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Esophagectomy. Hashmi. The choice of the appropriate technique for esophagogastrectomy depends on many factors the location of the tumor the stage of disease the risk profile of the patient the route through which the replacement conduit is to be placed

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slide2
The choice of the appropriate technique for esophagogastrectomy depends on many factors
    • the location of the tumor
    • the stage of disease
    • the risk profile of the patient
    • the route through which the replacement conduit is to be placed
    • the intended extent of lymphadenectomy
    • the experience and preference of the surgeon
slide3
Primary tumor (T)

TX: Primary tumor cannot be assessed

T0: No evidence of primary tumor

Tis: Carcinoma in situ

T1: Tumor invades lamina propria or submucosa

T2: Tumor invades muscularis propria

T3: Tumor invades adventitia

T4: Tumor invades adjacent structures

Regional lymph nodes (N)

NX: Regional lymph nodes cannot be assessed

N0: No regional lymph node metastasis

N1: Regional lymph node metastasis

Distant metastasis (M)

MX: Distant metastasis cannot be assessed

M0: No distant metastasis

M1: Distant metastasis

slide4
first hyperechoic layer (interface between lumen and mucosa)
  • second hypoechoic layer (deep mucosa including muscularis mucosa)
  • third hyperechoic layer (submucosa)
  • fourth hypoechoic layer (muscularis propria)
  • fifth hyperechoic layer (adventitia interface).
  • accuracy of EUS
    • 85% in assessing depth-of-wall penetration
    • 80% for assessment of nodal status
  • malignant lymph node:
    • >1cm
    • round
    • hypoechoic
    • distinct margins
slide5
Most common worldwide  Squamous (upper two-third)

smoking & alcohol

Most common in US/UK  Adenocarcinoma (lower third)

Barrett’s esophagus

Pulmonary complication rates

27% transhiatal

57% transthoarcic

Ventilation time, intensive care time, and hospital stay

longer for the transthoracic group

in-hospital mortality rates similar

2% transhiatal

4% transthoracic

lymph nodes

more harvested in transthoracic group

survival benefit

no significant difference for leaks

stapled 9%

hand-sewn 8%

strictures

stapled 27%

hand-sewn 16%

slide6
Pharyngolaryngoesophagectomy (PLE)

cervical esophageal cancer

laryngectomy and tracheostomy

pharyngogastric anastomosis in neck

McKeown / 3-field

Left Neck, Right Thoracotomy, Abdominal

Neck anastamosis

Ivor-Lewis / Lewis-Tanner

Right Thoracotomy & Abdominal

Thoracic anastamosis

Transhiatal

Abdominal & Left Neck

Neck anastamosis

Thoracoabdominal

Left 7th or 8th rib space

Minimally Invasive

slide7
largest randomized trial
  • 106 patients transhiatal
  • 114 patients transthoracic
  • mid-lower third/cardia adenocarcinomas
  • Pulmonary complication rates
    • 27% transhiatal
    • 57% transthoarcic
  • Ventilation time, intensive care time, and hospital stay
    • longer for the transthoracic group
  • in-hospital mortality rates similar
    • 2% transhiatal
    • 4% transthoracic
  • lymph nodes
    • more harvested in transthoracic group
    • survival benefit
slide8
Unresectable if local infiltration
    • Tracheobronchial tree
    • Aorta
    • Vertebrae
    • peritoneal metastases
    • Liver metastases
    • Celiac nodes
  • Transhiatal esophagectomy is indicated in virtually every condition for which esophageal resection and reconstruction is required
slide9
THE is performed in four phases
    • Abdominal
    • Cervical
    • Mediastinal
    • Anastomosis
slide12
the gastrocolic omentum off the greater curvature
  • preserving the right gastroepiploic vessels and arcades
  • short gastric vessels are ligated
  • gastrohepatic ligament is then detached
  • left gastric artery
slide13
triangular ligament of the liver exposing phrenoesophageal attachments and diaphragmatic hiatus
  • mobilization to the level of the carina
  • vagotomy in theory will inhibit gastric emptying
  • 13% of patients who did not have a drainage procedure had postoperative holdup at the pylorus
  • pyloroplasty vs pyloromyotomy
  • pyloromyotomy is not converted to pyloroplasty
    • avoid a suture line at right angles to the vertical axis of the stomach
  • 14 French rubber Weitzel jejunostomy feeding tube
slide14
oblique incision
  • anterior boarder of the left sternocleidomastoid muscle
  • omohyoid divided
  • carotid sheath retracted laterally
  • larynx and trachea retracted medially
  • blunt dissection with index finger
slide18
one or two layered, interrupted or continuous, hand-sewn, or stapled
  • viability & tension predispose to anastamotic breakdown
  • nasogastric tube is advanced through the anastomosis
slide20
bleeding from inadequate hemostasis during surgery
  • hypotension from insufficient volume replacement
  • hypotension may jeopardize the viability of the substitute
  • Arrhythmia
    • atrial fibrillation and supraventricular tachycardia
  • Respiratory complications
    • sputum retention, morphine / epidural catheter, atelectasis, pneumonia with or without aspiration
    • major causes of death
  • Decompression of the esophageal substitute by a nasogastric tube
  • Adequate nutritional support via feeding jejunostomy tube
  • Gastrografin contrast swallow is performed 1 week
slide21
no significant difference for leaks
    • stapled 9%
    • hand-sewn 8%
  • strictures
    • stapled 27%
    • hand-sewn 16%
  • Leaks that communicate with the mediastinum require exploration
  • methylene blue dye orally or water-soluble contrast study
  • leak-related mortality  1%
slide22
splenic injury necessitating a splenectomy  3%
  • membranous tracheal laceration  <1%
  • gastric/duodenal mucosa during a pyloromyotomy  <2%
  • bleeding  1%
  • recurrent laryngeal nerve injury  <5%
  • pulmonary complications  <2%
  • chylothorax  <1%
  • anastomotic leak  <3%