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After placing a dual-lumen endotracheal tube in the correct position, as confirmed by bronchoscopy, an 18F nasogastric tube is placed. The patient is placed in the right lateral decubitus position with the arm positioned such that it is flexed 45 to 90 degrees at the shoulder and elbow. The bed is then flexed at the patient's hips to widen the intercostal spaces. The surgeon stands to the patient's left side with the assistant to the patient's right side (Fig. 22-1).
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The patient's skin is prepared and draped widely to the right of the midline in the event that a laparotomy or thoracoabdominal incision is required. The eighth rib is identified by counting the ribs from caudad to cephalad by palpation. The skin is incised over the seventh intercostal space from 4 cm lateral to the costal margin to the posterior axillary line. The latissimus dorsi muscle is divided, but care is taken to preserve the serratus anterior muscle by freeing the inferior attachment of the muscle and thus allowing the muscle to be retracted superiorly. The ribs are again counted to confirm the position of the eighth rib. The seventh intercostal space is entered along the superior edge of the eighth rib. For patients who receive preoperative chemotherapy and radiation, the seventh intercostal muscle bundle is harvested during entry into the thorax to buttress the esophageal anastomosis.
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The rib is cut posteriorly just at the junction of the paraspinous muscles, and a small portion of the rib is resected. A rib spreader is used to permit exposure of the left chest. A systematic exploration of the left hemithorax is performed, and mediastinal lymph nodes are sampled for staging. The inferior pulmonary ligament is divided to permit cephalad retraction of the left lung, and the inferior pulmonary ligament lymph nodes (level 9) are removed for pathologic staging. The lung may be palpated for evidence of metastasis.
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The mediastinal pleura overlying the esophagus is incised anteromedially in a plane along the pericardiopleural reflection and posterolaterally along the medial aspect of the aorta (Fig. 22-2A). Dissection is continued for several centimeters superiorly and inferiorly to permit sufficient mobilization of the esophagus to identify and palpate the tumor. The nasogastric tube is used as a guide to identify the plane of dissection, and the esophagus is mobilized circumferentially using blunt finger dissection and then encircled with a Penrose drain (Fig. 22-2B). Esophageal mobilization is continued proximally to a point 5 cm above the superior edge of the tumor and distally until the surgeon's fingers can pass easily into the abdomen.
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After the esophagus is fully mobilized, the diaphragm is incised in a semilunar fashion approximately 2 to 4 cm from the costal margin. Given the direction of travel of the phrenic nerve fibers, radial incisions should be avoided on the diaphragm to prevent postoperative diaphragmatic paresis. As the diaphragm is being divided, marking sutures are placed on both sides of the divided diaphragm approximately every 5 cm along the incision line to assist with proper orientation of the diaphragm during closure. Care must be taken not to injure the underlying spleen or left colon.
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After dividing the diaphragm, the surgeon next explores the abdomen, paying particular attention to the celiac axis and liver. The peritoneum overlying the gastroesophageal junction is incised, and the gastroesophageal junction is freed by blunt finger dissection. The gastroesophageal junction then is encircled with a second Penrose drain (Fig. 22-3). A Harrington retractor is used to retract the left lateral lobe of the liver medially to provide exposure of the hiatus. Gentle retraction with a laparotomy pad or “sponge stick” over the spleen completes the exposure.
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The peritoneal reflection is incised to the left of the hiatus close to the gastric serosa. The peritoneum overlying the short gastric vessels is divided, and the vessels themselves are divided using a Harmonic Scalpel (Ethicon-Endosurgery, Inc.), taking care to divide the short gastric vessels well away from the gastroepiploic artery to maximally preserve the right gastroepiploic artery. If involved with tumor, the spleen may easily be included with the specimen. The stomach is further mobilized by dividing the posterior attachments. Care should be taken to identify, ligate, and divide the “unnamed” posterior gastric vessels, which arise as direct branches of the splenic artery and vein. These vessels are commonly encountered in the lesser sac, and inadvertent injury may result in significant hemorrhage.
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The mobilized stomach is grasped and retracted superiorly and to the right by the first assistant, standing to the right side of the patient. With the stomach retracted in this manner, the surgeon achieves excellent exposure of the lesser sac, and the left gastric artery and vein can be identified (Fig. 22-4). Palpation with the surgeon's right hand will permit identification of the celiac trunk branching from the aorta. Any celiac lymph nodes encountered are dissected free and are included with the specimen. Next, the left gastric artery and vein are sharply dissected, separately ligated over a clamp with 2-0 silk suture ligature, and divided. Alternatively, we now use an endoscopic linear vascular stapler with a white (vascular) load to divide the left gastric artery.
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With the stomach now fully mobilized, attention is directed to fashioning the gastric conduit. The nasogastric tube is pushed toward the lesser curvature in preparation for dividing the stomach. The gastric conduit is created using multiple firings of an endoscopic linear stapler with a large green load along a line parallel to the greater curvature of the stomach to create a gastric tube approximately 3 to 4 cm wide, eventually transecting the stomach from the specimen. The length of the conduit is determined by the location of the tumor and the proximal extent of the planned esophagectomy because a minimum of 5 cm of stomach distal to the tumor should be included with the conduit (Fig. 22-5). The staple line is reinforced using 3-0 silk interrupted Lembert sutures.
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The esophagus and proximal stomach specimens then are delivered into the chest through the diaphragm. Next, the gastric conduit is passed through the hiatus into the chest and is positioned without twisting or tension along the aorta in preparation for anastomosis.
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The esophagogastrostomy is performed as a two-layer anastomosis. The posterior wall anastomosis is performed before the esophagus is divided and the specimen is removed, because by retracting the intact specimen superiorly, the posterior esophagus is exposed to facilitate suturing (Fig. 22-6). The posterior wall outer-layer anastomosis is performed using interrupted 3-0 silk horizontal mattress sutures (Fig. 22-7A). After the posterior row of sutures is placed, the posterior esophagus is opened using an angled knife blade. The anterior half of the esophagus is not yet divided, again to permit traction on the specimen to expose the anastomotic site. Any large arterial vessels that are bleeding are point cauterized, but care is taken to minimize electrocautery along the anastomotic line.
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The gastrotomy is performed next, also using sharp incision through the gastric serosa and then mucosa. The inner layer of the anastomosis is performed using 4-0 interrupted absorbable sutures taking full-thickness bites of the esophagus and large seromuscular and small mucosal bites on the stomach (Fig. 22-7B). When the posterior half of the inner row of sutures is completed, the sutures are placed on clamps and retracted laterally, and the remainder of the esophagus is transected along a bevel to create a slightly longer esophageal length anteriorly than posteriorly (Fig. 22-7C). Before completing the anastomosis, the nasogastric tube is advanced under direct vision through the anastomosis and into the stomach (Fig. 22-7D). The anterior inner full-thickness anastomosis is then completed such that the knots are within the lumen at the completion of the inner layer. Finally, the anterior outer layer of interrupted 3-0 silk horizontal mattress suture is placed to complete the anastomosis.
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At this point, the anastomosis may be further buttressed by using an intercostal muscle bundle harvested during initial thoracotomy. The intercostal bundle is secured over the anastomosis with interrupted 3-0 absorbable sutures. Alternatively, the stomach may be used to reinforce the anastomosis (Fig. 22-7E). By taking a second row of Lembert sutures over the anterior suture line, the stomach serves to bury the entire anterior suture line, creating a so-called “ink well.” Some surgeons prefer a stapled anastomosis for this approach as well, in which case a circular load is probably easier than a linear load. After this, any redundant stomach is returned to the abdomen to avoid future technical issues related to torsion or sacculation of the gastric conduit.
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After ensuring adequate hemostasis, attention is directed to closing the diaphragmatic defect. The previously placed sutures within the diaphragm are used as markers for orientation, and the diaphragm is reapproximated using interrupted figure-of-eight absorbable monofilament sutures. To prevent herniation into the abdomen and subsequent traction on the anastomosis, the gastric tube may be secured to the mediastinal pleura and/or diaphragm with a number of interrupted 3-0 silk sutures. The chest is drained with a single 36F chest tube placed inferiorly and posteriorly to provide dependent drainage. After thorough reexpansion of the lung, the chest is closed using #1 absorbable PDS suture for the paracostal sutures, as well as #1 absorbable running suture to reapproximate the muscle layers. The subcutaneous tissues are closed using a 2-0 absorbable suture in a running fashion, and the skin is reapproximated with a running 3-0 subcuticular suture.
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Before the patient emerges from anesthesia, the nasogastric tube is secured in position using a bridle technique by passing an umbilical tape around the choana or suturing the tube to the septum with a large nylon suture. The patient is extubated in the OR after gaining consciousness.