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Decision making regarding the optimal incision to use is complex and is discussed earlier in this section. Once the decision has been made to proceed with esophagectomy, the distal esophagus is mobilized and the esophagus and stomach are freed from the diaphragmatic crura. The order in which this is accomplished depends on the approach being used. The proximal stomach is mobilized but no major blood supply (left gastric artery, right gastric artery) is divided at this point. Any prior fundoplication wrap is undone. This is usually accomplished with careful dissection of adhesions between the esophagus and stomach, dividing the fun-doplication sutures as they are encountered. Meticulous dissection usually succeeds in completely unwrapping the stomach, reestablishing the normal size and contour of the gastric fundus. Under some circumstances it is not possible to delineate the two portions of the wrap that make up a total fundoplication. If a plane between the esophagus and the wrap can be established, the wrap is divided with a linear cutting stapler (Figure 14.2).

If the stomach can be returned to its normal anatomy, all options outlined above for the extent of resection and the organ used for reconstruction remain available. If the amount of scarring, ulceration, fistula formation, or

Esophagectomy Pictures

MANAGING FAILED ANTI-REFLUX THERAPY

other pathologic abnormality is so extensive that the gastric anatomy cannot be reestablished, this usually necessitates partial gastrec-tomy as part of the esophagectomy, and precludes use of the stomach as an organ to replace the full length of the esophagus. In such a situation, the stomach remnant can be used as a pull-up for partial esophageal replacement or a short (or long) segment bowel interposition may be performed.

Near total esophagectomy. For a near total esophagectomy and reconstruction with a gastric pull-up, the esophagus is mobilized cir-cumferentially from the thoracic inlet to the esophagogastric junction. The vagus nerves are divided inferior to the azygos arch to minimize the risk of injury to the recurrent laryngeal nerves. The stomach is mobilized completely, with division of the left gastric vessels and left gastroepiploic arcade. The blood supply is based on the right gastric artery and the right gas-troepiploic vessels. Under circumstances in which prior fundoplication surgery has failed, the short gastric vessels will have been divided previously. This permits development of collateral circulation in the wall of the stomach and may provide for a better overall blood supply than is normally the case when preparing the stomach for use in reconstruction in a previously unoperated patient. Prior division of short

Proximal Gastrectomy

Figure 14.2. Management of a prior fundoplication. Options include dissection of the wrap (not shown), cutting across the wrap (left), and proximal gastrectomy (right).

ESOPHAGECTOMY: INDICATIONSJECHNIQUES, AND OUTCOMES

gastric vessels is often associated with the development of adhesions between the stomach and spleen that require careful dissection and division. The first and second portions of the duodenum are widely mobilized (Kocher maneuver) permitting the pylorus to reach almost to the diaphragmatic hiatus. A gastric drainage procedure (pyloric dilation, pyloro-plasty, pyloromyotomy) may be performed.

The esophagus is divided from the stomach with a linear cutting stapler in one of two ways: by simple transection below the squamocolum-nar junction, or by creating a gastric tube by resecting the lesser gastric curvature and the esophagogastric junction en bloc. The stomach is brought through the posterior mediastinum, the shortest available route, and is anastomosed to the esophagus either at the apex of the thorax or in the neck through a cervical incision. An anastomosis to the esophagus at the apex of the right hemithorax or in the neck is performed. If the operation is being performed through the left chest and a high intrathoracic anastomosis is considered, the esophagus is brought medial to the arch of the aorta before performing the anastomosis. Unless there is sufficient length of esophagus to then pull both the stomach and esophagus down lateral to the aortic arch to permit suturing the anastomosis, the surgeon should consider a cervical anastomosis instead. Therefore, the surgeon must ensure there is adequate length of the gastric tube before dividing the esophagus proximally.

Partial esophagectomy. The esophagus is mobilized proximally to a region where the muscular thickness and mucosa are normal, usually at or inferior to the level of the inferior pulmonary veins. This assessment may be aided by intraoperative endoscopy. The esophagus is divided from the stomach below the squamocolumnar junction (distal to the esophagogastric junction); it is not advisable to create a gastric tube. As mentioned previously, in patients in whom normal gastric anatomy cannot be restored, it may be necessary to resect the proximal stomach. Additional gastric mobilization is normally not necessary. A gastric emptying procedure may be performed.

If a short-segment jejunal interposition is planned, a segment of proximal jejunum based on the third or fourth branch of the superior mesenteric artery is prepared (Figure 14.3).

Distal

Figure 14.3. The blood supply to the jejunum and construction of a short-segment jejunal graft.

Alternatively, a short segment of colon based on the middle colic artery or on the ascending branch of the left colic artery is prepared (Figure 14.4). The conduit is brought posterior to the stomach and through the esophageal hiatus in an isoperistaltic orientation. An end-to-side proximal anastomosis is usually performed when jejunum is used, whereas an end-to-end anastomosis is performed when the colon is selected. The interposition graft is then drawn into the abdomen to eliminate any redundancy and is anastomosed to the back wall of the body of the stomach. The graft is sutured to the crura with several interrupted stitches to prevent herniation of intraabdominal contents. The stomach is tacked to the diaphragm in a horseshoe shape around the interposition to create a low-pressure antireflux barrier. Intestinal continuity is restored.

Postoperative care. A nasoenteral tube is placed to keep the upper gastrointestinal tract decompressed. Some surgeons leave the tube in place until a contrast study, typically performed on postoperative day 5 to 7, shows no evidence for a leak. However, routine postoperative contrast studies are notorious for failing to demonstrate leaks. An alternative management style is to leave the drainage tube in place only if there is clinical suspicion for a leak or delayed gastric

MANAGING FAILED ANTI-REFLUX THERAPY

Colon Arteries

Figure 14.4. The blood supply to the colon includes the ilecolic (IC), right colic (RC), and middle colic (MC) arteries that arise from the superior mesenteric artery (SMA),and the ascending branch (AB) of the left colic artery that arises from the inferior mesenteric artery (IMA).For left colon interposition based on the ascending branch of the left colic artery,a short segment (left) or a long segment (right) may be prepared; the latter requires division of the middle colic artery.

Figure 14.4. The blood supply to the colon includes the ilecolic (IC), right colic (RC), and middle colic (MC) arteries that arise from the superior mesenteric artery (SMA),and the ascending branch (AB) of the left colic artery that arises from the inferior mesenteric artery (IMA).For left colon interposition based on the ascending branch of the left colic artery,a short segment (left) or a long segment (right) may be prepared; the latter requires division of the middle colic artery.

emptying. If the patient is doing well, the drainage tube is removed as soon as bowel activity has resumed, as evidenced by lack of abdominal distension and passage of flatus.

Many surgeons routinely administer intravenous low-dose dopamine (3-5 mg/kg/min) for the first 48-72 hours postoperatively. Patients sometimes experience hemodynamic instability in the early postoperative period because of fluid shifts, myocardial depression, or mediasti-nal pressure due to the esophageal reconstructive organ. When this happens, the mesenteric vascular bed is the first to be adversely affected by the body's attempt to regulate perfusion. The routine use of dopamine theoretically has the effect of maintaining mesenteric blood flow even if the patient has some depression of myocardial performance or alterations in blood pressure.

Perioperative antibiotics are used routinely, but there is no benefit in administering more than one or two doses postoperatively. Overuse of antibiotics in a prophylactic setting leads to antibiotic resistance. If infection develops, antibiotics are restarted and are tailored to the specific source of infection.

Although there is some controversy regarding the utility of postoperative tube feedings, most surgeons place jejunostomy tubes and use them routinely beginning on the first postoperative day. Tube feedings help maintain nutritional levels and help to prevent bacterial translocation leading to sepsis. Most patients are sent home receiving tube feedings at night whereas eating during the day; the feedings provide a "safety net" so the patients do not have to overeat to maintain adequate nutrition and hydration. This gives them more time to accommodate to the new configuration of their gastrointestinal tract.

The most common complications after esoph-agectomy are related to pulmonary problems and include pneumonia and respiratory insufficiency. These perturbations result from a number of factors: thoracotomy or upper abdominal incisions causing diaphragmatic dysfunction; fluid shifts postoperatively resulting in pulmonary fluid overload; interruption of pulmonary lymphatics; a space occupying reconstructive organ limiting lung expansion; and recurrent nerve injury preventing patients from generating high airway pressures during cough

ESOPHAGECTOMY: INDICATIONSJECHNIQUES, AND OUTCOMES

Table 14.2. Operative outcomes after esophagectomy for failed antireflux therapy.

Author

Year

Patients

Leak

Graft Necrosis

Pneumonia

Other

Mortality

Colon/jejunum

Curet-Scott33

1987

32

5

6

5

5

1

DeMeester34

1988

24

1

2

2

Mansour35

1997

49

8

2

2

7

3

Thomas36

1997

13

2

1

2

4

1

Gandenstetter37

1998

17

1

0

1

2

0

Stomach

Young38

2000

29

3

1

2

3

1

Orringer39

2001

53

7

0

1

2

Totals

12%

5%

6%

6%

5%

ing exercises. Patients are given supplemental oxygen as needed and are asked to do deep breathing and coughing exercises regularly. Use of an incentive spirometer helps the medical staff and the patients assess their performance in deep breathing maneuvers. Optimal pain management is critical in permitting vigorous pursuit of pulmonary toilet exercises.

Delayed gastric emptying, which is manifested by chest pressure, early satiety, and sometimes regurgitation or aspiration, is managed expectantly. Gastric emptying time is substantially reduced with administration of prokinetic agents such as erythromycin,which acts as a mo-tilin receptor agonist. For patients who cannot tolerate or do not respond to erythromycin, metoclopramide may suffice as an alternative.

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