Of The Esophagus

Lesions in the mid-esophagus, constitute a much more difficult situation because of the possibility of local invasion into major mediastinal structures, in particular into the trachea and mainstem bronchi, as well as hilar vessels. First one must try to assess resectability in terms of the lesion; this is initially done by examination of the patient followed by CT scan to assess the proximity of the lesion to other major mediastinal structures. It is very important also to do bronchos-copy in these patients to assess the airway. However if there is still a question of encasement of the major mediastinal structures and the patient is still considered a candidate for surgery, the patient should be positioned for a right posterolateral thoracotomy and a 5th and 6th intercostal space incision made. The entire esophagus is mobilized and the tumor dissected free of surrounding structures after ensuring that this is indeed possible.

After the esophagus is entirely mobilized, but without transsecting it, the patient's chest is closed with a chest tube inserted for drainage. The patient then lays supine and a standard laparotomy and cervical dissection are performed for a transhiatal esophagectomy. Figure 17.4 illustrates a patient with esophageal cancer managed in this manner.

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