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'From Orringer, M.B., Marshall, B., and lannettoni, M.D.: Transhiatal esophagectomy: Clinical experience and refinements. Ann. Surg., 230:392-400, 1999, with permission.

'From Orringer, M.B., Marshall, B., and lannettoni, M.D.: Transhiatal esophagectomy: Clinical experience and refinements. Ann. Surg., 230:392-400, 1999, with permission.

addition of a partial upper sternal split is helpful in facilitating dissection of the upper and midthoracic esophagus in patients with tumors in both of these locations as well as in those with periesophageal fibrosis following prior surgery in this area.

I believe that the stomach is the preferred organ for esophageal replacement for both benign and malignant disease. Unlike thin-walled small or large intestine, the stomach is a resilient, thick-walled upper gastrointestinal organ that functions normally to transmit semisolid chewed food and is not prone to the redundancy that frequently occurs with intestinal esophageal substitutes. The extremely high incidence of significant gastroesophageal reflux and esophagitis that accompanies an intrathoracic esophagogastric anastomosis is seldom encountered with a properly performed cervical anastomosis. Based on my communications with several other esophageal surgeons, it appears that an anastomosis between the end of the cervical esophagus and the end of the amputated

Figure 25-31 Histology-dependent Kaplan-Meier survival curves in patients undergoing transhiatal esophagectomy for carcinoma of the intrathoracic esophagus and cardia. (From Orringer, M.B., Marshall, B., and Iannettoni, M.D.: Transhiatal esophagectomy: Clinical experience and refinements. Ann. Surg., 230:392, 1999, with permission.)

Figure 25-31 Histology-dependent Kaplan-Meier survival curves in patients undergoing transhiatal esophagectomy for carcinoma of the intrathoracic esophagus and cardia. (From Orringer, M.B., Marshall, B., and Iannettoni, M.D.: Transhiatal esophagectomy: Clinical experience and refinements. Ann. Surg., 230:392, 1999, with permission.)

Figure 25-32 Cervical esophagogram in a patient with a large squamous cell carcinoma involving the cervicothoracic esophagus within the thoracic inlet. The head of the clavicle has been highlighted to emphasize how such tumors may straddle the thoracic inlet.

Figure 25-33 An extended collar incision is used to determine that the cervicothoracic esophageal tumor is not invading the adjacent prevertebral fascia or carotid vessels. Once it has been determined that the tumor is resectable, the anterior cervical skin and platysma flap are elevated, and the origins of the sternocleidomastoid muscle are divided. The inset shows the bipedicled upper thoracic "apron" flap popularized by GrlllcJ 1 for anterior mediastinal tracheostomy. (From Orringer, M.B., and Sloan, H.: Anterior mediastinal tracheostomy. J. Thorac. Cardiovasc. Surg., 78:850, 1979, with permission.)

Figure 25-34 Inset A, Resection of the anterior thoracic "breast plate" (the medial thirds of the clavicles, short segments of the first and second costal cartilages, and the upper manubrium) permits exposure of the superior mediastinum and its contents, specifically, the trachea, cervicothoracic esophagus, and associated great vessels. Inset B, The oblique division of the trachea preserves as much of the posterior membranous portion (asterisk) as possible because this is the area that will have to reach most anteriorly when the trachea is brought forward over the innominate artery and sutured to skin. (From Orringer, M.B., and Sloan, H.: Anterior mediastinal tracheostomy. J. Thorac. Cardiovasc. Surg., 78:850, 1979, with permission.)

Figure 25-35 The completed pharyngogastric anastomosis. Thyroid and parathyroid function are preserved whenever possible. The divided trachea is positioned over the innominate artery for construction of the mediastinal tracheostomy. Inset A, Suturing of the pectoralis muscle over the edge of the divided bony chest wall is shown. Inset B, Transposition of the tracheal stump inferiorly and to the right of the Innominate artery and vein minimizes tension when the trachea is sewn to the skin. This maneuver is utilized liberally to prevent postoperative innominate artery erosion. (From Orringer, M.B., and Sloan, H.: Anterior mediastinal tracheostomy. J. Thorac. Cardiovasc. Surg., 78:850, 1979, with permission.)

Figure 25-36 Postoperative esophagogram in patient shown in Figure 25-32 after laryngopharyngectomy, anterior mediastinal tracheostomy, and pharyngogastric anastomosis. Left, The pharyngogastric anastomosis is indicated by the arrow. Right, The level of the pyloromyotomy (arrow).

Figure 25-37 The extended collar incision combined with vigorous downward retraction of the anterior upper thoracic skin in most cases permits resection of the anterior breast plate without the need for the additional transverse incisions and skin grafts on the upper chest and abdomen that are required with the Grillo bipedicled upper thoracic "apron" flap. (From Orringer, M.B.: Anterior mediastinal tracheostomy with and without cervical exenteration. Ann. Thorac. Surg., 54:628, 1992, with permission.) \

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