a Kocher maneuver starting at the pylorus and extending around the curve of the duodenum. Care must be taken to avoid the right gastric artery and the common bile duct during the dissection. The duodenum and pancreas then are swept off the inferior vena cava by blunt dissection. The Kocher maneuver can mobilize the stomach sufficiently to reach to the thoracic inlet, which is rarely needed for the thoracoabdominal approach.
Drainage of the stomach remains controversial. In our opinion, a gastric drainage procedure makes sense from a physiologic perspective; that is, after vagotomy, there is clinical experience to suggest that obstructive symptoms are encountered without a drainage procedure. A pyloromyotomy is preferred because it does not distract from the length of the stomach. The pyloric muscle may retain some of its barrier capacity against bile reflux into the esophagus (Fig. 21-4). Initially, traction sutures are placed on either side of the pyloric vein to facilitate exposure. Once the submucosal plane is reached, the incision is carried onto the first portion of the duodenum and distal stomach. The myotomy is usually limited to 2 cm. If the mucosa is inadvertently violated, the safest course of action is to convert the procedure to a Heineke-Mikulicz pyloroplasty with coverage of the pyloroplasty with omentum.
A. A 2-cm incision across the pylorus provides exposure of the muscle for division down to the mucosal layer. B. The principal risk of entry is where the duodenal mucosa covers the undersurface of the pyloric muscle.
There are multiple options for performing the gastroesophageal anastomosis. Many advocate for a stapled approach which can be done in a number of different ways. However, we prefer a two-layer hand-sewn technique with interrupted 4-0 silk sutures (Fig. 21-5). Basic principles of performing the anastomosis are (1) to avoid placing crushing clamps on tissue to be included in the anastomosis and (2) to transect the esophagus with a fresh knife blade rather than cautery. No matter how preformed, there must be no tension on the anastomosis. The interrupted fashion of the anastomosis does not allow for purse-stringing and permits blood vessels to reach the anastomotic edge. If the anastomosis is sufficiently secure after these basic principles are followed, there should be no concern about placing the anastomosis in the mediastinum.
A. The first step in the Sweet anastomosis developed at the Massachusetts General Hospital. An end-to-side anastomosis is initiated with excision of a button of gastric wall. This button must not be placed too close to the gastric turn-in. The button actually can be placed quite close to the greater curvature, often between the last two branches of the gastroepiploic arcade. The outer posterior row of the anastomosis is performed with interrupted mattress sutures of fine silk placed across the longitudinal muscle fibers of the esophagus. All these sutures are placed before tying. B. The gastric button has been excised. With the specimen still attached and excluded with the right-angle clamp, the mucosae of the esophagus and stomach are approximated with interrupted fine silk sutures. C. The corner of the anastomosis is turned to begin the anterior row of sutures. These are placed, again in interrupted fashion, with the knots tied on the inside. D. Omentum is brought into the chest and used to wrap the anastomosis.
The anastomosis is performed end (esophagus) to side (gastric tube). A point approximately 2 cm from the gastric suture line is selected, and a small circle of the size of a nickel is scored in the serosa with a knife blade. The small submucosal vessels exposed by this maneuver then are ligated with fine silk. A long right-angled clamp is placed just distal to the planned line of transection and the specimen remains attached to the proximal esophagus and is reflected proximally to expose the planned line of transection. The two-layer anastomosis is performed in the following fashion: The first row of 4-0 silk sutures is placed in a horizontal mattress fashion between the muscularis of the esophagus and the serosa–muscular layer of the stomach. A total of four to six sutures are placed posteriorly and tied while the stomach is brought up to the esophagus (because the esophagus is a fixed structure). This outer posterior layer should cover only one-third of the circumference, which provides exposure for placement of an inner layer.
The esophagus then is opened sharply 4 to 5 mm distal to the initial row of sutures, and the incision is extended to each corner. The mucosal button of the stomach then is opened, and the inner back row of oiled 4-0 silk sutures is placed. Each stitch is placed approximately 5 mm back from the cut edge. The sutures should include the full thickness of the stomach and submucosa and mucosa of the esophagus. Attempts should be made not to manipulate the mucosa. Elevating the previous stitch guides placement of the next. Once the posterior row is complete, the esophagus can be transected. The nasogastric tube is advanced through the anastomosis to the level of the gastric antrum. The anterior inner row is completed in a similar fashion such that the knots are always within the lumen with complete inversion of the mucosa. The outer layer of horizontal mattress sutures is completed over the remaining two-thirds of the circumference. The stomach is suspended by a series of nonabsorbable sutures to the fascia overlying the thoracic spine. Omentum is brought into the chest and used to wrap the anastomosis.
A jejunostomy tube is placed at the conclusion of the case for feeding purposes to speed recovery, to improve nutrition, and to promote healing. Patients are usually discharged on tube feeding and limited oral intake. The jejunostomy tube is usually removed at the first postoperative visit.