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Esophagectomy

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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Esophagectomy

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  1. Esophagectomy Hashmi

  2. 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

  3. 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

  4. 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

  5. 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%

  6. 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

  7. 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

  8. 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

  9. THE is performed in four phases • Abdominal • Cervical • Mediastinal • Anastomosis

  10. 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

  11. 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

  12. 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

  13. one or two layered, interrupted or continuous, hand-sewn, or stapled • viability & tension predispose to anastamotic breakdown • nasogastric tube is advanced through the anastomosis

  14. 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

  15. 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%

  16. 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%

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