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Figure 24-1 To perform a counterincision, the scapula is retracted off the chest wall and a higher interspace selected. A seventh and fourth interspace approach is illustrated. (From the Society of Thoracic Surgeons. Ann. Thorac. Surg., 46:250, 1988, with permission.)

Figure 24-1 To perform a counterincision, the scapula is retracted off the chest wall and a higher interspace selected. A seventh and fourth interspace approach is illustrated. (From the Society of Thoracic Surgeons. Ann. Thorac. Surg., 46:250, 1988, with permission.)

Figure 24-2 A, Anterior cervical skin and platysma are elevated inferiorly over the pectoral fascia, especially in the midline. The sternocleidomastoid muscle is detached from the sternal and clavicular attachments. B and C, Resection of a plate of sternum, clavicle, and the first and second ribs. Usually, the left half is all that is required to enlarge the thoracic inlet, but both sides may be needed in special circumstances.

Figure 24-3 Anatomic variations in the distribution to the colon of branches of the superior mesenteric artery. The extreme variation and the inconstancy of a marginal artery connecting the right colic artery and the ileocolic artery branches make use of the right colon less reliable than use of the left colon. (From Sonneland, J., Anson, B.J., and Beaton, L.E.: Surgical anatomy of the arterial supply to the colon from the superior mesenteric artery based upon a study of600 specimens. Surg. Gynecol. Obstet, 106:385, 1958, with permission.)

Figure 24-5 The gastric fundus should be preserved (A) to maximize gastric length, which will permit extension of the gastric tube to the neck (a) if needed. It is important not to assume adequate gastric length and to prematurely amputate the gastric fundus (B). The proposed esophagogastric site is indicated by a circle.

Figure 24-5 The gastric fundus should be preserved (A) to maximize gastric length, which will permit extension of the gastric tube to the neck (a) if needed. It is important not to assume adequate gastric length and to prematurely amputate the gastric fundus (B). The proposed esophagogastric site is indicated by a circle.

Figure 24-6 This illustration (lower right) illustrates peritoneal freeing of the outer aspect of the duodenal curve, permitting its retraction to the left and exposure of the retroduodenal structures. This permits maximal mobilization of the stomach upward in the thorax; thus, the pylorus actually lies at the level of the diaphragmatic hiatus. (From Netter, F.H.: The CIBA Collection of Medical Illustrations. Vol. 3: Digestive System. Parti: Upper Digestive System. New York, CIBA-GEIGY Corp., 1959, p. 58, with permission.)

Figure 24-6 This illustration (lower right) illustrates peritoneal freeing of the outer aspect of the duodenal curve, permitting its retraction to the left and exposure of the retroduodenal structures. This permits maximal mobilization of the stomach upward in the thorax; thus, the pylorus actually lies at the level of the diaphragmatic hiatus. (From Netter, F.H.: The CIBA Collection of Medical Illustrations. Vol. 3: Digestive System. Parti: Upper Digestive System. New York, CIBA-GEIGY Corp., 1959, p. 58, with permission.)

Figure 24-7 A, This illustration demonstrates both removal of the lesser curvature of the stomach and elongation of the stomach by traction on the greater curvature. The subsequent esophagogastric anastomosis will be made to a point toward the greater curvature from the surgeon's thumb. (From Akiyama, H.: Surgery for carcinoma of the esophagus. Curr. Probl. Surg., 17:56,1980, with permission.) B, Multiple applications of the GIA-60 stapler are used to "unfold" the lesser curvature and achieve maximal length of the gastric tube. (From Shriver, C.D., Spiro, R.H., and Burt, M.: A new technique of gastric pull-through. Surg. Gynecol. Obstet. 177:519, 1993.)

Figure 24-7 A, This illustration demonstrates both removal of the lesser curvature of the stomach and elongation of the stomach by traction on the greater curvature. The subsequent esophagogastric anastomosis will be made to a point toward the greater curvature from the surgeon's thumb. (From Akiyama, H.: Surgery for carcinoma of the esophagus. Curr. Probl. Surg., 17:56,1980, with permission.) B, Multiple applications of the GIA-60 stapler are used to "unfold" the lesser curvature and achieve maximal length of the gastric tube. (From Shriver, C.D., Spiro, R.H., and Burt, M.: A new technique of gastric pull-through. Surg. Gynecol. Obstet. 177:519, 1993.)

Figure 24-8 Pyloromyotomy. The 3-cm incision across the pylorus provides complete exposure of the sphincter muscle for division down to the mucosal layer. A fine hemostatic forceps is helpful in this dissection. The principal risk of entry into the duodenum is shown in the cross section at the right, where the duodenal mucosa covers the undersurface of the pyloric muscle at the duodenal aspect.

Figure 24-8 Pyloromyotomy. The 3-cm incision across the pylorus provides complete exposure of the sphincter muscle for division down to the mucosal layer. A fine hemostatic forceps is helpful in this dissection. The principal risk of entry into the duodenum is shown in the cross section at the right, where the duodenal mucosa covers the undersurface of the pyloric muscle at the duodenal aspect.

Figure 24-9 The gastric tube is secured to the plastic bag by a horizontal mattress suture, and the apex of the bag is tied to the No. 5 silk emerging from the posterior mediastinum through the hiatus. The tube is now ready for transposition to the neck. (From Shriver, C.D., Spiro, R.H., and Burt, M.: A new technique of gastric pull-through. Surg. Gynecol. Obstet. 177:519, 1993.)

Figure 24-10 The retrosternal tunnel has been bluntly dissected with the finger so that the entire hand can be extended upward in the anterior mediastinum. This figure illustrates passage of the stomach through this tunnel to the thoracic inlet and the cervical incision. Note that the thoracic inlet has been enlarged by resection of the inner end of the clavicle and a portion of the manubrium. (From Orringer, M.B., and Sloan, H.: Substernal gastric bypass of (he excluded thoracic esophagus for palliation of esophageal carcinoma. J. Thorac. Cardiovasc. Surg., 70:836, 1975, with permission.)

Figure 24-11 A, The first step in the Sweet anastomosis developed at the Massachusetts General Hospital. An end-to-side anastomosis is being initiated with excision of a button of gastric wall. This button must not be placed too close to the gastric turn-in. The button can actually be placed quite close to the greater curvature, often between the last two branches of the gastroepiploic arcade. The outer posterior row of the anastomosis is being performed with interrupted mattress sutures of fine silk placed across the longitudinal muscle fibers of the esophagus. My preference is to place all of these sutures before tying. B, The gastric button has been excised. With the specimen still attached and excluded with the right-angle clamp, the mucosae of the esophagus and stomach are approximated with interrupted fine silk sutures. C, Completion of the posterior inner row and excision of the specimen. D, The corner of the anastomosis is being turned to begin the anterior row of sutures. These are placed, again in interrupted fashion, with the knots tied on the inside. E, Completion of the anastomosis with mattress sutures of interrupted silk in the outer anterior row. Each suture approximates the muscle of esophagus to the musculoserosa of stomach. These sutures are placed in horizontal mattress fashion (not as actually shown) so that there is less risk of cutting through. (From Mathisen, D.J., Grillo, H.C., Wilkins, E.W. Jr., et al.: Transthoracic esophagectomy: A safe approach to carcinoma of the esophagus. Ann. Thorac. Surg., 45:137, 1988, with permission.)

TABLE 24-1 -- Indications for Esophagocoloplasty

Malignant tumors

1. Replacement of esophagus after gastrectomy

2. Bypass of unresectable carcinoma

3. Palliation of esophagotracheal or bronchial fistula

4. Staged complex esophageal resections Benign conditions

1. Staged bypass of caustic esophageal stricture

2. Esophageal atresia (congenital) when primary anastomosis is not feasible

3. Bypass of long peptic esophageal stricture in physiologically impaired patient

Preoperative Preparation

Emphasis has already been placed on performing colon evaluation by colonoscopy, mesenteric arteriography, and barium enema, in that order. Of these, complete opacification of the colon arterial blood supply is the most important in providing a complete map of the several colic arteries for the abdominal surgeon. In older patients, the presence of atherosclerotic plaques, which might impair successful vascularity of the interposing colon, are identified by these studies. Any of the estimated 10% of major mesenteric arterial anomalies (see Fig. 24-3 ) may be identified. Although in most cases, the details of this anatomy can be worked out by intraoperative transillumination of the colon mesentery, arteriographic study saves both time and confusion in the actual conduct of the operation.

Mechanical cleansing of the colon to be placed in the chest is an important fundamental procedure. A clean colon is essential to primary healing of the esophagocolic anastomosis in the neck, where spillage of residual fecal contents must be avoided. The first step in providing a clean colon is the cleansing necessary for either the colonoscopy or the barium enema. If barium is used, its total evacuation must be verified by a preoperative plain abdominal radiograph. An elemental diet providing oral alimentation of essential amino acids is often satisfactory in patients with dysphagia. Mechanical cleansing of the colon (GoLYTELY) is the major element in assuming a clean colon. Enemas are rarely required and should not be administered within 12 to 18 hours before surgery. Oral intestinal antibiotics are favored by some, with 1 g of neomycin and 1 g of erythromycin every 4 hours times four doses the most common regimen. Broad-spectrum, so-called prophylactic, antibiotics are initiated parenterally on-call to the operating theater, and maintenance doses are continued in bolus intravenous fashion during the procedure and 48 hours after.

Operative Technique

The use of colon in a bypass procedure is described here. Its use as a replacement differs only in the orthotopic route of placement in the posterior mediastinum, the shortest distance to the neck. This avenue should not be chosen if gross residual carcinoma is left in the mediastinum. Many surgeons prefer to use the retrosternal position

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