History

Denk performed the first reported blunt transmediastinal esophagectomy without thoracotomy in 1913 in cadavers and experimental animals using a vein stripper to avulse the esophagus from the posterior mediastinum. Turner, the British surgeon, carried out the first successful transhiatal blunt esophagectomy for carcinoma in 1933 and re-established continuity of the alimentary tract using an antethoracic skin tube at a second operation.[ ] The advent of endotracheal anesthesia permitted transthoracic esophagectomy under direct vision, and transhiatal esophagectomy without thoracotomy became a seldom-used approach, finding occasional use as a concomitant procedure with laryngopharyngectomy for pharyngeal or cervical esophageal carcinomas when the stomach was used to restore continuity of the alimentary tract. Ong

and Lee in 1960 and LeQuesne and Ranger in 1966 reported the first successful primary pharyngogastric anastomoses after laryngopharyngectomy and thoracic esophagectomy- In these cases, and in the report by Akiyama and associates,1 • blunt resection of the normal thoracic esophagus was carried out. Kirk used this approach for palliation of incurable esophageal carcinoma in five patients.1 • Thomas

and Dedo treated four patients with severe chronic pharyngoesophageal caustic strictures by blunt thoracic esophagectomy without thoracotomy, mobilization of the stomach through the posterior mediastinum, and pharyngogastric anastomosis.

In 1975, Orringer and Sloan proposed the technique of substernal gastric bypass of the excluded thoracic esophagus as a method of palliation of incurable esophageal carcinomas, both those that were invading contiguous major structures, such as the trachea or aorta, and those that had metastasized to either cervical or abdominal lymph nodes. This procedure was envisioned as a "simple" bypass to relieve dysphagia

without the potential postoperative morbidity of a thoracotomy and intrathoracic esophageal anastomosis ( Fig. 25-1 Fig. 25-2 Fig. 25-3 Fig. 25-4 Unfortunately, further experience with this operation failed to substantiate its value as a worthwhile palliative procedure achievable with minimal morbidity. 1 ' The two major complications of this procedure were cervical anastomotic

Figure 25-1 Routine mobilization of the stomach for esophageal replacement either in the substernal or posterior mediastinal position. The left gastric artery and left gastroepiploic vessels are divided, whereas the right gastric and right gastroepiploic arteries are preserved. A pyloromyotomy and generous Kocher maneuver are routine. The divided stapled cardia is always oversewn to reinforce the staple suture line. Inset shows the left cervical incision and the upper midline abdominal incision used both for substernal gastric interposition and for transhiatal esophagectomy and esophageal replacement with stomach in the posterior mediastinum. (From Orringer, M.B., and Sloan, H.: Substernal gastric bypass of the excluded thoracic esophagus for palliation of esophageal carcinoma. J. Thorac. Cardiovasc. Surg., 70:836, 1975, with permission.)

Figure 25-2 Enlarging the anterior opening into the superior mediastinum for esophageal bypass or replacement using the retrosternal route. Inset shows normal position of the cervical esophagus at the thoracic inlet, posterior and to the left of the trachea. When performing an anastomosis between the cervical esophagus and a retrosternal visceral esophageal substitute (either stomach or colon), compression of the graft by the posterior prominence of the head of the clavicle may occur. Thus, the medial clavicle and adjacent manubrium, and often the medial first rib as well, are routinely resected when using the anterior mediastinal route to allow more room for the transposed stomach (or colon) at the anterior thoracic inlet. (From Orringer, M.B., and Sloan, H.: Substernal gastric bypass of the excluded thoracic esophagus for palliation of esophageal carcinoma. J. Thorac. Cardiovasc. Surg., 70:836, 1975, with permission.)

Posterior promtnence of head of clavicle

Figure 25-3 Positioning the mobilized stomach in the anterior mediastinum for substernal gastric bypass. The gastric fundus, not the divided cardia, reaches most superiorly, several centimeters above the level of the clavicles, for the esophagogastric anastomosis. The anterior opening into the superior mediastinum has been widened by resection of the clavicle and medial manubrium of the sternum. (From Orringer, M. B., and Sloan, H.: Substernal gastric bypass of the excluded thoracic esophagus for palliation of esophageal carcinoma. J. Thorac. Cardiovasc. Surg., 70:836, 1975, with permission.)

Figure 25-4 Lateral view showing final position of the retrosternal stomach and the excluded thoracic esophagus in the posterior mediastinum. The gastric fundus has been suspended from the prevertebral fascia; the anastomosis has been performed on the anterior wall of the stomach; and the esophagus, with its unresectable tumor, is excluded in the posterior mediastinum. (From Orringer, M.B., and Sloan, H.: Substernal gastric bypass of the excluded thoracic esophagus for palliation of esophageal carcinoma. J. Thorac. Cardiovasc. Surg., 70:836, 1975, with permission.)

Figure 25-5 Transhiatal mobilization of the upper and lower esophagus from the posterior mediastinum is facilitated by traction on rubber drains placed around the esophagogastric junction and the cervical esophagus. The volar aspects of the fingers are kept against the esophagus to reduce the chance of injury to adjacent structures. (From Orringer, M.B.: Surgical options for esophageal resection and reconstruction with stomach. In Baue, A.E., Geha, A.S., Hammond, G.L., et al. [eds.]: Glenn's Thoracic and Cardiovascular Surgery, 6th ed. Stamford, CT, Appleton & Lange, 1996, p. 899, with permission.)

Figure 25-6 Transhiatal mobilization of the esophagus away from the prevertebral fascia is facilitated using a half-sponge on a stick inserted through the cervical incision and advanced until it makes contact with the hand inserted from below through the diaphragmatic hiatus. (From Orringer, M.B.: Surgical options for esophageal resection and reconstruction with stomach. In Baue, A.E., Geha, A.S., Hammond, G.L., et al. [eds.J: Glenn's Thoracic and Cardiovascular Surgery, 6th ed. Stamford, CT, Appleton & Lange, 1996, p. 899, with permission.)

Figure 25-7 Anterior transhiatal esophageal mobilization carried out as a mirror-image of the posterior dissection, keeping the volar aspects of the fingers against the esophagus, particularly near the posterior membranous trachea and left mainstem bronchus. (From Orringer, M.B.: Surgical options for esophageal resection and reconstruction with stomach. In Baue, A.E., Geha, A.S., Hammond, G.L., et al. [eds.J: Glenn's Thoracic and Cardiovascular Surgery, 6th ed. Stamford, CT, Appleton & Lange, 1996, p. 899, with permission.)

Figure 25-8 As the anterior esophageal dissection is performed, constant pressure should be exerted posteriorly against the esophagus to minimize the hemodynamic effects of cardiac displacement. (From Orringer, M.B.: Surgical options for esophageal resection and reconstruction with stomach. In Baue, A.E., Geha, A.S., Hammond, G.L., et al. [eds.]: Glenn's Thoracic and Cardiovascular Surgery, 6 th ed. Stamford, CT, Appleton & Lange, 1996, p. 899, with permission.)

Figure 25-9 The right hand inserted through the diaphragmatic hiatus is advanced upward into the superior mediastinum until the undivided lateral esophageal attachments are felt. (From Or ringer, M.B.: Transhiatal blunt esophagectomy without thoracotomy. In Cohn, L.H. fed. J: Modern Technics in Surgery, Vol. 62. Cardiovascular Surgery. New York, Futura Publishing, 1983, p. 1, with permission.)

Figure 25-10 With the esophagus trapped between the index and middle fingers against the prevertebral fascia, a downward raking motion of the hand avulses the lateral periesophageal attachments. (From Orringer, M.B.: Transhiatal blunt esophagectomy without thoracotomy. In Cohn, L.H. fed.J: Modern Technics in Surgery, Vol. 62. Cardiovascular Surgery. New York, Futura Publishing, 1983, p. 1, with permission.)

Figure 25-11 Exposure of the upper thoracic esophagus through a partial sternal split. Main illustration demonstrates the course of the left recurrent laryngeal nerve beneath the aortic arch and in the tracheoesophageal groove. Inset A, The left cervical incision is extended onto the anterior chest in the midline. Occasionally, a curved anterior thoracic incision may be used to avoid a scar on the low anterior neck. Inset B, The sternotomy incision extends from the suprasternal notch through the manubrium and across the angle of Louis. (From Orringer, M.B.: Partial median sternotomy: Anterior approach to the upper thoracic esophagus. J. Thorac. Cardiovasc. Surg., 87:124, 1984, with permission.)

Figure 25-13 Partial proximal gastrectomy performed routinely in transhiatal esophagectomy and esophageal replacement with stomach. The mobilized stomach and attached distal esophagus are delivered from the abdominal incision and retracted superiorly as the surgical stapler is applied sequentially, beginning from the high lesser curvature and proceeding toward the high greater curvature (as indicated by the dotted line). This technique is also used for tumors of the cardia (as shown), where the stapler can be applied 4 to 6 cm distal to palpable tumor. (From Orringer, M.B., and Sloan, H.: Esophageal replacement after transhiatal esophagectomy without thoracotomy. In Nyhus, L.M., and Baker, R.J. [eds.]: Mastery of Surgery, 2nd ed. Boston, Little, Brown, 1992, p. 569, with permission.)

Figure 25-13 Partial proximal gastrectomy performed routinely in transhiatal esophagectomy and esophageal replacement with stomach. The mobilized stomach and attached distal esophagus are delivered from the abdominal incision and retracted superiorly as the surgical stapler is applied sequentially, beginning from the high lesser curvature and proceeding toward the high greater curvature (as indicated by the dotted line). This technique is also used for tumors of the cardia (as shown), where the stapler can be applied 4 to 6 cm distal to palpable tumor. (From Orringer, M.B., and Sloan, H.: Esophageal replacement after transhiatal esophagectomy without thoracotomy. In Nyhus, L.M., and Baker, R.J. [eds.]: Mastery of Surgery, 2nd ed. Boston, Little, Brown, 1992, p. 569, with permission.)

Figure 25-14 Identification of the site on the high greater curvature of the stomach that will reach most superiorly to the neck. The oversewn staple suture line where the cardia was divided is shown. (From Orringer, M.B., and Sloan, H.: Esophageal replacement after transhiatal esophagectomy without thoracotomy. In Nyhus, L.M., and Baker, R.J. [eds.]: Mastery of Surgery, 2nd ed. Boston, Little, Brown, 1992, p. 569, with permission.)

Figure 25-15 The mobilized stomach is gently manipulated through the diaphragmatic hiatus and into the posterior mediastinum in the original esophageal bed. Cardiac displacement is minimized by keeping the hand flat and as much against the spine as possible. After the stomach has reached the superior mediastinum beneath the aortic arch, the tip is grasped with a Babcock clamp inserted through the cervical incision and carefully drawn into the cervical field until it can be grasped by the finger tips (inset). The clamp is not ratcheted closed completely to minimize gastric trauma. Four to five centimeters of stomach is delivered above the level of the clavicle primarily by pushing from below in the chest rather than applying traction in the neck. (From Orringer, M.B., Marshall, B., and Iannettoni, M.D.: Eliminating the cervical esophagogastric anastomotic leak with a side-to-side stapled anastomosis. J. Thorac. Cardiovasc. Surg., 119:277,2000.)

Figure 25-16 The tip of the mobilized stomach rests anterior to the prevertebral fascia in the neck, 4 to 5 cm above the level of the left clavicle and well behind the divided cervical esophagus. The end of the esophagus is retracted superiorly, the oversewn gastric staple suture line is rotated more medially toward the patient's right side, and a Babcock clamp is used to elevate the anterior gastric wall into the field. A 3-0 silk traction suture placed distal to the clamp is fixed to the drapes and elevates the stomach to the surface of the wound. (From Orringer, M.B., Marshall, B., and Iannettoni, M.D.: Eliminating the cervical esophagogastric anastomotic leak with a side-to-side stapled anastomosis. J. Thorac. Cardiovasc. Surg., 119:277, 2000.)

Figure 25-17 Using a needle-tip electrocautery, a 1.5-cm vertical gastrotomy is made on the anterior gastric wall, well away from the staple suture line and after carefully assessing where the end of the cervical esophagus will ultimately rest in a tension-free fashion when the traction suture is removed. (Modified from Orringer, M.B., Marshall, B., and Iannettoni, M.D.: Eliminating the cervical esophagogastric anastomotic leak with a side-to-side stapled anastomosis. J. Thorac. Cardiovasc. Surg., 119:277, 2000.)

Figure 25-18 The esophageal staple suture line is amputated obliquely in an anterior to posterior orientation, again creating a longer anterior than posterior tip. An atraumatic vascular forceps is used as a guide for amputation of the staple suture line, which is submitted as the "proximal esophageal margin." (Modified from Orringer, M.B., Marshall, B., and Iannettoni, M.D.: Eliminating the cervical esophagogastric anastomotic leak with a side-to-side stapled anastomosis. J. Thorac. Cardiovasc. Surg., 119:277, 2000.)

Figure 25-19 Two 4-0 polyglycolic acid stay sutures are placed, one at the tip of the anterior corner of the beveled esophagus and the other from the superior corner of the vertical gastrotomy and the posterior corner of the esophagus. (Modified from Orringer, M.B., Marshall, B., and Iannettoni, M.D.: Eliminating the cervical esophagogastric anastomotic leak with a side-to-side stapled anastomosis. J. Thorac. Cardiovasc. Surg., 119:277, 2000.)

Figure 25-20 A, The two stay sutures are retracted inferiorly as the ENDO-GIA 30-3.5 staple cartridge is inserted, the thinner anvil portion into the stomach and the thicker staple-bearing portion into the esophagus. B, The staple cartridge is gradually rotated and pointed toward the patient's right ear as it is advanced into the esophagus and stomach (inset). The posterior wall of the esophagus and the anterior wall of the stomach are carefully aligned In a parallel fashion, keeping the site of the anastomosis well away from the gastric staple suture line. (From Orringer, M.B., Marshall, B., and lannettoni, M.D.: Eliminating the cervical esophagogastric anastomotic leak with a side-to-side stapled anastomosis. J. Thorac. Cardiovasc. Surg., 119:277, 2000.)

Figure 25-21 A, The jaws of the stapler are approximated by squeezing the handle, but before firing it, the stapler is rolled from one side to the other as two "suspension" sutures between the esophagus and adjacent stomach are placed on either side. B, A 3-cm long side-to-side anastomosis is created by firing the stapler and thereby advancing the knife assembly. The stapler is removed, the anastomosis inspected for bleeding, a nasogastric tube inserted, and "corner" sutures placed in preparation for completion of the anastomosis. (From Orringer, M.B., Marshall, B., and lannettoni, M.D.: Eliminating the cervical esophagogastric anastomotic leak with a side-to-side stapled anastomosis. J. Thorac. Cardiovasc. Surg., 119:277, 2000.)

Figure 25-22 The gastrotomy and open esophagus are apposed in two layers: (A) a running Inner layer of 4-0 monofilament absorbable suture, and (B) an outer interrupted layer. (From Orringer, M.B., Marshall, B., andlannettoni, M.D.: Eliminating the cervical esophagogastric anastomotic leak with a side-to-side stapled anastomosis. J. Thorac. Cardiovasc. Surg., 119:277, 2000.)

Figure 25-23 Transhiatal esophagectomy and proximal partial gastrectomy for lesions of the cardia and distal esophagus. A 4- to 6-cm gastric margin is obtained while preserving the entire greater curvature and that point (asterisk) that reaches most cephalad. The stippled area indicates the portion of stomach that is typically resected in a standard hemigastrectomy for distal esophageal carcinoma, thus eliminating the possibility of a cervical esophagogastric anastomosis. (From Orringer, M.B., and Sloan, H.: Esophagectomy without thoracotomy. J. Thorac. Cardiovasc. Surg., 76:643, 1978, with permission.)

Figure 25-25 Postoperative barium swallow in patient shown in Figure 25-24 after transhiatal esophagectomy and cervical esophagogastric anastomosis. The two silver clips above the level of the clavicle mark the cervical esophagogastric anastomosis.

Figure 25-26 Final position of the mobilized stomach after transhiatal esophagectomy and cervical esophagogastric anastomosis. The stomach rests in the posterior mediastinum in the original esophageal bed. Two "suspension" sutures on either side of the anastomosis between the back of the cervical esophagus and the adjacent stomach limit tension on the anastomosis and are preferable to "tacking" sutures between the stomach and the prevertebral fascia. The pylorus (not shown) generally comes to rest several centimeters below the level of the diaphragmatic hiatus. (From Iannettoni, M.D., Whyte, R.I., and Orringer, M.B.: Catastrophic complications of the cervical esophagogastric anastomosis. J. Thorac. Cardiovasc. Surg., 110:1493, 1995, with permission.)

TABLE 25-1 -- Indications for Transhiatal Esophagectomy (1085 Patients)

Diagnosis

No. of Patients (%)

Benign Conditions

285(26)

Neuromotor dysfunction

93 (33)

Achalasia

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