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The first 25 slides, exactly as they appear. The full deck has 182 content slides.
General Surgery
Surgical Procedures to Resect and Replace the Esophagus
Built from Maingot's Abdominal Operations
What’s inside
13 sections · 182 slides
Overview
- Scope of this topic
- Three questions every esophagectomy answers
How esophageal resection developed
From an external rubber tube to the modern three-incision operation
- The first esophageal resections
- Torek's transthoracic resection, 1915
- Torek's external rubber tube conduit
- Landmarks after Torek
- Timeline of esophageal resection
- The two operations in common use today
Treatment before surgery
Chemotherapy and radiation given first, and what the trials actually showed
- The case for treating before operating
- Randomized trials of preoperative chemoradiation
- The Walsh trial and its criticisms
- CALGB 9781
- Urschel and Vasan meta-analysis
- Neoadjuvant chemotherapy without radiation
- Chemotherapy versus chemoradiotherapy, head to head
- Why the question stays unsettled
Staging before the decision to operate
CT, PET and endoscopic ultrasound, and what each one can and cannot see
- Why stage IV disease must be identified
- Staging decides who gets treatment first
- Computed tomography in esophageal cancer
- Positron emission tomography
- Endoscopic ultrasound of the esophageal wall
- The five layers seen on endoscopic ultrasound
- Accuracy of endoscopic ultrasound for tumor depth
- Nodal criteria on endoscopic ultrasound
- Surgical staging by laparoscopy and thoracoscopy
- A common staging algorithm
- Staging an obstructed esophagus
Cancer of the cervical esophagus
The neck operation, when to abandon it, and rebuilding to the pharynx
- Team and preparation for a cervical lesion
- Neck incision and when to abandon the operation
- Extent of resection in the neck
- Airway and pharynx during cervical resection
- Reconstruction after cervical resection
Choosing an approach below the thoracic inlet
Tumor level, and the evidence comparing transhiatal with transthoracic resection
- Three levels of the intrathoracic esophagus
- Approach matched to tumor level
- Preference of the authors
- Rindani meta-analysis of the two approaches
- Hulscher meta-analysis: complications by approach
- Hulscher meta-analysis: what it covered
- Goldmine randomized trial, 1993
- Chu randomized trial
- The Dutch randomized trial
- Five-year update of the Dutch trial
- What the randomized trials add up to
- Consequences of where the anastomosis sits
- Blood pressure during transhiatal dissection
Tri-incisional esophagectomy (McKeown technique)
Chest, abdomen and neck - the operation the authors prefer for malignant disease
- Rationale for the tri-incisional technique
- Sequence of the tri-incisional operation
- Endoscopy before the incision
- Positioning and opening the right chest
- Right posterolateral thoracotomy incision and muscle layers
- First steps inside the chest
- Vessels and cautery in the mediastinum
- Protecting the vagus and recurrent nerves
- Dissection at the thoracic inlet
- Parking the Penrose drain for the neck phase
- Completing the lower mediastinal dissection
- Checking for thoracic duct injury
- Closing the chest
- Turning to the abdomen
- Starting gastric mobilization
- Working along the greater curvature
- Dividing the short gastric vessels
- Dissection toward the pylorus
- Taking the left gastric pedicle
- Duodenal mobilization and gastric drainage
- Opening the left neck
- Finding the esophagus in the neck
- Dividing the cervical esophagus
- Delivering the specimen into the abdomen
- Building the gastric tube
- Stapled creation of the gastric conduit
- Final checks before the pull-up
- Delivering the conduit to the neck
- Camera bag secured around the gastric conduit
- Gastric conduit drawn through the posterior mediastinum
- Hand-sewn cervical anastomosis
- Stapled cervical anastomosis
- Closing the stapled anastomosis
- Finishing the neck and the abdomen
Ivor Lewis technique
Abdomen then right chest, with the anastomosis high inside the thorax
- Abdominal phase of the Ivor Lewis operation
- Repositioning for the chest
- Margin and the level of the anastomosis
- Churchill and Sweet double-layer anastomosis
- Completing the double-layer anastomosis
- Handling tissue and fixing the conduit
- Esophagogastric anastomosis in the apical right chest
- Closing the chest after Ivor Lewis resection
Transhiatal technique
Freeing the chest esophagus by hand, through the hiatus and the neck
- When the transhiatal approach is appropriate
- Positioning and opening the hiatus
- Mediastinal dissection from below
- Neck exposure in the transhiatal operation
- Freeing the cervical esophagus
- Blunt posterior dissection
- Blood pressure during the blind dissection
- Blunt anterior dissection
- Releasing the lateral attachments
- Finishing the transhiatal operation
Left thoracoabdominal approach
A compromise operation for the distal esophagus and the GE junction
- Limits imposed by the aortic arch
- Reflux risk and the best indication
- Incision options
- The most versatile thoracoabdominal setup
- Diaphragm incision and mediastinal dissection
- Proximal margin from the left chest
- Gastric mobilization through this incision
- Conduit and anastomosis from the left chest
- Extending to the neck and closing
Alternative conduits: colon and jejunum
What to build the new esophagus from when the stomach cannot be used
- Why the stomach is first choice
- Order of preference for the conduit
- Left colon versus right colon
- Preparing a patient for colon interposition
- Mobilizing the left colon
- Testing the colonic blood supply
- Preparing the stomach and measuring the conduit
- Isolating the colon conduit
- Routes for the colon conduit to the neck
- Proximal anastomosis of a colon conduit
- Cologastric anastomosis and fixation
- When the right colon is needed
- Preparing the right colon conduit
- Vascular pedicle of the right colon conduit
- The ileocecal valve question
- Delivering a right colon conduit
- Making room behind the sternum
- Three ways to use jejunum
- Where jejunum fits among the conduits
- Preparation before jejunal interposition
- Roux-en-Y replacement: indication and length
- Testing and routing the Roux limb
- Reaching the esophagus with a Roux limb
- Stapled esophagojejunostomy
- Preventing hernia and tension
- Pedicled jejunal interposition: indication and incision
- Building the pedicled jejunal segment
- Routing and joining the pedicled graft
- Free jejunal transfer: when it is needed
- Trade-offs of a free jejunal graft
- Technique of free jejunal transfer
- Microvascular anastomosis and monitoring
Complications and how to avoid them
Leak, stricture, nerve injury, pneumonia, bleeding, chyle leak, poor emptying
- How often anastomoses leak
- Why a cervical anastomosis leaks more often
- Risk factors for anastomotic leak
- Hand-sewn versus stapled anastomosis
- Intrathoracic leak: severity and warning signs
- Confirming and treating an intrathoracic leak
- Cervical leak: presentation
- Draining and detecting a cervical leak
- Anastomotic stricture: frequency
- Risk factors for stricture
- Protecting the blood supply of the anastomosis
- Stapler size and stricture
- Treatment of anastomotic stricture
- Recurrent laryngeal nerve injury: risk
- Why the left neck is used
- Technique that lowered nerve injury
- Recognising recurrent nerve injury
- Acting on recurrent nerve injury
- Respiratory failure now leads mortality
- Pneumonia rates by approach
- Reducing pulmonary complications
- Bleeding after esophagectomy
- Avoiding bleeding during dissection
- Course of the thoracic duct
- Chyle leak: frequency and prevention
- Diagnosing a chyle leak
- Bedside test and why chyle leak matters
- Operative repair of a chyle leak
- Interventional treatment of chyle leak
- Factors that slow conduit emptying
- The pyloroplasty trial
- Conduit width, drainage and emptying
Volume, experience and outcome
Where the operation is done changes the chance of surviving it
- 25%
- What decides the risk of the operation
- Key points: selecting patients and approach
- Key points: conduits and their blood supply
- Key points: avoiding complications
- References
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- Maingot's Abdominal Operations, 12th Edition