Esophaegeal resection & reconstruction

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  • Drawings illustrate an Ivor Lewis esophagectomy. (a) During the abdominal stage of the procedure, the stomach is elevated by grasping its greater curve (external to the right gastroepiploic artery), and the short gastric arteries (thick white arrow) are clamped and tied. The greater omentum is dissected distally near the pylorus with care to avoid injuring the right gastroepiploic artery (thick black arrows). The gastrohepatic ligament (thin white arrow) is then carefully divided to preserve the right gastric artery. The esophageal hiatus and distal esophagus are dissected free, and a pyloromyotomy (arrowhead) is performed. Note the tongue of the omentum (thin black arrows) attached to the greater curvature of the stomach; it will be used to wrap the anastomosis. Dotted lines indicate resection lines. (b) Following right thoracotomy, the azygos vein is divided and the esophagus is dissected out of its bed. Dissection is continued up to the apex of the thorax. The stomach is then pulled up into the chest and divided. Dotted line represents proposed resection line for gastric division. (c) An anastomosis is created between the end of the esophagus and the fundus of the stomach. The remaining (tumor-containing) esophagus is divided and removed. The omentum that was preserved with the stomach is wrapped around the anastomosis (arrows). Arrowheads indicate the original cardioesophageal junction.
  • Drawings illustrate an Ivor Lewis esophagectomy. (a) During the abdominal stage of the procedure, the stomach is elevated by grasping its greater curve (external to the right gastroepiploic artery), and the short gastric arteries (thick white arrow) are clamped and tied. The greater omentum is dissected distally near the pylorus with care to avoid injuring the right gastroepiploic artery (thick black arrows). The gastrohepatic ligament (thin white arrow) is then carefully divided to preserve the right gastric artery. The esophageal hiatus and distal esophagus are dissected free, and a pyloromyotomy (arrowhead) is performed. Note the tongue of the omentum (thin black arrows) attached to the greater curvature of the stomach; it will be used to wrap the anastomosis. Dotted lines indicate resection lines. (b) Following right thoracotomy, the azygos vein is divided and the esophagus is dissected out of its bed. Dissection is continued up to the apex of the thorax. The stomach is then pulled up into the chest and divided. Dotted line represents proposed resection line for gastric division. (c) An anastomosis is created between the end of the esophagus and the fundus of the stomach. The remaining (tumor-containing) esophagus is divided and removed. The omentum that was preserved with the stomach is wrapped around the anastomosis (arrows). Arrowheads indicate the original cardioesophageal junction.
  • Drawings illustrate an Ivor Lewis esophagectomy. (a) During the abdominal stage of the procedure, the stomach is elevated by grasping its greater curve (external to the right gastroepiploic artery), and the short gastric arteries (thick white arrow) are clamped and tied. The greater omentum is dissected distally near the pylorus with care to avoid injuring the right gastroepiploic artery (thick black arrows). The gastrohepatic ligament (thin white arrow) is then carefully divided to preserve the right gastric artery. The esophageal hiatus and distal esophagus are dissected free, and a pyloromyotomy (arrowhead) is performed. Note the tongue of the omentum (thin black arrows) attached to the greater curvature of the stomach; it will be used to wrap the anastomosis. Dotted lines indicate resection lines. (b) Following right thoracotomy, the azygos vein is divided and the esophagus is dissected out of its bed. Dissection is continued up to the apex of the thorax. The stomach is then pulled up into the chest and divided. Dotted line represents proposed resection line for gastric division. (c) An anastomosis is created between the end of the esophagus and the fundus of the stomach. The remaining (tumor-containing) esophagus is divided and removed. The omentum that was preserved with the stomach is wrapped around the anastomosis (arrows). Arrowheads indicate the original cardioesophageal junction.
  • Drawings illustrate transthoracic esophagectomy through a right thoracotomy. Drawing a shows how tumors of the upper thoracic esophagus are assessed through a right thoracotomy (arrow) and upper abdominal incision (arrowhead). Drawing b demonstrates how the esophagus is partially resected through the right thoracotomy. Arrows indicate resection lines. Drawings c and d show how an intrathoracic ( c ) or cervical ( d ) anastomosis is created between the remaining esophagus and the esophageal substitute. Open arrows indicate the anastomosis site, solid arrows indicate the original cardio esophageal junction, and arrowheads indicate pyloromyotomy.
  •   Drawings illustrate transhiatal esophagectomy without thoracotomy. (a) Cervical (arrowhead) and upper abdominal midline (arrow) incisions are made. (b) Mobilization of the stomach for esophageal replacement is performed through a laparotomy with pyloroplasty. The right gastric and gastroepiploic arteries are preserved. The esophagus is mobilized from the back wall of the trachea through the cervical incision. From below, the surgeon’s hand passes through the widened hiatus. Any remaining attachments of the muscular esophageal tube are avulsed from the esophageal wall. (c) The cervical esophagus is clamped, leaving adequate length for reconstruction by preserving 3-4 cm of peristaltic esophagus (open arrow). The esophagus is then extracted from the mediastinum. The stomach is divided at the proximal region with a stapler or clamp (solid arrow). Pyloromyotomy is performed at the distal portion with a suture technique (arrowhead). Finally, the remaining portion of the stomach is advanced to the neck for esophagogastric anastomosis.
  •   Drawings illustrate transhiatal esophagectomy without thoracotomy. (a) Cervical (arrowhead) and upper abdominal midline (arrow) incisions are made. (b) Mobilization of the stomach for esophageal replacement is performed through a laparotomy with pyloroplasty. The right gastric and gastroepiploic arteries are preserved. The esophagus is mobilized from the back wall of the trachea through the cervical incision. From below, the surgeon’s hand passes through the widened hiatus. Any remaining attachments of the muscular esophageal tube are avulsed from the esophageal wall. (c) The cervical esophagus is clamped, leaving adequate length for reconstruction by preserving 3-4 cm of peristaltic esophagus (open arrow). The esophagus is then extracted from the mediastinum. The stomach is divided at the proximal region with a stapler or clamp (solid arrow). Pyloromyotomy is performed at the distal portion with a suture technique (arrowhead). Finally, the remaining portion of the stomach is advanced to the neck for esophagogastric anastomosis.
  •   Drawings illustrate transhiatal esophagectomy without thoracotomy. (a) Cervical (arrowhead) and upper abdominal midline (arrow) incisions are made. (b) Mobilization of the stomach for esophageal replacement is performed through a laparotomy with pyloroplasty. The right gastric and gastroepiploic arteries are preserved. The esophagus is mobilized from the back wall of the trachea through the cervical incision. From below, the surgeon’s hand passes through the widened hiatus. Any remaining attachments of the muscular esophageal tube are avulsed from the esophageal wall. (c) The cervical esophagus is clamped, leaving adequate length for reconstruction by preserving 3-4 cm of peristaltic esophagus (open arrow). The esophagus is then extracted from the mediastinum. The stomach is divided at the proximal region with a stapler or clamp (solid arrow). Pyloromyotomy is performed at the distal portion with a suture technique (arrowhead). Finally, the remaining portion of the stomach is advanced to the neck for esophagogastric anastomosis.
  • Esophaegeal resection & reconstruction

    1. 1. Esophageal Resection & Reconstruction Yasser Elghoneimy M.D. Assistant Professor of Cardiothoracic Surgery King Faisal University 2008
    2. 2. Objectives <ul><li>Indications of Esophageal resection </li></ul><ul><li>Common techniques of resection </li></ul><ul><li>Conduits used for reconstruction </li></ul><ul><li>Routes of Reconstruction </li></ul><ul><li>Complications of reconstruction </li></ul>
    3. 3. Indications for Resection <ul><li>Carcinoma of the esophagus </li></ul><ul><li>High Grade Dysplasia in Barrett esophagus </li></ul><ul><li>Destrcution of the esophagus by Caustic injury </li></ul><ul><li>Esophageal Dysfunction: Scleroderma, Achalasia, Spasm </li></ul><ul><li>Esophageal Perforation </li></ul><ul><li>Recurrent GE reflux </li></ul>
    4. 4. Indications For Reconstruction <ul><li>Resection of Esophagus/Stomach: </li></ul><ul><ul><li>Neoplasms </li></ul></ul><ul><ul><li>Dysfunctional Esophagus </li></ul></ul>
    5. 5. Indications For Reconstruction <ul><li>Esophagectomy/Gastrectomy Complications </li></ul><ul><ul><li>Fistula </li></ul></ul><ul><ul><li>Stricture </li></ul></ul>
    6. 6. Indications For Reconstruction <ul><li>Failed Esophageal continuity Procedures: </li></ul><ul><ul><li>Dehiscence </li></ul></ul><ul><ul><li>Stricture </li></ul></ul><ul><ul><li>Dysfunction </li></ul></ul>
    7. 7. The surgical option is chosen on the basis of: <ul><li>The nature of the condition:benign or malignant.T </li></ul><ul><li>The extent of the lesion. </li></ul><ul><li>The presence of complications </li></ul>
    8. 8. Incisions <ul><li>Dictated by Approach to Resection </li></ul><ul><ul><li>Upper midline laparotomy </li></ul></ul><ul><ul><li>Right thoracotomy </li></ul></ul><ul><ul><li>Left Thoracotomy </li></ul></ul><ul><ul><li>Left Thoracoabdominal incision </li></ul></ul><ul><ul><li>Left Neck incision </li></ul></ul><ul><ul><li>Ivor-Lewis (Laparotomy/Right thoracotomy) </li></ul></ul><ul><ul><li>McKewn (Right thoracomty/Laparotomy/Neck incision) </li></ul></ul>
    9. 9. Rules for Anastomotic Technique <ul><li>Hand Sewn: </li></ul><ul><ul><li>Double layer </li></ul></ul><ul><ul><li>Single layer </li></ul></ul><ul><ul><li>Interrupted suture </li></ul></ul><ul><ul><li>Continuous suture </li></ul></ul><ul><ul><li>Combination </li></ul></ul><ul><li>Stapled </li></ul><ul><li>End to Side </li></ul><ul><li>Tension Free anastomosis </li></ul><ul><li>Intact blood supply </li></ul>
    10. 10. Ivor-Lewis Technique <ul><li>Laparotomy/Right Thoracootmy </li></ul>
    11. 16. Ivor Lewis – Phase I
    12. 17. Ivor Lewis – Phase II
    13. 18. Resection
    14. 19. Gastric Tube - Stapling
    15. 20. Gastric Tube - Stapling
    16. 21. Gastric Tube - Length
    17. 22. Proximal Esophagus
    18. 23. Anastomosis
    19. 24. Gastric Tube - Anastomosis
    20. 25. Gastric Tube - Posterior Mediastinum
    21. 26. Indications <ul><li>Mid esophageal carcinomas </li></ul>
    22. 27. Indications <ul><li>High-grade dysplasia in Barrett esophagus. </li></ul><ul><li>Destruction of the distal two-thirds of the esophagus by : </li></ul><ul><ul><li>caustic ingestion, peptic stricture and ulcer, </li></ul></ul><ul><li>Persistent reflux esophagitis causing pulmonary complications that fail to respond to antireflux procedures. </li></ul><ul><li>Perforation of the mid- to distal esophagus . </li></ul>
    23. 28. Contraindications <ul><li>High esophageal carcinomas located within 20 cm of the incisors. </li></ul><ul><li>Patients with previous right thoracotomy due to postoperative adhesion </li></ul>
    24. 29. Transhiatal Esophagectomy without Thoracotomy <ul><li>Same Indications </li></ul><ul><li>Safe procedure only when tracheobronchial or aortic involvement is Not suggested at CT . </li></ul>
    25. 33. Transthoracic Esophagectomy through a Left Thoracotomy Distal esophageal and gastro esophageal lesions
    26. 34. Conduits for Esophageal Reconstruction <ul><li>Skin Tubes </li></ul><ul><li>Stomach </li></ul><ul><li>Colon </li></ul><ul><li>Jejunum </li></ul><ul><li>Combination </li></ul>
    27. 35. Skin Tube
    28. 36. Stomach
    29. 37. Stomach
    30. 38. Colon
    31. 39. Colon Redundency
    32. 41. Colon
    33. 42. Blood Supply of the Colon
    34. 43. Different Segment Grafts
    35. 44. Right Colon Interposition
    36. 45. Left Colon Interposition
    37. 46. Transverse Colon Interposition
    38. 47. Colon – Surgical Hints
    39. 48. Posterior Cologastric Anastomosis
    40. 49. Jejunum
    41. 51. Vascular Pedicle
    42. 52. Jejunum – Roux-en-Y
    43. 53. Jejunum – Free Graft
    44. 54. Jejunum – Free Graft
    45. 55. Jejunum – Identifying Free Graft Free Graft
    46. 56. Jejunum – Free Graft Isolated
    47. 57. Jejunum – Free Graft Anastomosis
    48. 58. Combined Conduits
    49. 59. Combined Conduits
    50. 60. Combined Conduits
    51. 61. Combined Conduits
    52. 62. Routes of Reconstruction <ul><li>Posterior Mediastinal (Esophageal Bed) </li></ul><ul><li>Substernal </li></ul><ul><li>Subcutaneous </li></ul>
    53. 63. Reconstruction Route Selection
    54. 64. Reconstruction Route
    55. 65. Subcutaneous Substernal
    56. 66. Complications of Reconstruction
    57. 67. Complications of Reconstruction
    58. 68. Complications of Reconstruction
    59. 69. CONCLUSIONS <ul><li>1 st Goal of esophageal resection and reconstruction is to have a viable patient. </li></ul><ul><li>2 nd Goal is to have GI tract that is in continuity and functional </li></ul><ul><li>A successful reconstruction: </li></ul><ul><ul><li>Last over a long period of time </li></ul></ul><ul><ul><li>Provide a nutrition and quality of eating </li></ul></ul><ul><ul><li>Be done safely </li></ul></ul>
    60. 70. CONCLUSIONS <ul><li>Surgeon must have a “Game Plan” with several options and be felxibleduring the operation. </li></ul><ul><li>A team approach is essential for an excellent outcome. </li></ul>
    61. 71. Thank You

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