Approach

The incision(s) used for esophagectomy is tailored to the individual patient's needs first and also to the personal preferences of the surgeon (Table 14.1). In patients in whom possible redo

Table 14.1. Options for technical approaches to esophagectomy.

Approach Left thoracotomy

Laparotomy for transhiatal technique Left thoracoabdominal incision Ivor Lewis incisions or modifications thereof Minimally invasive (especially laparoscopic transhiatal)

Extent of esophageal resection Distal only

Subtotal (high intrathoracic anastomosis) Near total (cervical anastomosis)

Options for reconstruction Gastric pull-up (high intrathoracic or cervical anastomosis) Short-segment bowel interposition Long-segment bowel interposition Composite reconstruction (intrathoracic stomach and bowel or other conduit)

Figure 14.1. Options for surgical approaches to esophagectomy for failed anti-reflux therapy include the transhiatal approach (A + C),an Ivor Lewis resection (A + B), a modified Ivor Lewis esophagectomy (A + B + C), and an exclusive left thoracotomy or left thoracotomy extended across the costal margin into the left upper quadrant of the abdomen (D).

fundoplication is being weighed against possible resection, an approach should be chosen that permits either procedure to be accomplished; either a left thoracotomy or a laparo-tomy is appropriate in such situations (Figure 14.1). In contrast, a right thoracotomy does not permit adequate visualization of the hiatus and is not appropriate when simultaneous access to the chest and abdomen is required.

When the diagnosis remains enigmatic, especially because of a suspicious stricture, a left transthoracic approach permits optimal visualization of the region of interest and facilitates biopsies. A left thoracotomy permits complete esophageal mobilization and allows an easy approach to the gastroesophageal junction and proximal stomach either through the esophageal diaphragmatic hiatus or through a peripheral incision in the diaphragm. When technically feasible, an esophagectomy and reconstruction may be performed through this incision alone; it provides exposure to enable the surgeon to complete the resection and perform reconstruction with stomach or bowel interposition. If necessary, the left thoracotomy incision may be extended across the costal margin into the left upper quadrant to provide additional exposure to the upper abdomen. However, this incision is associated with a higher frequency of chronic postoperative pain and has an appreciable incidence of chondritis.

ESOPHAGECTOMY: INDICATIONSJECHNIQUES, AND OUTCOMES

A laparotomy incision facilitates dissection of a previously performed fundoplication as long as most of the region of interest remains in the abdomen. If an esophagectomy is found to be necessary, the incision may be used as part of a transhiatal esophagectomy or distal esophagec-tomy. However, the amount of scarring that is present when end-stage GERD is the indication for surgery sometimes can make adequate and safe dissection of the distal intrathoracic esophagus difficult. Total esophageal replacement is straightforward after completing a transhiatal esophagectomy. Distal esophageal replacement with a short segment of jejunum or colon is technically feasible under some circumstances using the transhiatal approach.

Reoperative surgery for benign esophageal disease, especially recurrent gastroesophageal reflux, is possible in many patients using laparo-scopic techniques and has been show to be both safe and effective in the hands of experienced laparoscopic surgeons. Similarly, esophagec-tomy is now being performed in some centers using a minimally invasive approach exclusively. Current experience with reoperative minimally invasive esophagectomy is quite limited; such experience is likely to grow in the future as surgeons become more adept at this technically challenging approach.

Herbal Remedies For Acid Reflux

Herbal Remedies For Acid Reflux

Gastroesophageal reflux disease is the medical term for what we know as acid reflux. Acid reflux occurs when the stomach releases its liquid back into the esophagus, causing inflammation and damage to the esophageal lining. The regurgitated acid most often consists of a few compoundsbr acid, bile, and pepsin.

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