Operation for Tumors behind and above the Aortic Arch

Because cancers in this location are more often inoperable than not, it is important to utilize every modality to determine operability before resorting to exploration. Other than the appearance of the x-ray film, there are three examinations which should be done: laryngoscopy to determine the presence or absence of paralysis of the left recurrent laryngeal nerve, as indicated by hoarseness (paralysis indicates extension of the tumor beyond the confines of the esophagus), preoperative bronchoscopy to detect neoplastic invasion of the trachea or left main bronchus, and finally, preoperative azygogram to determine the blockage of the azygos vein which definitely denotes inoperability. Operation may be undertaken should these examinations prove to be negative.

If it is decided to carry out a one-stage procedure, the operation of Ivor Lewis is probably the most effective and the least traumatizing. In the conduct of this operation, the draping should allow for three incisions, the right transthoracic, the abdominal, and the cervical. The first incision is over the right seventh rib which is removed subperiosteally. If the patient is placed on a tilting table, his position for this step should be at a 50 to 60 degree angle. The rib-spreader is used as previously described. Complete mobilization of the esophagus with ligation of the esophageal vessels coming from the aorta should be deferred until resectability is demonstrated. Otherwise, necrosis of the mid-esophagus may occur postoperatively should an inoperable growth be disclosed and no resection carried out. It is much easier to mobilize the esophagus behind and above the aortic arch through the right approach than the left. Of course, it becomes necessary to ligate and divide the azygos vein as it crosses the upper esophagus.

The esophagus is tied off above and below the tumor with heavy silk ligatures or umbilical tape as previously noted, and mobilization is completed down to the esophageal hiatus. The rib-spreader is removed, the contiguous ribs are approximated with a Bailey rib approximator, the wound is covered, and the table is tilted back to the supine position. The abdomen is opened through an upper midline incision, and exploration is performed. Mobilization of the stomach for transplantation is now effected in the manner previously described in detail. The crus should be transected in order to create a larger opening in the diaphragm to accommodate the transplanted stomach without compression. The mobilized stomach is pushed gently into the chest, avoiding any twisting of the organ, and the abdominal incision is closed temporarily with a few through and through sutures.

The table is now tilted back to its original position, and the rib-spreader is reinserted. After setting up a “dirty field,” the surgeon divides the upper portion of the stomach as previously described. The esophageal end is covered with a rubber envelope, and the gastric opening is closed in two layers. The contaminated field is discarded, and the stomach is drawn upward toward the apex of the chest. The surgeon should avoid axial twisting or distortion of the organ. The stomach should lie over the arch with the anterior surface facing the surgeon. There should be sufficient length of stomach to permit bringing 2 to 3 inches of its upper end through the apex of the chest into the neck without the slightest tension. The surgeon should be wary of any change in color of the stomach. The importance of gentle handling of the organ cannot be overemphasized. The development of cyanotic areas, especially at the upper end, calls for careful examination of the blood supply (pulsations in the gastroepiploic arch and the right gastric artery). Readjustment of the stomach in its new position will frequently be of help. The surgeon should under no circumstances bring a cyanotic organ upward into the neck for anastomosis. Rather, he should replace the stomach in the abdomen, perform a gastrostomy, bring out the esophagus through a neck incision, ablate it subtotally, and fashion a cervical esophagostomy, thus performing the first stage of a two-stage procedure. Reestab – lishment of gastrointestinal continuity can be undertaken more safely at a second stage 7 to 10 days later, utilizing either the stomach or a section of colon, placed retrosternally.

If the one-stage operation is to be continued, the stomach is anchored in its new position with fine silk sutures to the mediastinal pleura. It is also fixed to the enlarged hiatus in a circumferential manner. Two guide sutures of silk are now inserted into the gastric wall at the approximate site of the subsequent anastomosis. The surgeon now draws the completely mobilized esophagus out of the posterior mediastinum as far as the apex of the left chest. The pleura over the apex is incised, and by blunt dissection, a cavity is created in the base of the neck into which the ends of the two gastric guide sutures are placed. The rib-spreader is removed, and the chest wound is partially closed as before. The patient is returned to the supine position, and the neck is exposed. An incision is made along the anterior border of the left sternocleidomastoid. The exposure is the same as for a Zenker’s diverticulum. Blunt dissection brings into view the prevertebral fascia with the esophagus lying in front of it. By a combination of gentle blunt dissection and traction on the organ, the surgeon draws the mobilized thoracic esophagus up through the neck incision. This must be done with care in order to preserve the branches of the inferior thyroid artery which nourish the esophagus in this location.

The two gastric guide sutures are identified and drawn into the cervical wound, bringing into the field the upper anterior end of the stomach. An esophagogastric anastomosis is now effected in exactly the same way as previously described. While this is being done, a second team may close the abdominal incision. A thin layer of iodoform gauze is packed loosely in the region of the apical pleural opening, and

the cervical incision is closed. The patient is tilted back to the original position, and the chest wound is repaired after inserting an underwater drainage tube through a subjacent intercostal space. All the details of the closure previously described should be followed carefully. This operation is a complicated one. The time required for its performance may be shortened considerably by the use of two teams of surgeons.

An alternative procedure is the two-stage operation. The first stage is really an extension of the original Torek operation and has been described in the previous section. However, there should be no mobilization of the stomach. The abdominal part of the operation consists only of the fashioning of a gastrosomy which effects a mucocutaneous junction. The cervical esophagostomy completes the procedure. Irradiation of the posterior mediastinum may be carried out in the interval between the two stages. At the second operation, the right half of the colon may be utilized instead of the stomach to bridge the distance between the stomach and the cervical esophagus. Experience indicates that the safest position for the transplanted colon is extrapleurally behind the sternum. Nakayama, because of his high incidence of leakage, places the transplanted colon or stomach subcutaneously and anteriorly.

 

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