Of The Esophagus

After it is established that the patient is a surgical candidate and that the tumor is resectable, there are several surgical procedures that can be successfully used. It is important to note that tumors of the gastric cardia can be included in the category of malignant tumors of the lower third of the esophagus. These tumors are usually adenocarcinomas, whereas most tumors of the esophagus are squamous cell carcinomas.

Resection of malignant tumors of the lower esophagus consists of esophagogastrectomy including removal of the esophagus and proximal stomach with margins of at least 5 cm at either end, as well as resection in continuity of para-esophageal and left gastric and celiac axis lymph nodes. The extent of proximal esophageal resection is the most controversial, i.e. should only a 5 cm margin be achieved with an anastomosis in the chest or should the entire esophagus be removed? Our approach is to perform a total esophagectomy for several reasons.

First, removing the entire esophagus permits resection of any further possible source of malignancy in the proximal esophagus. It has been found that there is some frequency in which proximal esophageal carcinoma occurs simultaneous with distal esophageal carcinoma, and removal of the entire esophagus obviates this. Additionally, total esophagectomy performed via the transhiatal approach obviates the need for a thoracotomy. An Ivor-Lewis resection with gastroesoph-ageal anastomosis, which will be described later, is a useful procedure and may be done depending on the surgeon's preference.

The transhiatal approach to esophagectomy is as follows: The patient is placed in the supine position and an upper midline abdominal excision is performed. An exploration and assessment of resectability is done. This is performed by taking down the greater omentum and the left gastroepiploic and short gastric vessels to mobilize the greater curvature of the stomach. The lesser sac is then entered and the left gastric vessel taken via the lesser sac. The esophagus is mobilized at the hiatus and a Penrose drain placed about this. The hand is placed up the hiatus, taking as many perforating vessels as possible with clips. One then mobilizes up into the mediastinum going behind the heart and carina and watching for hemodynamic stability, so as not to compress the heart too much with the hand (Fig. 17.3). With the esophagus completely imobilized high into the mediastinum, an extensive Kocher maneuver is done, as well as a pyloromyotomy, which may be done in one of several ways. One is to incise the serosa and muscular coat of the pylorus, leaving the mucosa intact. Another way is to finger-fracture the pylorus and simply fracture the mucosa and muscular layers. The left gastric and left gastroepiploic vessels are taken. Hence, the entire blood supply of the stomach comes from the right gastric and right gastroepiploic vessels and these should be left intact.

While the abdominal mobilization is being performed, a second team of surgeons operates via a left neck approach to mobilize the cervical esophagus. An incision is made parallel to the sternocleidomastoid retracting the muscle and carotid sheath laterally and the thyroid gland medially. A finger is placed on the anterior portion of the vertebral body and a space dissected retroesophageally. The gloved finger is used to surround the esophagus with special care on the right side to hug the surface of the esophagus to avoid the right recurrent nerve. This is an important point. Most surgeons like to dissect the esophagus in the left neck not only because the esophagus lies more on the left than on the right in the neck, but also because there is less chance of injury to the recurrent nerve on the right

Fig 17.3. Blunt transhiatal esophagectomy. The stomach has been mobilized in the abdomen and the esophagus has been mobilized in the neck. The surgeon's hand bluntly frees the esophagus within the mediastinum. If the esophagus is felt to be adherent to mediastinal structures, direct exposure is obtained through a thoracotomy or the procedure is terminated.

SURGEON S HAND BLUNTLY MOBILIZING ESOPHAGUS FROM BELOW

side when the gloved finger is used to go around the esophagus from the left side. This, however, is not an absolute surgical principle, and some surgeons still do the esophageal dissection from the right neck.

The esophagus is then mobilized deep into the superiormost portion of the mediastinum. This is facilitated by transsection of the strap muscles including the omohyoid. The esophagus is then hemi-transsected. The vein-stripper is passed into the stomach from below through a hole in the lesser curve of the stomach. The vein-stripper is then passed up out of the esophageal hole the neck, and the esophagus is transsected completely and stripped down from above into the abdomen. The GIA staple gun is then used across the angle of His down to the lesser curve to resect this portion of the stomach, taking care not to injure the right gastric artery.

The esophagogastrectomy specimen is then sent to pathology and the margins checked on frozen section. A moist, plastic bag is placed on the stomach remnant and suction applied to the stomach bag going through the mediastinum. The entire apparatus is smoothly dragged up the mediastinum into the neck. The plastic bag allows for a smooth placement of the stomach into the neck. The two layer anastomosis is then performed between the antrum of the stomach to the esophagus. A Penrose drain is placed in the neck and feeding jejunostomy performed.

An additional advantage of this approach is that there is no intrathoracic anastomosis which may leak and cause sepsis. If a leak occurs in the cervical esophago-gastrostomy portion, this is a much less lethal condition and can be easily drained via the Penrose neck drain.

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