Esophagectomy Hashmi The choice of the appropriate technique

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Esophagectomy

• Hashmi

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• 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

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• 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

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• 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
• gt1cm

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• Most common worldwide ? Squamous (upper
  two-third)
• smoking alcohol
• Most common in US/UK ? Adenocarcinoma (lower
  third)
• Barretts 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

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• 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

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• 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

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• 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

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

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• 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

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• 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

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• 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

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

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• 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

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• 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

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• splenic injury necessitating a splenectomy ? 3
• membranous tracheal laceration ? lt1
• gastric/duodenal mucosa during a pyloromyotomy ?
  lt2
• bleeding ? 1
• recurrent laryngeal nerve injury ? lt5
• pulmonary complications ? lt2
• chylothorax ? lt1
• anastomotic leak ? lt3