32

Abdominal and right thoracic esophagectomy

S. Michael Griffin and Shajahan Wahed

HISTORY

Before 1946, the only widely practiced approach to the thoracic esophagus had been described by Sweet using a left-sided thoracotomy. Although this operation permitted relatively good access to the lower third of the esophagus, cancers of the middle and upper third of the esophagus were dissected with greater difficulty because of the overlying aortic arch. In 1946, Ivor Lewis described the abdominal and right thoracic approach for subtotal esophagectomy. This operation was adopted by Tanner in the United Kingdom (Lewis-Tanner operation) and by Santy in France (LewisSanty operation). This has remained the favored operation for an abdominal and right thoracic subtotal esophagectomy.

PREPARATION

A two-stage resection with a two-field lymphadenectomy is the procedure of choice for lower and middle third esophageal cancers, and types I and II junctional cancers. Prophylactic antibiotics are administered. A pneumatic calf compression device is used to reduce to the risk of venous thromboembolism. It is our practice to ask the radiologists to insert an inferior vena cava filter preoperatively in patients who already have proven venous thromboembolism on staging imaging. This is more likely after neoadjuvant chemotherapy. Epidural analgesia is established before anesthetizing the patients. A double lumen endotracheal tube and a nasogastric tube are inserted after induction. The patient is positioned supine with both arms extended and catheterized. A headlight is used routinely to improve visualization. The operation should be performed with minimal blood loss; precise dissection and meticulous hemostasis are crucial.

ABDOMINAL APPROACH

Access and exposure

Access for the gastric mobilization and abdominal lymphadenectomy is achieved with an upper midline incision skirting the umbilicus and extending to the xiphisternum (see Figure 32 .1a). Excision of the xiphisternum improves access. A rooftop incision is a suitable alternative strategy particularly in patients with a wide angle at the costal margin. A wide exposure is achieved by using a retraction device fixed to the table such as the Omni-Tract® (see Figure 32 .1b). A careful laparotomy is performed to exclude the presence of abdominal metastases. The ligament attaching the tip of the left lobe of the liver to the diaphragm is occasionally divided. One blade of the retractor is used to retract the left and caudate lobes of the liver once the pars flaccida has been divided close to the liver edge. This provides full access to the lesser curve and the right crus.

Gastric mobilization

The stomach is the standard conduit used to replace the resected esophagus (see Chapter 30, “Use of the stomach as an esophageal substitute”). It is imperative that the right and left gastroepiploic vascular arcades are identified before any dissection commences. The operator needs to be aware of the variations in the extramural anastomoses between the two gastroepiploic arteries so that these can be identified. All vessels associated with the greater curve are preserved to optimize the vascularity of the gastric conduit.

The initial dissection releases any adhesions from the gastrosplenic ligament to the lower pole of the spleen, as this reduces the risk of an inadvertent traction injury. The authors use bipolar diathermy for this and much of the rest of the dissection. Placing the patient in a reverse Trendelenburg position will aid exposure. The dissection of the greater curve must always maintain a safe distance away from the arcade (see Figure 32 .2). The authors advocate the preservation of omental fat along the greater curve. This fat can be used to cover the anastomosis and gastrotomy in the chest, and protect the membranous part of the trachea from the anastomosis. This precaution reduces the chance of a fistula. Avoid taking excessive amounts of omentum, as this will make subsequent delivery of the stomach through the hiatus difficult.

Once the window between the left gastroepiploic and short gastric arteries is identified, the dissection can migrate closer to the stomach. The short gastrics can be individually dissected, ligated, and divided. The use of a right-angled clip helps isolate and circumvent the vessels before ligation. Division of the short gastric vessels in this way can be difficult and time-consuming, particularly in the obese patient. The newer ultrasonic energy devices can make the dissection and division easier, although use of such devices should not be an excuse for poor dissection and isolation of the vessels. An inadequate dissection and subsequent use of the device on only part of a vessel can lead to troublesome bleeding. The dissection is continued on to the left crus. It is usual practice to take part of both crura en bloc with the specimen. The pars flaccida is dissected up to the right crus.

The duodenum is kocherized and the adhesions between the hepatic flexure and duodenum divided. The “C” of the duodenum is mobilized. These three maneuvers reduce the tension on the stomach and allow the stomach to be delivered easily into the chest with the pylorus positioned at or above the level of the hiatus.

The dissection along the greater curve is taken distally as far as the origin of the right gastroepiploic vessels. It is not necessary to completely skeletonize these vessels, as any inadvertent injury may jeopardize the blood supply to the conduit.

En bloc abdominal lymphadenectomy

The stomach can now be lifted cranially or retracted caudally to allow dissection of the common hepatic nodes. The tissues can be grasped gently with Wangensteen forceps to minimize bleeding. The dissection can be performed with a variety of techniques but the use of forceps diathermy or bipolar diathermy scissors allows for precise dissection and reduces the risk of bleeding from small vessels. The dissection follows closely the line of the common hepatic artery back to its origin and the proximal splenic artery is also dissected in the same way. The left gastric vein is isolated and ligated in continuity with a 2-0 absorbable suture. The dissection leads on to the left gastric artery and celiac axis. All nodes around the left gastric artery and celiac trunk are removed en bloc. The left gastric artery is ligated in continuity then divided (see Figure 32 .3). The suture on the specimen side is cut long to help with identification of the left gastric nodes when the specimen is dissected ex vivo. The remainder of the tissue from the left gastric territory up to the hiatus is dissected upward onto the stomach until it is completely mobilized (see Figure 32 .4).

The dissection should continue through the hiatus, removing all the fat from the posterior aspect of the pericardium. The assistant could use a copper blade retractor or a renal vein retractor to provide optimum exposure. Both pleurae are dissected and the para-aortic tissue dissected off the aorta. Care needs to be taken not to damage the cisterna chyli. This is particularly vulnerable in thin patients.

Pyloroplasty

A pyloroplasty is routinely performed by the authors to improve gastric emptying and reduce the risk of aspiration. The authors use 3-0 PDS (polydioxanone) stay sutures inserted either side of the center of the pylorus. A small (1 cm) incision is made using diathermy to divide the pylorus longitudinally (see Figure 32 .5). Suction is applied to remove bile or gastric juices through the pyloroplasty. The pyloroplasty is closed transversely with 3-0 PDS sutures, ensuring the corners are inverted. Each bite should incorporate a small amount of mucosa. A Gambee-type suture incorporating a circle of the mucosa and submucosa reduces the risk of bleeding. Often, only three sutures are required to close the pyloroplasty.

Feeding jejunostomy

It is the authors’ practice to routinely insert a feeding jejunostomy. This is an important procedure and meticulous attention to detail is crucial to minimize complications. It allows for early enteral nutrition but, most important, allows for postoperative feeding in the event of complications preventing oral intake. A suitable loop of proximal jejunum is identified by tracing distally away from the duodenal-jejunal flexure. The loop should reach the left side of the abdominal wall without tension. The authors’ preference is to use a 14 Fr MIC feeding tube (Kimberly-Clark, Ballard Medical Products, USA). The jejunostomy is flushed through with sterile saline. A small stab incision in the skin is made and a clip passed from the peritoneal side to exit through this incision. The tip of the feeding tube is grasped and pulled through to the peritoneal side. The tube is much longer than required so it can be shortened so that it is approximately 30 cm in length. A seromuscular purse-string suture is inserted into the chosen loop of jejunum on the antimesenteric aspect.An absorbable suture such as a 2-0 Vicryl should be used. Diathermy is used to make a stab incision into the jejunal lumen and this is widened just enough with a mosquito forceps or small artery clip to allow insertion of the feeding tube. The tube is inserted and advanced along the jejunum, ensuring that the tip is in the lumen and not within the wall of the jejunum. Slow flushing of the tube during this stage aids in the smooth passage of the tube and reduces the risk of coiling. A distance of approximately 2 cm is left between the distal end of the jejunostomy balloon and the entry point in the lumen. The purse-string suture is ligated and then the suture ends are wrapped around the tube itself and retied. This prevents slippage of the jejunostomy tube out of the jejunal lumen.

A Witzel tunnel is created using seromuscular 2-0 Vicryl sutures either side of the tube to cover the length between the distal balloon end and the entry point. It is important not to narrow the jejunal lumen when doing this. Interrupted 2-0 Vicryl sutures are inserted to secure the peritoneum to the jejunal wall all around the start of the Witzel tunnel. The lateral suture is inserted first and clipped. At least one more of the sutures is inserted before pulling the feeding tube back so that the balloon sits within the abdominal wall. The sutures can now be tied and a total of three or four sutures are used to secure the peritoneum to the jejunal wall. A slit is made in the omentum so that it can lie either side of the jejunostomy. A further 2-0 Vicryl suture is inserted above the jejunostomy site incorporating peritoneum, omentum, jejunum, omentum and then tied. A similar suture below the jejunostomy site ensures that there is no fulcrum around which the jejunum can kink or twist and that the omentum is anchored in place. Creating this omental wrap reduces the possibility of infracolic bowel herniating through the widened hiatus. The jejunostomy is flushed to ensure there is free flow (see Figure 32 .6). The bolster is secured loosely to the skin with interrupted 3-0 Ethilon sutures and the balloon is filled with 1-4 mL of water.

The abdominal cavity is washed with water and hemostasis checked, particularly around the lymph node dissection sites. The authors’ preference is for 1 nylon sutures to close the midline and 3-0 subcuticular Monocryl sutures for the skin.

THORACIC APPROACH

Right posterolateral thoracotomy

The patient is secured in a left lateral decubitus position with the right arm rotated forward across an arm support. A posterolateral incision following the line of the ribs is made, skirting below the tip of the scapula, aimed toward the nipple, and terminating at the anterior axillary line. Diathermy and a bipolar electrosurgical tissue-sealing device are used to dissect through the tissues and divide the latissimus dorsi and serratus anterior muscles. The rib spaces are counted after insertion of the hand anterior to the scapula and pushed toward the apex. The 4th intercostal space should be used to allow for an anastomosis toward the apex of the thoracic cavity and permit a supra-azygos dissection if required. For middle-third squamous lesions, the 3rd rib space may be needed. Too low an incision makes this part of the operation difficult. The intercostal muscles are dissected off the top of the rib for the identified rib space with diathermy. A small incision is made to breach the pleura, ensuring the underlying lung is not damaged. At this stage, the anesthetist should be asked to deflate the right lung. The remainder of the pleura in the rib space is opened while a retractor is used to protect the underlying lung. One centimeter of the neck of the rib is excised to allow improved exposure and retraction while reducing the risk of uncontrolled rib fractures. The intercostal nerve is stripped along the rib, ligated, and excised. It is the authors’ experience that this reduces the incidence of postthoracotomy wound pain. The rib space is gradually opened using a rib spreader. A retraction device such as the Omni-Tract® or a Finochietto is used to gain exposure.

Stay updated, free articles. Join our Telegram channel

Join