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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
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- References (continued)
- Maingot's Abdominal Operations, 12th Edition