Extent of Resection

Patients operated on for recurrent benign esoph-ageal disease should undergo a so-called "standard" esophagectomy. There is no rationale for an en bloc resection or for an extended or three-field lymph node dissection. The lateral extent of resection is determined by identifying the easiest periesophageal plane to work in that permits esophagectomy. Under most circumstances, this dictates dissection directly on the wall of the esophagus. Entering planes lateral to this exposes the patient to a variety of complications: excess bleeding from damage to surrounding structures such as azygos vein, aorta, and inferior pulmonary vein; pulmonary parenchymal injury with resultant air leak; chy-lothorax; pericardial injury associated with postoperative arrhythmias or postpericardiotomy syndrome; and recurrent laryngeal nerve injury.

The appropriate proximal extent of resection is controversial. Patients who have failed medical and conservative surgical management of GERD likely have increased sensitivity to refluxate. This may be manifest as an increased susceptibility to tissue injury and/or a heightened sense of pain and discomfort during esophageal exposure to the refluxate. Limiting the resection to a distal esophagectomy with a low intrathoracic esophagogastric anastomosis predisposes patients to continued reflux because it is difficult to create an effective anti-reflux mechanism in this situation. As a result, most experts recommend performing a near total esophagectomy, creating a high intrathoracic or cervical anastomosis, if the stomach is to be used for reconstruction. It must be kept in mind that, after one or more prior fundoplication operations, the viability of the gastric fundus may be compromised. This increases the risk of anastomotic leak or gastric fundic necrosis when the stomach is used for total esophageal replacement.

Alternatively, a distal esophagectomy with short-segment jejunal interposition may be performed. Because the peristaltic activity of the jejunum is preserved in this setting, it helps prevent reflux of gastric contents into the esophagus. The jejunum is also relatively resistant to acid-peptic injury when used for short-segment esophageal reconstruction. A short-segment colon interposition is not quite as good an alternative for esophageal reconstruction. The colon lacks true peristaltic properties, and therefore does not provide as much protection for the esophagus from gastric contents. However, the colon is very resistant to acid-peptic injury, which makes it the favorite organ among some surgeons for short-segment esophageal reconstruction.

There is no controversy regarding the appropriate distal extent of esophagectomy. All of the squamous mucosa must be removed, necessitating division of the esophagus below the anatomic and histologic squamocolumnar junction. It is useful to visually inspect the margin to ensure this has been accomplished; if a question remains, frozen section confirmation that the distal margin is free of squamous mucosa is appropriate. If residual squamous esophageal mucosa is allowed to remain it will constantly be exposed to gastric acid and digestive pep-tides, resulting in pain, ulceration, stricture formation, or perforation.

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