The Surgery Technique of Esophagectomy with Supra-aortic Esophagogastrostomy

The Surgery Technique of Esophagectomy with Supra-aortic Esophagogastrostomy

After an extended experience with all varieties of anesthetic agents, my conviction is strong that the safest combination for these patients is nitrous oxide-oxygen – ether by the intratracheal route. My anesthetist, Dr. Sidney Lyons, with whom I have been associated for 20 years concurs wholeheartedly. I need hardly stress the fact that the excellence of administration of the anesthesia is of the greatest importance. I feel very strongly that, unless a competent anesthetist is available, the operation should not be undertaken.

The patient is placed on his right side with the right upper extremity free for the blood pressure cuff and the left upper extremity held forward for the site of intravenous fluids. The right leg is bent at the knee and the left leg extended with a pillow between them. The pelvis is fixed in the up and down position by a long broad strip of adhesive tape stretching across at the iliac crest level and attached to the operating table on each side. This maintains the patient in a steady position (Fig. 38). The ribs are counted, and a long incision is made over the seventh rib. The thoracic musculature is divided along the line of incision with careful ligation of all bleeding points. In performing this operation, I have for some years used an all-silk technique to diminish as much as possible the likelihood of serum accumulations which occur frequently when catgut is used in a wound of this magnitude. Of course, the hundreds of ligatures needed to obtain complete hemostasis can be avoided by the use of electrocoagulation, but I must say that I have been far from pleased with the appearance of the latter wounds postoperatively. There is little doubt that wound morbidity is far greater after the electrocoagulation technique.

The seventh rib is removed subperiosteal from cartilage to angle posteriorly. Any remaining bone spicules at the posterior stump should be removed with a rongeur. Each side of the operative wound is now protected with moist pads. The proper use of a rib-spreader (they come in various sizes) will usually make the splitting of additional ribs unnecessary in order to attain wide exposure of the left thoracic cavity. If the rib-spreader is opened gradually, one notch at a time over a period of 8 to 10 minutes, the ribs above and below will give gradually. Occasionally an adjacent rib will crack, but this should not cause concern. Realignment of this rib occurs when the incision is closed.

The inferior pulmonary ligament is divided. The lung is permitted to partially deflate and is retracted upward and forward after covering it with a moist pad. Inspection and palpation of the tumor site will indicate whether or not there is neoplastic invasion of the aorta or lung hilus. In either case, inoperability is indicated if there is direct extension to these structures. The lung should be palpated for metastases which may be small in size and not demonstrated in the preoperative chest film. An incision is then made in the mediastinal pleura mesial to the descending aorta, thus exposing the esophagus which lies deep to this vessel (Fig. 39). At an uninvolved segment, the esophagus is freed bluntly in a circumferential direction, care being exerted not to penetrate the right mediastinal pleura which lies deep to the organ. A Penrose tube placed around the esophagus may be utilized as a nontraumatizing traction sling to facilitate mobilization. Before proceeding further in the chest the upper abdomen should be explored for metastatic spread.

To diminish respiratory movement of the left leaf of the diaphragm, the phrenic nerve should be either pinched or injected with Novocain just above its entrance into the diaphragm. In spite of statements to the contrary, I have not seen any complication which could be attributed to this maneuver. As a matter of fact, healing of the diaphragmatic incision seems to be considerably expedited by the resultant diminution of respiratory heaving. A radial incision in the diaphragm is now made extending from the hiatus to the rib cage, avoiding, in the process, injury to the phrenic nerve distribution (Fig. 39). Each divided vessel should be ligated separately. Visualization of these vessels is helped considerably by having the light shine through the diaphragm as the incision is made. The phrenic artery, coursing near the crus, can be accurately secured before its division. Palpatory exploration of the abdomen through the diaphragmatic incision will demonstrate the presence or absence of metastatic spread. Enlarged nodes along the left gastric vessels should not deter the surgeon from attempting a radical excision. This finding, in itself, is not an indication of inoperability.

Alimentary Tract Surgery online helper

Position of patient on operating table for a left transthoracic esophagectomy

Fig 38. Position of patient on operating table for a left transthoracic esophagectomy The patient should be closer to the edge of the operating table than has been detected here The incision follows the complete course of the seventh rib which is resected subpcriosteally. (From Cooper. The Craft of Surgery. Courtesy of Little, Brown and Company).

 

The Craft of Surgery

Fig. 39. The chest has been opened by gradual separation of the blades of the rib spreader. An incision has been made in the mediastinal pleura overlying the esophagus which lies deep to the aorta. The radial incision in the left leaf of the diaphragm is indicated. The phrenic nerve is pinched to minimize movement of the diaphragm. (From Cooper. The Craft of Surgery. Courtesy of Little, Brown and Company.)

Once resection is decided upon, complete mobilization of the infra-aortic esophagus is begun. Umbilical tape ties or strands of heavy silk are placed around the esophagus above and below the tumor to prevent intraluminal dissemination of broken-off tumor cells and also the milking of cancer cells into the lymphatics by the manipulations of the surgeon (Fig. 40). All the areolar tissue in the mediastinum and the hilar structures should be removed with the esophagus. The two or three esophageal arteries arising from the thoracic aorta should be carefully isolated and securely ligated. Both vagus nerves are, of course, sacrificed. The esophagus is now freed from its attachments at the hiatus. Mobilization of the stomach may be greatly simplified by a few simple maneuvers. After dividing the gastrohepatic ligament, the surgeon may enter the lesser sac and push forward the gastrocolic omentum, thus bringing into clearer view the gastroepiploic arch.

infra-aortic esophagus

Fig. 40. Mobilization of the infra-aortic esophagus is practically complete. Ties of heavy silk have been placed around the esophagus distal and proximal to the tumor to prevent lymphatic and intraluminal spread of cancer cells during operative manipulation. The stomach is transected so as to remove the proximal 2 or 3 inches of the greater curvature and practically the entire lesser curvature, thus transforming the stomach into a tubelike structure. Complete hemostasis in the edge of the stomach to be utilized for transplantation must be assured. (From Cooper. The Craft of Surgery. Courtesy of Little, Brown and Company. /alimentary tract www.imsurgeon.com

The Surgery Technique of Esophagectomy with Supra-aortic Esophagogastrostomy

The integrity of this arch must be preserved at all cost, if the stomach is to be utilized for transplantation. The small vessels extending from the arch to the greater omentum can be accurately ligated and divided along the entire extent of the greater curvature. The gastrosplenic ligament containing the vasa brevia is then divided, avoiding injury to the spleen. I would like to stress the importance of gentle handling of the stomach. Never apply grasping clamps to the gastric wall. I am convinced that the indiscriminate use of grasping clamps predisposes to localized thromboses which may lead to later perforation. Cover the stomach with a moist pad and grasp it with the flat of the fingers, not the tips. This is the least traumatic method of handling the stomach in this situation.

stomach should leave an intact epiploic arch

Fig. 41. Mobilization of the greater curvature of the stomach should leave an intact epiploic arch. Final step in complete mobilization is the ligation and division of the left gastric artery at its orgin of the left celiac axis. (From Cooper. The Craft of Surgery. Courtesy of Little, Brown and Company.)

The final step in mobilizing the stomach is the ligation of the left gastric vessels at their origin (Fig. 41). These vessels may be brought clearly to view by grasping the stomach and holding it forward and cephalad. The vessels are carefully dissected up to their sites of origin, removing the accompanying lymph nodes in the process. For these important ties, I use No. 1 chromic catgut. Division f the gastric vessels permits the surgeon to transplant the stomach as far as the apex of the chest and higher. The last maneuver in the abdomen is the mobilization of the duodenum by incising its lateral peritoneal attachment, the Kocher step (Fig. 42). This is done to prevent axial rotation of the duodenum which may occur when the stomach is brought upward into the chest. One such occurrence early in our series prompted the routine employment of this precautionary measure.

Measures should be adopted to prevent contamination of the operative area during transection of the stomach and the subsequent esophagogastric anastomosis. I have watched surgeons performing the operation of esophagectomy (as well as other operations on the gastrointestinal tract) and have been startled to see extensive spillage of gastric and esophageal contents into the unprotected pleural cavity. The antibiotics cannot be expected to cover up this form of sloppy technique which is usually followed by a high morbidity and increased mortality rates. To attain desirable results, a most meticulous technique becomes mandatory. Therefore, the use of

mobilization of the duodenum

Fig. 42. The Kocher maneuver for mobilization of the duodenum. This is particularly applicable in the operation with supra-aortic anastomosis to prevent axial rotation of the duodenum which can produce obstruction. (From Cooper. The Craft of Surgery. Courtesy of Little, Brown and Company.)

“clean and dirty fields” is obligatory. The entire pleural cavity should be covered with moist towels, with change of instruments, towels, and gloves after closure of gastric and esophageal openings. The line of division of the stomach is shown in Figure 40. It is important to remove about 2 inches of the beginning of the greater curvature because this area is the most vulnerable from the standpoint of blood supply and is the site of necrosis postoperatively should it occur. Its removal is a good preventive measure. A thin-bladed noncrushing clamp is now applied to the stomach in such a way as to remove most of the lesser curvature as well as the upper 2 inches of greater curvature. As the stomach is incised, each vessel encountered in both the anterior and posterior walls is clamped and ligated with fine silk. The distal stomach opening is then closed with a continuous Connell suture of 000 silk. A second layer of interrupted Cushing sutures of the same material completes the closure (Fig. 42 and 43).

Fig. 43. Closure of the stomach to be used for transplantation in two layers: the inner of a continuous Connell stitch, and the outer of interrupted Lembert sutures. The proximal end has been covered with a rubber envelope. The incision in the supra-aortic mediastinal pleura overlying the esophagus is depicted. (From Cooper. The Craft of Surgery. Courtesy of Little, Brown and Company.)

The proximal remnant of stomach attached to the esophagus is now covered with thin rubber dam, tied securely into place with heavy silk, the ends of which remain long. The “dirty field” is discarded. Attention is now directed to the supra – aortic segment of the esophagus. The collapsed lung is covered with a moist pad and retracted downward and to the right, thus exposing the apex of the chest. By pulling downward on the mobilized lower esophagus, the location of the supra-aortic portion behind and to the left of the subclavian artery will be disclosed beneath the pleura. The latter is incised from the apex of chest to the aortic arch (Fig. 42). The underlying esophagus is now freed bluntly from its areolar tissue attachments.

The maneuver of freeing the esophagus

Fig. 44. The maneuver of freeing the esophagus from behind the aortic arch. This is done bluntly with care to prevent injury to the recurrent laryngeal nerve and the deeply placed thoracic duct. After the mobilization has been completed, a right angle clamp placed behind the arch grasps the string encircling the distal rubber envelope, and by upward traction and slight pressure from below, the surgeon is able to bring the infra-aortic esophagus to lie above the arch. Gentleness is essential. Frequently a marked fall in blood pressure may be noted but following the completion of the manuever, the blood pressure returns to a normal level. (From Cooper. The Craft of Surgery. Courtesy of Little, Brown and Company.)

This maneuver and the subsequent mobilization behind the arch must be carried out with great gentleness, keeping the dissection as close to the esophagus as possible. In this fashion, the surgeon avoids injury to the deeply placed thoracic duct and also the left recurrent laryngeal nerve as it hooks around the arch. Mobilization of the esophagus behind the arch is accomplished by using the right index finger from above and the left index finger from below (Fig. 44). It must be remembered that, occasionally, an accessory esophageal artery is given off from the under surface of the arch. This can be felt with the exploring fingers and should be securely ligated. Accidental tearing can precipitate serious hemorrhage. The anesthetist is now asked to remove the Levin tube. Once this supra-aortic segment of esophagus is freed, a narrow-bladed right-angle clamp is passed from above, behind the arch and made to grasp the string tied about the rubber covering at the distal end of the esophagus (Fig. 44). Withdrawal of the clamp and traction on the string with gentle pushing from below brings the entire mobilized organ to the thoracic apex above the aortic arch (Fig. 45).

completion of the maneuver

Fig. 45. Appearance of the operative field at the completion of the maneuver depicted in Figure 44. The esophagus is mobilized as far as the apex of the chest. The indwelling Levin tube should be removed before the maneuver shown in Figure 48 is begun. (From Cooper. The Craft of Surgery. Courtesy of Little, Brown and Company.)

Occasionally, the rubber-covered end may be found too bulky for the confined space behind the arch. Under such circumstances, force should be scrupulously avoided. It is wiser to ablate the distal bulky end and reapply the rubber covering. This assures easier passage behind the arch. During these manipulations, there usually occurs a significant drop in blood pressure. However, this is of momentary significance because circulatory stability returns once the maneuver is completed.

the esophagus and upper stomach

Fig. 46. A, Details of the anastomosis between the esophagus and upper stomach. A circular opening is made in the upper anterior wall of the stomach with careful ligation of the vessels in the edge. B, The first layer of the posterior row is indicated. These are Cushing sutures rather than the Lembert variety. C, The posterior layer of the mucosal suture is indicated. These are interrupted and consist of fine silk. D, The anterior inner row of interrupted stitches of the inverting variety. E, The outer anterior row of interrupted Cushing sutures which completes the anastomosis. (From Cooper. The Craft of Surgery. Courtesy of Little, Brown and Company.)

Before starting the anastomosis, the surgeon should wall off the thoracic cavity in anticipation of a contaminated field. A site is selected on the upper anterior aspect of the stomach, away from the previously sutured area and nearer the greater curvature. A button of stomach wall, approximately the same diameter as the esophagus, is now removed from this selected site. Every bleeding vessel at the edge of the opening should be accurately ligated with fine silk (Fig. 46A). This insures a desirable dry field for the important details of the anastomosis. While an assistant exerts traction on the distal esophagus in a cephalad direction, the surgeon selects the site for the anastomosis and inserts five or six Cushing sutures in the esophagus and the stomach wall behind the circular opening (Fig. 46B). The stomach is approximated to the esophagus and the sutures are tied so as to approximate the two structures without tension. If these stitches are tied too snugly, the esophageal musculature will be severed. The insertion of too many sutures should also be avoided, to minimize the possibility of impairment of the circulation of the esophageal stump which derives its nourishment at this site from a branch of the inferior thyroid artery.

As previously stated, the Levin tube is removed before bringing the esophagus to the supra-aortic position. From my observations, I am convinced that the use of a Levin tube through an esophagogastric anastomosis postoperatively is contraindicated. It is rare, indeed, for a patient to vomit after operation, and the stomach seldom distends if it has been handled with care and hemostasis has been complete at the turned-in divided end. In addition, postoperative pylorospasm has been exceedingly rare in my experience. A thin-bladed right-angle clamp is now applied to the esophagus about 1.5 cm distal to the posterior first row of sutures. With a right-angled scissors, the esophagus is transected behind the clamp (Fig. 46A and B). The operative field is kept dry with the aid of suction. The mucosa of the esophagus is approximated to the mucosa of stomach using interrupted sutures of 000 or 0000 silk with the knots toward the lumen (Fig. 46C and D). Twelve to fourteen sutures for the entire circumference should suffice. I have tried various methods of making this anastomosis and feel that the one described is the most efficient. The contaminated field is now discarded. The anterior row of Cushing sutures is now inserted, an extra effort being made to invert every bit of pouting mucosa (Fig. 46E). May I emphasize that this anastomosis is a most meticulous one and merits special attention on the part of the surgeon to assure successful union.

It will be noted that the transplanted stomach has assumed the shape of an elongated tube and rests in the posterior mediastinum inferiorally, swinging upward over the aortic arch to terminate at the anastomosis near the apex of the chest. It should now be anchored in its new position in such a way as to obviate any drag on the suture line. This is accomplished by placing interrupted fine silk sutures between stomach wall and mediastinal pleura on each side below the arch and to pleura overlying the arch and apex of the chest (Fig. 47). The incised diaphragm is now accurately repaired with interrupted stitches of 00 silk. Extra care is needed in suturing the hiatal area to the stomach to prevent postoperative herniation of abdominal contents. A 24 or 26 F open-end catheter with two side holes is inserted through a subjacent intercostal space posterolaterally for underwater drainage of the pleural cavity.

diaphragm to the stomach wall

Fig. 47. The completion of the operative procedure with fixation of the transplanted stomach to the mediastinal pleura on each side, repair of the diaphragmatic incision, and suturing of the large hiatus in the diaphragm to the stomach wall. (From Cooper. The Craft of Sur­gery. Courtesy of Little, Brown and Company.)

Before closure of the thoracic incision is begun, the anesthetist is asked to inflate the collapsed lung so that it hugs the thoracic cage. This inflation must be maintained by the anesthetist until the final dressing is applied. The intercostal tube must, of course, be clamped. Strict adherence to this technique will obviate the possibility of trapped air in the pleural cavity, a frequent and alarming complication in the early days of our experience. The use of the Bailey rib approximator facilitates the wound closure. The surgeon should exert every effort to avoid the intercostal neurovascular bundles when he repairs the intercostal muscles. For this reason, I suture only the external intercostal muscles and have abandoned the use of pericostal sutures. Since the adoption of this method, intercostal neuralgia has all but disappeared. The thoracic musculature is repaired in layers, using interrupted sutures. In spite of the weariness of the surgeon at this stage, there should be no letdown in the meticulous attention to details until the last skin suture is inserted. The final step is the connection of the intercostal catheter to the underwater drainage bottle. I use a simple one-bottle system with the tubing securely fixed to prevent dislodgement. Suction is not necessary. The anesthetist increases the pressure in the breathing apparatus, thus expelling air which may have accumulated in the chest cavity during the wound closure. A snugly applied dressing gives support and lessens postoperative pain.

I have purposefuly enumerated all the finer details of this operation because of my conviction that the surgeon who undertakes the operation of esophagectomy cannot expect a minimum of complications and a lessened mortality rate unless the significance of these details is realized. A technic should evolve which discards maneuvers which have proved both undesirable and dangerous. An operative mortality that exceeds 8 to 10 percent should call for a reappraisal by the surgeon of the entire conduct of the operation and the postoperative care of the patient. I believe that this operation may often be one of the most difficult in the whole realm of general surgery and must be approached with a great deal of circumspection. I believe that the results to date warrant the efforts of the surgeon in his continued search for methods to best treat this dread disease.

 

13 comments

  1. http://google.com/

    Good post but I was wondering if you could write a litte more on this topic?
    I’d be very thankful if you could elaborate a little bit more.

    Cheers!

  2. Heya i’m the first time here. I found this
    board and I discover it really useful & it helped me
    out a lot. I really hope to give something back and help
    others such as you helped me.

  3. Finley

    I must say you have high quality articles here.
    Your blog should go viral. You need initial boost only. How to get it?
    Search for; Etorofer’s strategies

  4. This really replied my issue, thank you!

Leave a Reply