Figure 43-12. Creation of gastric conduit. The first stapler along the lesser curve is a vascular endo GIA stapler after which the

thick antrum is divided with the 4.8 mm (green) loads that are 45 mm long fired sequentially. The antrum and the fundus are

pulled in opposite direction to provide adequate tension during the gastric conduit creation.

Pyloroplasty

The pylorus is visually identified and 2-0 Surgidac (Covidien, Mansfield, MA) stay sutures are placed on

the superior and inferior aspects using the Endostitch device (U.S. Surgical, Norwalk, CT) to place it on

stretch (Fig. 43-14). The anterior wall of the pylorus is then transected with ultrasonic shears. The

pyloromyotomy is then closed transversely in a Heineke–Mikulicz fashion using simple, interrupted 2-0

Surgidac sutures. An omental patch (with a vascular pedicle if the patient received neoadjuvant

treatment) is placed over the pyloroplasty prior to termination of the abdominal portion of the

operation.

Figure 43-13. Completed gastric conduit with an intact right gastroepiploic arcade and an intact right gastric artery.

Figure 43-14. Creation of pyloroplasty (A) and vertical closure (B) in a Heineke–Mikulicz fashion.

Feeding Jejunostomy Tube Placement

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A 10-French jejunostomy catheter is placed in the left lower quadrant using a percutaneous technique

(Fig. 43-15). The transverse colon is retracted superiorly to expose the ligament of Treitz and a position

in the jejunum is identified 30 to 40 cm from this location. The antimesenteric border of the bowel is

sutured to the abdominal wall with a 2-0 Surgidac suture. The 12-mm right paraumbilical port is used

by the surgeon with the camera positioned in the right paramedian location. A Seldinger technique is

then used to introduce the catheter into the jejunum under direct laparoscopic vision. Air insufflation

via the catheter can be used to verify luminal placement. The jejunum is then tacked to the abdominal

wall anterior to the catheter entry site to prevent leakage, and an additional suture to the abdominal

wall is placed in the distal limb of jejunum to prevent rotation and obstruction.

Preparation for Thoracoscopic Phase

The gastric conduit is again assessed for viability and, if needed, resection of the nonviable portion and

further mobilization with extension of the Kocher maneuver are performed at this time. Once viability

of the conduit is ensured, the most superior portion of the gastric tube is stitched to the specimen (Fig.

43-16). It is imperative to maintain the alignment of the conduit so that twisting is avoided as the

stomach is brought into the chest. We ensure this by suturing the greater curvature along the short

gastric vessels to the staple line of the proximal gastric remnant. If an omental flap has been created,

the distal end is sutured to the conduit tip. Clips are applied to the staple line as needed for hemostasis.

The specimen and gastric conduit are then placed in the lower mediastinum, again taking care to

preserve the proper orientation of the gastric conduit (Fig. 43-17). If the hiatal opening appears large,

the crura are reapproximated with a stitch to prevent delayed thoracic herniation of the conduit. A

nasogastric tube is then placed in the esophagus for decompression in preparation for the thoracic phase

of the operation.

Thoracoscopic Phase

Positioning and Port Placement

Turn the patient to the left lateral decubitus position and reconfirm placement of the double-lumen

endotracheal tube. The operating surgeon stands on the right side of the table (facing the patient’s back)

while the assistant stands on the left side of the table. A total of five thoracoscopic ports are used (Fig.

43-18). A 10-mm camera port is placed in the eighth or ninth intercostal space, just anterior to the

midaxillary line. The working port is a 10-mm port placed in the eighth or ninth intercostal space,

posterior to the posterior axillary line. Another 10-mm port is placed in the anterior axillary line at the

fourth intercostal space, through which a fan-shaped retractor aids in retracting the lung to expose the

esophagus. A 5-mm port is placed just inferior to the tip of the scapula for the surgeon’s left hand. A

final 5-mm port is placed at the sixth rib, at the anterior axillary line for suction by the assistant.

Thoracoscopic Dissection and Resection of the Esophagogastric Specimen

Adequate retraction of the diaphragm is essential to the thoracoscopic phase of the dissection. A 48-in, 0

Surgidac suture is placed through the central tendon of the diaphragm using the Endostitch. The suture

is brought out through the lateral chest wall at the level of the insertion of the diaphragm through a

small stab incision, retracting the diaphragm inferiorly and exposing the distal esophagus. The inferior

pulmonary ligament is divided to the level of the inferior pulmonary vein to allow for maximal

retraction to the lung. This dissection is carried onto the avascular plane along the surface of the

pericardium, which becomes the medial border of the dissection. This dissection is carried superiorly to

the subcarinal space, with the lymph nodes kept en bloc with the esophagus (Fig. 43-19). Care must be

taken to identify the membranous wall of the right mainstem bronchus because it is easily injured

during this phase of the dissection. Removing any suction from the right lung during this dissection will

prevent the membranous wall from collapsing and can aid in visualization. The lung is then retracted

anteriorly and the pleura incised along the anterior border of the esophagus to the level of the azygos

vein. The azygos vein and vagus nerve are divided to facilitate the dissection and prevent traction

injuries to the recurrent laryngeal nerve during esophageal mobilization. Above the level of the azygos

vein, dissection is kept close to the esophagus to avoid injury to the recurrent nerves. The extent of

superior dissection and mobilization depends upon the location of the tumor and the intended site of

resection. To facilitate lateral mobilization, the pleura is divided in the groove posterior to the

esophagus. This dissection is kept superficial to avoid injury to the thoracic duct and underlying thoracic

aorta. Bridging lymphatics and aortoesophageal vessels are controlled with endoclips and subsequently

divided with the ultrasonic shears. A careful thoracic duct ligation should be considered if there is

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concern for trauma to the duct. This lateral dissection is carried along the length of the esophagus from

above the azygos vein to the level of the gastroesophageal junction. The contralateral pleura marks the

deep margin of the dissection. The left pleural space may be entered if needed to remove a bulky

tumor. The insertion of a Penrose drain to encircle the esophagus can also be useful to provide traction

and elevate the esophagus from the mediastinal bed.

Figure 43-15. Placement of a 10-French needle jejunostomy catheter and an antitorsion stitch 3 to 4 cm distally along the

antimesenteric border.

Figure 43-16. The gastric conduit is secured to the specimen along the lesser curve staple line for proper orientation during the

thoracoscopic portion with a horizontal U stitch.

Figure 43-17. Proper orientation of the gastric conduit during the thoracoscopic part.

Once the esophagus has been completely mobilized, the specimen and attached gastric conduit are

delivered into the chest, preserving the orientation of the gastric tube. The conduit staple line should be

directly facing the lateral chest wall. The stitch between the specimen and the conduit is cut and the tip

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of the conduit secured to the diaphragm with an Endostitch to prevent it from retracting into the

abdomen. The specimen is then retracted anteriorly and superiorly, away from the esophageal bed, and

the dissection completed along the contralateral pleural surface. Above the level of the azygos vein, this

dissection again moves to the plane along the wall of the esophagus itself to avoid recurrent laryngeal

nerve injury. Lymph node sampling is not routinely performed at this level.

Once mobilization of the esophagus is complete, a 4- to 5-cm minithoracotomy is made between the

surgeon’s working port and the tip of the scapula. A wound retractor (Applied Medical, Rancho Santa

Margarita, CA) is placed to protect the skin and chest wall. The esophagus is then sharply transected

using laparoscopic scissors at or above the level of the azygos vein as determined by the proximal

extent of tumor. The nasogastric tube is pulled back into the proximal esophagus under direct vision as

this is done. The esophagogastrectomy specimen is then withdrawn through the wound protector and

sent for frozen section evaluation of the resection margins.

Creation of the Gastroesophageal Anastomosis

Attention is next turned to construction of the EG anastomosis. Our preferred technique utilizes an endto-end anastomosis (EEA) stapling device (Fig. 43-20). The anvil of the stapler is placed in the cut

proximal end of the esophagus and secured in place with two pursestring sutures of 2-0 Surgidac. All

layers of the esophagus must be included in the suture to ensure a competent anastomosis. Typically, a

28-mm EEA stapler can be used without difficulty. This size will help to minimize stricture formation

and potentially decreases the need for postoperative dilation. If the proximal esophagus does not appear

large enough to accommodate the 28-mm anvil, a Foley catheter can be used to gently dilate the

esophageal lumen in an attempt to facilitate placement of the anvil before electing a smaller stapler

size. The gastric conduit is pulled further into the chest and the tip of the gastric conduit is opened using

ultrasonic shears to the right side of the staple line. The EEA stapler is placed through the wound

protector and positioned through the gastrotomy inside the conduit. The stapler spike is brought out

along the greater curve of the gastric conduit to dock with the anvil. Prior to creating the anastomosis,

we carefully estimate the amount of conduit that will lie in the chest. It is a common mistake to bring

an excess stomach into the chest with the intent of minimizing tension on the anastomosis. A redundant

conduit above the diaphragm can lead to significant problems with conduit emptying. In addition,

ensuring proper orientation of the stomach is critical to prevent twisting. The stapler is then opened two

complete turns and withdrawn. The tissue rings are inspected to ensure that they are complete prior to

proceeding further.

Figure 43-18. Thoracoscopic port placement.

After stapling, the remaining excess gastric tip, including the gastrotomy through which the stapler

was introduced, is resected with two or three loads of the endovascular GIA stapler (Fig. 43-21). If an

omental flap was created during the abdominal dissection, it is wrapped around the anastomosis and

secured in place with two or three sutures. The chest is then thoroughly irrigated and inspected for

hemostasis. Final anatomy of the reconstruction is demonstrated in Figure 43-22.

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Figure 43-19. Thoracoscopic esophageal mobilization. The lung is retracted anteriorly and the pleura along the esophagus is

excised. The subcarinal lymph nodes are excised en bloc along with the specimen.

Drain Placement and Closure

Adequate drainage of the mediastinum and the area surrounding the anastomosis is imperative to

mitigate complications related to anastomotic leak. A 10-mm Jackson–Pratt drain is placed posteriorly

along the anastomosis and a 28-French chest tube is directed posteriorly toward the apex. The

previously placed nasogastric tube is advanced past the anastomosis under thoracoscopic visualization.

The gastric conduit is sutured to the right crus with a single 2-0 Endostitch to prevent torsion or delayed

herniation of the conduit. A long aspirating needle is used to instill a multilevel intercostal nerve block

to aid in postoperative pain control. The minithoracotomy is closed using pericostal sutures with a

multilayer soft tissue closure. The Jackson–Pratt drain is secured with multiple sutures to prevent it

from becoming dislodged. Once the patient is turned to the supine position, the oropharynx and

nasopharynx are suctioned free of all secretions. The double-lumen endotracheal tube is withdrawn and

the patient reintubated with a single-lumen endotracheal tube. Use of a tube exchange catheter should

be discouraged because this device is placed blindly and may cause injury to the right mainstem

bronchus, which is potentially vulnerable owing to the dissection of the thoracic esophagus. A toilet

bronchoscopy is then performed using an adult bronchoscope. At this time, both right and left mainstem

bronchi are examined for any evidence of airway injury.

Postoperative Care

Patients are taken to the intensive care unit postoperatively and typically remain there for the first

postoperative day before transferring to the surgical floor. The typical hospital stay is 7 days in patients

with an uncomplicated postoperative course. The nasogastric tube may be removed on day 2 and

“trickle” (20 to 30 mL/hr) jejunostomy tube feeds are started. A contrast esophagram is obtained on day

3 to 4 if the patient has adequate pulmonary toilet and a good cough. If there is no evidence of leak,

oral intake is initiated in the form of 1 to 2 oz of clear liquids per hour. This is advanced over 2 days to

full liquids, no more than 3 to 4 oz/hr along with cycled tube feeds. The chest tube is removed when

output low (<150 cc/d) and the clinical course negative for leak. The Jackson–Pratt drain is pulled

back 3 to 5 cm on postoperative day 5 and resecured. The drain is removed at the first postoperative

clinic visit in 2 weeks’ time.

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Figure 43-20. Creation of the esophago-gastric anastomosis. The anvil is secured in the proximal esophagus with two purse-string

sutures. The EEA stapler is introduced into the conduit via a gastrostomy and is docked with the anvil keeping the conduit aligned

with the lesser curve staple line facing the camera.

Figure 43-21. The gastrotomy is closed with an Endo GIA stapler and this part of the stomach is sent as final gastric margin. Care

is taken not to encroach this staple line too close to the circular EEA staple line. A JP drain is left in the esophageal bed posterior

to the anastomosis.

PALLIATIVE OPTIONS IN ADVANCED ESOPHAGEAL CANCER

9 In the event that patients have unresectable disease, metastatic disease, or are medically unfit for

surgery, numerous palliative therapies are available. The goal of these therapies is to maintain comfort

by restoring as much swallowing function as possible and support nutrition.

Figure 43-22. Completed reconstruction.

Nutrition support and hydration can be provided through alternative enteral access. PEG or surgical

jejunostomy tube should be placed whenever possible under endoscopic guidance. Open gastrostomy or

jejunostomy tubes are an alternative in patients with bulky obstructive lesions who cannot receive a

PEG.

Chemotherapy

Chemotherapy can also provide palliation in patients with esophageal cancer. Many regimens are

available that have been extensively studied. Agents such as fluorouracil and taxanes may be used either

alone or in combination with platin-based agents to provide symptomatic relief. Palliative

chemotherapy typically requires time to effectively reduce dysphagia. Special attention is needed while

implementing these chemotherapeutic agents in usually debilitated, malnourished patients.

Radiation

Radiotherapy can be used for palliative reasons in patients with dysphagia. The typical dosage used is

4,000 to 5,000 cGy delivered over 4 weeks. The goal for this treatment is to allow patients with

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