A vagal-sparing procedure should be considered in any patient with a benign process that is to undergo esophagectomy. Ideal conditions include achalasia, end-stage reflux disease, and Barrett's with high-grade dysplasia or perhaps intramucosal cancer. Absolute contraindications for a vagal-sparing esophagectomy are the need for a lymphadenectomy because sparing the vagus nerves precludes a lymph node dissection, and prior vagal transection or evidence of gastric dysfunction, particularly a gastric bezoar. Because of the potential for gastric emptying problems, diabetes should be considered a relative contraindication for a vagal-sparing procedure. Other relative contraindications include strictures or a history of caustic injury to the esophagus. In these circumstances, medi-
astinal inflammation may prohibit safe stripping of the esophagus or may lead to vagal disruption even if the stripping is accomplished safely. We have had one tear in the membranous wall of the trachea in this circumstance, although it was easily repaired via the cervical incision. Nonetheless, in these circumstances, consideration should be given to a formal transthoracic esophagectomy. Prior anti-reflux surgery or other esophageal surgery (repair of perforation, congenital trachea-esophageal fistula, etc.) are also relative contraindications because preservation of the vagus nerves is more difficult in this setting. Lastly, prior gastric surgery such as antrectomy or pyloroplasty may preclude a significant advantage to preserving the vagal nerves, although even in this setting avoidance of postvagotomy diarrhea may be a sufficient reason to spare the vagus nerves if possible.
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