anatomy of the pharynx and oesophagusoesophagectomy-right... · 2012-11-16 · the anatomy of the...

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Romeo Bardini, Raffaele De Caro Romeo Bardini, Raffaele De Caro

SURGERY OF THE OESOPHAGUS SURGERY OF THE OESOPHAGUSANATOMY ANATOMY

ANATOMY OF THE PHARYNX AND OESOPHAGUSANATOMY OF THE PHARYNX AND OESOPHAGUS

ANATOMY OF THE PHARYNX AND OESOPHAGUS

The pharynx is an unpaired, medial passage extending from the base of the skull to the lower margin of the cricoid cartilage in the larynx. It is derived from the primitive pharynx and constitutes an undifferentiated segment that is common to the alimen-tary canal and the airway. It is actually shaped like a cylinder with a portion missing from the anterior face, rather like a rainwater pipe, with its convex portion facing the vertebral plane. In fact, this cav-ity has a large area of communication with the nasal and oral cavities and the laryngeal inlet in front of it. Because of these connections it is divided into three portions: nasal (nasopharynx) extending from the base of the skull to the free margin of the soft palate; oral (oropharynx), the lower limit being the margin of the epiglottis; and laryngeal (laryn-gopharynx or hypopharynx), extending to the lower margin of the cricoid. In the frontal plane the pharynx is like a funnel with the truncated apex at the bottom and a diameter of about 6.5 cm at the top, reducing to 2 cm at the junction with the oesophagus. In adults, the length varies between 15 cm in men and 13 cm in women. The dimensional variations in the frontal plane also correspond to differences in the sag-ittal plane, both as regards the lumen and the size of the three parts of the organ.

Insertions: the pharynx, which is like a cylinder without an anterior face, has fixed insertion points at the upper end and the two long lateral margins. The upper end is insert-ed into the base of the skull at the body of the occipital bone and the proximal part of the body of the sphenoid. The margin of this insertion forms a line, leading from the pharyngeal tubercle of the occipital bone on both sides to the anterior-medial margin of the external opening of the ca-rotid canal and then turning forward and converging slightly, until it reaches the posterior margin of the medial plates of the pterygoid processes of the sphenoid. In the segment between the carotid aperture and that pterygoid process, the line of insertion is interrupted by the presence of the cartilage of the Eustachian (auditory) tube. The two lateral margins are inserted in succession (from top to bottom) on the base of the skull (pharyngeal tubercle of the pterygoid process), the mandible, the hyoid bone and lastly the laryn-geal cartilage. This forms two linear, anterior-lateral inser-tions towards which the lateral and posterior walls of the pharynx move when its muscles contract. The upper end of the pharynx, corresponding to the lower face of the sphe-no-occipital synchondrosis, is vault-like in appearance, and forms the continuation of the nasal cavities. Here there is a lymphoepithelial structure, the pharyngeal tonsil or adenoid, which takes the form of a ridge made of folds of mucosa flanked by sulci running sagittally.

Oropharynx

The apertures of the Eustachian tube open into the oro-pharynx, and the tube forms a channel of communication between the cavity of the middle ear and the pharyngeal cavity. These apertures, located about 1 cm behind the end of the inferior turbinate, have a hook-like curved shape with the shortest point at the front. They are bordered by the end of the cartilage of the tube, which has two folds: a shorter anterior and then lateral one, and a posterior one with a medial protuberance. The mucosal covering of these folds continues downwards with two ridges in the lateral wall of the pharynx, anteriorly the salpingopalatine fold and poste-riorly the salpingopharyngeal fold. Incidentally, it should be noted that two of the muscles of the soft palate have a relation to the tubal orifice. One is the levator veli palatini (inserted at its top into the lower face of the pyramid of the temporal bone) which, extending downwards into the ve-lum, passes immediately below the orifice and, on contract-ing, causes the orifice to close. The other is the tensor veli palatini (inserted at the top into the scaphoid fossa of the pterygoid process where it is adjacent to the greater wing of the sphenoid) which, also being inserted into the cartilage of the tube, dilates its orifice on contraction (swallowing).

At the front, this is connected to the oral cavity via the isthmus of the fauces, bordered by the free margin of the velum, the palatoglossal and palatopharyngeal arches, the pharyngoepiglottic folds and the base of the tongue.

Laryngopharynx or hypopharynx

The anatomy of the hypopharynx is somewhat more rel-evant to this work. The entrance to the pharynx is at the front and under-neath it is the protuberance formed by the cricoid cartilage. The piriform sinuses, or pharyngolaryngeal grooves, are two recesses in the laryngeal cavity, located anteriorly on either side where the anterior and lateral walls of the pharynx meet. In fact the pharyngeal wall is specialised to form two spaces containing the constituent parts of the larynx facing it: these are between the cricoid cartilage, arytenoid carti-lage and aryepiglottic fold medially, and between the inner surface of the thyroid lamina (divergent) and the thyrohyoid membrane laterally. A horizontal cross-section taken at this level reveals the marked medial prominence of the cricoid ring and the divergence of the thyroid laminae, which give rise to two recesses representing peripheral paths along which the food can progress towards the oesophagus. The mucosa covering the recesses has a fold pointing down-wards and medially, defined by the underlying course of the internal branch of the superior laryngeal nerve. At this level,

the lumen of the pharyngeal cavity has a half-moon shape with its concavity corresponding to the cricoid prominence and the two ends in the piriform sinuses.

Oesophagus

The oesophagus is the portion of the alimentary tract that comes after the pharynx and ends in a connection with the stomach at the cardia (fig.1). It has the form of a long passage, flattened anterior-posteriorly, located deep to and in close contact with the vertebral column. Its upper limit is constituted by the cricopharyngeus muscle, located approxi-mately on the horizontal plane touching the lower margin of the cricoid cartilage of the larynx or the body of the 6th cer-vical vertebra, when the neck is in an intermediate position between flexion and extension. In contrast, the lower limit is very clear, level with the cardia on the left side of the body

of the 10th thoracic vertebra, because of its abrupt increase in diameter. The oesophagus can be divided into three por-tions (cervical, thoracic and abdominal) since its shape and relations differ significantly as it passes through the three different segments of the trunk. The shape of the organ, which resembles a hollow cylinder about 23-25 cm long, actually looks different in cross-sections taken at various lev-els. In fact, its muscular and membranous structure, which has no rigid components, fits into the boundaries formed by its relation to the adjacent anatomical forms and the ef-fects of pressure in the thoracic and abdominal cavities. For this reason, even though it has the appearance of an organ flattened anterior-posteriorly for much of its course, with an anterior wall, a posterior wall and two lateral margins, and a virtual lumen in its cervical and thoracic portion above the left bronchus, below the latter and as far as the diaphragm it becomes circular and spindle-shaped with a wide lumen through the effect of negative pressure in the chest. The ab-

fig.1 - The position of the oesophagus in the posterior mediastinum and its continuity with the stomach.

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dominal portion is shaped like a short cone (2-3 cm), form-ing a gentle curve to the left where it meets the stomach. Its average transverse diameter varies between 1.5 and 2 cm and its star-shaped appearance is due to the presence of ridges formed of mucosa and submucosa running axially like long folds along the inner surface of the organ. The lumen can, however, be dilated because its walls are slightly elastic, so that rigid or flexible instruments (oesophagoscope) up to 2-2.5 cm in diameter can be passed through. The axis of the oesophagus, which is vertical overall, is not actually straight since in the frontal plane it has a first, slightly con-vex inflection to the left in the cervical portion and lower down, from the 7th thoracic vertebra, it describes a concave leftward curve as far as the diaphragmatic hiatus, caused by its relation to the heart. In the sagittal plane it also de-scribes a slight forwardly convex curve at the top, to follow the course of the vertebral column as far as the 4th tho-racic vertebra, then gradually moves away from the vertebral plane because of the interposition of the descending tho-racic aorta, and describes a second slight forwardly concave curvature. Furthermore, because of their close relation to the oesophagus and their more rigid or compact structure, some anatomical components limit its capacity for dilatation at specific, invariable points forming constrictions.

These, in a downward direction, are: • the cricoid constriction formed on the wall of the alimen-

tary tract in the anterior cervical portion of the lamina of the cricoid;

• the aortic constriction, formed by the aortic arch which, in its course from anterior to posterior mediastinum, passing above the left main bronchus, rests on the left side of the thoracic oesophagus; and immediately below the latter, but on the anterior wall of the oesophagus, the bronchial constriction, created by the posterior wall of the left main bronchus, as a consequence of the slight rightward inclination the of the axis of the trachea.

The diaphragmatic hiatus constitutes a further zone of constriction. Here, in fact, the oesophagus is joined to the muscle fascicles of the diaphragm by a structure of muscle fibres, the ring-shaped Bertelli phrenoesophageal mem-brane, which encircles the oesophagus and connects it to the margin of the diaphragmatic hiatus. This membrane projects a short way up the distal thoracic oesophagus and also extends downwards onto the adjacent part of the ab-dominal oesophagus and is attached to the adventitia of the organ. This produces an anatomical system that anchors the oesophagus to the diaphragm, preventing any fluid col-lections from passing between the abdominal and thoracic cavities.

Anatomic relationship

The cervical portion of the oesophagus, 5 cm long on average, corresponds to the subhyoid region. It occupies the deepest plane of the visceral space of the neck, in the cavity between the trachea and the vertebral column, bounded at the side by the two neurovascular bundles of the neck. The oesophagus is separated from the adjacent organs by a layer of areolar tissue that is continuous, at the top, with the retropharyngeal areolar tissue and, at the bottom, with the areolar tissue of the posterior mediastinum. Its lower limit is superficial to the jugular notch of the manubrium sterni and deep to the first thoracic vertebra. It is flattened in the anterior-posterior direction, and the lumen has the shape of a transverse fissure 5 to 12 cm long. The slight rightward displacement of the axis of the trachea is notice-able even in the neck. The thoracic portion of the oesopha-gus, 16-18 cm long, runs within the posterior mediastinum, in the space bounded by the trachea and the heart at the front, the vertebral plane at the back, and the two pleuropul-monary regions at the sides. It is divided into two portions, the proximal and distal thoracic oesophagus respectively, the terms describing their relation to the tracheal bifurcation. In the upper, proximal thoracic oesophagus, which extends as far as the 4th thoracic vertebra, the anterior surface has a relation to the membranous part of the trachea, from which it protrudes somewhat to the left, and then to the tracheal bifurcation and the left bronchus. Its posterior relation is to the vertebral column surrounded by the long neck muscles; between these and the oesophagus there is a layer of loose connective tissue continuous with that of the prevertebral region. At the sides its relation is to the mediastinal pleura, but between them on the right is the terminal arch of the azygos vein, while the following are on the left: the recurrent nerve, the initial portion of the common carotid and the left subclavian, the thoracic duct and, immediately below, the aortic arch. The distal thoracic oesophagus has a relation, at the front, to several tracheobronchial lymph nodes and to the posterior surface of the pericardium in the segment covering the left atrium. Posteriorly the oesophagus always follows the vertebral column, but between them is a “vas-cular plane” consisting of the descending thoracic aorta on the left, the azygos vein on the right and, between them, the right intercostal arteries, the hemiazygos vein and the thoracic duct. Laterally, the distal thoracic oesophagus has a relation to the two vagus nerves; before passing through the hiatus, the left vagus nerve runs over the anterior surface of the oesophagus and the right one over the posterior surface.The mediastinal surface of the pleuropulmonary regions constitutes the other lateral relation. Part of the mediastinal pleura penetrates between the posterior surface of the oesophagus and the vessels at the rear, forming two small recesses: an undeveloped one be-

tween aorta and oesophagus on the left and a larger one between azygos and oesophagus on the right. The abdomi-nal portion of the oesophagus, which is about 3 cm long and funnel-shaped, lies close to the left side of the 10th-11th thoracic vertebrae. Its anterior surface, the only part covered with peritoneum, has a relation to the lower surface of the left lobe of the liver. The posterior surface lies close to the left medial crus of the diaphragm, to which it is connect-ed by dense connective tissue, while on the right it partly covers the initial portion of the abdominal aorta. Laterally, on the right, it comes into contact with the caudate lobe of the liver while, on the left, it forms an acute angle, opening upwards, with the gastric fundus. In this portion the relation to the two vagus nerves continues. All along its course the oesophagus is surrounded by loose areolar tissue filling the gaps between it and the adjacent organs, and giving it a degree of mobility. There are fixed points consisting of the connection with the hypopharynx at the top and with the phrenoesophageal membrane and the left medial crus of the diaphragm at the bottom. The muscle fascicles connect-ing the trachea and the pleura to the oesophagus limit the mobility of the organ itself. Particular consideration should be given to the relation between oesophagus and aorta. The latter passes first over the left side of the oesoph-agus, then runs over its posterior surface and, within the abdomen, settles on its right side: this produces a cross-ing point between the two structures, in which the aorta penetrates progressively into the long “buttonhole” formed between the distal thoracic oesophagus and the vertebral plane.

fig.2 - Section of the oesophagus demonstrating the layers of its wall. fig.3 - Blood supply for the oesophagus.

Working outwards, the wall of the oesophagus consists of: mucosa, submucosa, a layer of circular smooth muscle fibres and a layer of longitudinal smooth muscle fibres.(fig.2)

The oesophageal sphincters

The oesophagus starts and ends with two sphincters that act as valve mechanisms: The upper oesophageal sphincter marks the transition between the hypopharynx and the cervical oesophagus and is formed by the cricopharyngeus muscle. The lower oesophageal sphincter is located on the lower oesophagus and does not correspond to a genuine ana-tomical structure. It is considered a “functional” structure: a combination of various structures such as the crura of the diaphragm and the phrenoesophageal membrane, and positive intra-abdominal pressure.

Vasculature

Many arterial vessels provide a blood supply to the vari-ous parts of the oesophagus. (fig.3)In the cervical and upper thoracic portion these are the

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branches of the inferior thyroid artery. Then, working down-wards, branches of the bronchial arteries, the right intercos-tal arteries, which pass behind the oesophagus to reach the respective intercostal spaces, and the oesophageal arteries, direct branches of the descending thoracic aorta. The ab-dominal portion receives its blood supply from branches of the left inferior phrenic artery and left gastric artery. Overall, there are many small vessels that can easily be lacerated without causing severe haemorrhage: this fact is exploited by surgeons when excising the oesophagus by blind tech-niques, using cervical and abdominal access, and stripping the organ without opening up the thoracic cavity. The venous network is located within the tunica submu-cosa which, being formed of loose connective tissue, pro-vides little opposition to the dilatation of the vessels under circulatory overload. In the cervical and upper thoracic por-tion, the venous trunks arising from the submucosal plexus join the bronchial, pericardial, azygos and phrenic veins. From the abdominal oesophagus there are veins that drain into the left gastric vein. This is how the system of the supe-rior vena cava is connected to that of the hepatic portal vein in the submucosa of the lower segment of the oesophagus. The lymph vessels flow into the deep cervical, paratra-cheal, perioesophageal, posterior mediastinal lymph nodes

and, from the abdominal oesophagus, in to the lymph nodes of the cardia. The nerves arise from the vagus and sympathetic nerves and, having penetrated through the oesophageal wall, form connections with the small intramural ganglia.

Surgical anatomy

From a surgical and particularly an oncological point of view, the following should be noted:

• the subdivisions of the oesophagus • its relations with the recurrent nerves

Subdivisions of the oesophagus: (fig.4)

• cervical oesophagus: starts at the upper oesophageal sphincter and ends at the thoracic inlet

• upper thoracic oesophagus: from the thoracic inlet to the tracheal bifurcation

• midthoracic oesophagus: from the tracheal bifurcation to the inferior pulmonary vein

• lower thoracic oesophagus: from the inferior pulmonary vein to the oesophageal hiatus

• abdominal oesophagus: from the oesophageal hiatus to the Z-line

Relations with the recurrent laringeal nerves

The recurrent laryngeal nerves, which are branches of the vagus nerves, innervate the vocal folds running very close to the cervical and upper thoracic oesophagus. (fig.5)The two nerves have different routes. The left recurrent nerve arises from the left vagus nerve below the aortic arch and, passing below this, “rises up” as far as the left vocal fold along the groove between oesopha-gus and trachea. The right recurrent nerve arises from the right vagus nerve below the right subclavian artery and, passing below this, runs transversely towards the right vocal fold.

Surgery on the cervical and upper thoracic oesophagus therefore exposes one or both of the recurrent laryngeal nerves to the risk of injury, and consequently dysphonia or also, in the case of bilateral injury that keeps them in adduc-tion, severe dyspnoea sometimes requiring a tracheostomy. If such injuries are the consequence of surgery for a be-nign lesion this obviously also has medico-legal implications.

fig.4 - Subdivision in segments of the oesophagus fig.5 - Relationships between the cervical oesophagus and left recurrent nerve in the neck.

Cricoid cartilage

Thoracic inlet

Aorta

Cervical oesophagus

Upper thoracic oesophagus

Midthoracic oesophagus

Lower thoracic and abdominal oesophagus

Tracheal bifurcation

Diaphragm

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Romeo Bardini Romeo Bardini


ANATOMY OF THE STOMACHANATOMY OF THE STOMACH

ANATOMY OF THE STOMACH

The stomach is the organ preferred as a substitute for the oesophagus, for several reasons:

• the stomach wall has a very good vasculature• the gastric mucosa is very resistant to ischaemia• it can be delivered right up to the root of the tongue

when suitably prepared in almost all cases• just one anastomosis between oesophagus or pharynx

and stomach is required to restore the continuity of the intestinal tract

• the stomach wall has a structure well suited to suturing to another organ

The vasculature of the stomach is the most important factor in determining whether it will be successful as a re-placement for the oesophagus

It has been the subject of extensive study, including find-ing the best way to prepare the stomach as a substitute for the oesophagus.

Intramural vasculature

The intramural vasculature of the stomach allows com-munication selectively between all the areas related to a major vessel. This means that a good blood supply to the whole stom-ach wall can be maintained and that stomach tubes can be produced in different ways to replace the oesophagus.

Creation of a stomach tube

Preparing the stomach as a substitute for the oesopha-gus involves mobilising the duodenum by the Kocher ma-noeuvre, resecting the gastrocolic ligament externally to the right gastroepiploic vessels and ligating the left gastric, left gastroepiploic, short gastric and posterior gastric vessels.The blood supply to the stomach will thus be maintained by the right gastroepiploic vessels. In a “long-segment” substitution of the oesophagus as far up as the neck, the right gastroepiploic arcade should be kept as long as possible and any anastomoses with the left gastroepiploic vessels should be spared (ph.1-2). An important stage in preparing the stomach is forming a

ph.1 - As the arcade of the right gastroepiploic vessels is interrupted, the left gastroepliploic vessels should be preserved as possible col-lateral arcade.

Vasculature of the stomach

Major vessels

The blood is carried to the stomach and drains from it via at least six major vessels (fig.1):

1. left gastric vessels 2. right gastric vessels

These vessels course along the lesser curvature of the stomach, and join directly with no change in calibre the left gastric vessels inosculate fully to form the arterial and ve-nous arcade of the lesser curvature.

3. right gastroepiploic vessels 4. left gastroepiploic vessels5. short gastric vessels

These vessels are located along the greater curvature of the stomach; the right and left gastroepiploic vessels anas-tomose together in about two-thirds of cases.

6. posterior gastric vessels

ph.2 - Detail of the vascular arcade.fig.1 - The vascular network of the stomach is constituted by six major vascular pedicles.

1

2

3

6

5

4

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tube from it, to straighten and lengthen it so that the gastric fundus can easily reach the desired level in the mediasti-num or the neck. Many ways of forming the stomach tube are described.In our opinion the most interesting suggestions have been made by Gayet, Marmuse and Gignoux. (fig.2) Gayet uses a linear stapling device to remove barely one cm of stomach wall along the lesser curvature, with the aim of preserving the whole intramural vasculature; howev-er, this has the defect of not making the antrum sufficiently straight. In contrast, Marmuse prepares a very narrow tube along the greater curvature starting from the pylorus, which in-volves the risk of ischaemia at the apex of the tube and of not giving enough capacity for food. (ph.3) Gignoux uses a line halfway between Gayet’s and Mar-muse’s to make a stomach tube. Collard’s technique (fig.3) involves using a whole stom-ach but taking off the lesser curvature and thereby remov-ing the lymph nodes within the lesser omentum.

In our opinion, this has the following drawbacks:• the greater curvature is not straight• it occupies a lot of space in the mediastinum and ex-

poses the stomach to compression of the vascular (particularly the venous) arcade

ph.4 - A long whole stomach prepared as Collard’s technique can easily reach the neck.

fig.3 - Collard’s technique.

ph.3 - A long narrow tube as Marmuse can involve the risk of ischemia at its apex.

In our opinion the anatomy of each patient’s stomach should be assessed individually, both as regards its shape and particularly its vasculature. For instance, the length of the right gastroepiploic arcade will affect the width of the tube, which needs to be made larger if the arcade is particularly short, to allow the intra-mural network to provide an acceptable blood flow to the gastric fundus. In general, we use different forms of tube depending on the level of the body that the stomach has to reach: wider if it has to come up to the neck (ph.4) and slightly narrower (ph.5) when it is anatomosed to the oesophagus in the chest. We generally oversew the staple line with a manual run-ning suture or with interrupted sutures to prevent fistulas, particularly at points where parts are superimposed (ph.6). To prevent ischaemia and necrosis of the proximal part of the gastric tube (ph.7) it is important to make a large enough incision at the oesophageal hiatus; this is done ver-tically, ligating or coagulating the inferior phrenic vein. (ph.8) This prevents compression of the right gastroepiploic vein, which we consider to be responsible for most cases of ischaemia.

Akiyama

Gayet

Gignoux

Marmuse

fig.2 - Different ways to prepare a gastric tube: Akiyama, Gayet, Gig-noux and Marmuse

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ph.6 - The staple line is usually oversewn with a manual running suture.

ph.5 - A slightly narrower tube is prepared for a thoracic oesophagogastrostomy.

ph.7 - Partial necrosis of the proximal part of a gastric tube due to compression of the right gastroepiploic vein.

ph.8 - A wide opening of the hiatal ring is recommended to avoid any compression to the right gastroepliploic vein by the diaphragmatic crura. We suggest a vertical incision of the diaphragm ligating or coagulating the inferior diaphragmatic vein as proposed by Seineldin.

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ph.9 - Long and curved forceps designated by the Author to transpose the stomach or the colon to the neck.This instrument helps avoiding twisting on its axis of the transposed viscus

ph.11 - The stomach is grasped by the forceps and pulled to the neck.

ph.10 - This instrument is introduced through the neck and advanced to the abdomen through the posterior mediastinum.

Transposition of the stomach

There is no problem with transposing the stomach into the chest during a thoracotomy.Gentle traction on the lower oesophagus is all that is re-quired, taking care not to twist it along its axis.

Transposition to the neck can be done:• through the posterior mediastinum• through the anterior mediastinum

The posterior mediastinal route is shorter but can lead to more problems during transposition: • twisting along the longitudinal axis• hooking on the left bronchus

To avoid these problems we usually cover the stomach with a plastic bag, tractioning it into the neck with forceps of a suitable design (ph.9), which is advanced from the neck into the abdomen through the posterior mediastinum (ph. 10-11). The anterior mediastinal route is easy to prepare but in-volves the risk of damaging the pleura. The only problem is the cervicothoracic opening, which may be tight because of the left clavicle; it is sometimes

necessary to resect this. The insertion of the medial cervical fascia must always be resected. The anterior mediastinal route is recommended when there has not been radical resection of the tumour and when postoperative radiotherapy is planned.

The pylorus

Denervation of the stomach as consequence of resect-ing the vagus nerves involves the possibility of pyloric spasm, which can lead to impaired gastric emptying.The pylorus can be treated by:

• pyloroplasty• digital dilatation• no treatment

For many years we performed digital dilatation of the pylorus but since then, like other surgeons, we have left the pylorus intact and have not observed any particular impair-ment of gastric emptying, using either radiological or clinical observation.

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ANATOMY OF THE JEJUNUMANATOMY OF THE JEJUNUM

ANATOMY OF THE JEJUNUM

The jejunum is the first segment of the small intestine and starts at the ligament of Treitz, as a continuation of the duodenum The arterial supply comes direct from the superior mes-enteric artery via jejunal arterial branches that form a mar-ginal arcade along the intestinal wall.This anatomical arrangement is a very important factor for preparing long loops with a good blood supply. Anatomical variations in the vasculature of the jejunum are common and sometimes do not allow long, isolated loops to be prepared. This applies where the jejunal arteries are short and nu-merous, and arise perpendicular to the superior mesenteric artery and a bordering arcade some way from the intestinal wall. (fig.1) More favourable from the surgical point of view is an anatomical arrangement with long, large-diameter jejunal arteries and a bordering arcade close to the intestinal wall and clearly distinguishable. (fig.2) For the strictly anatomical reasons described, the small intestine can be used to replace the oesophagus in about 50% of cases.

supply.In our opinion, obvious beating of the terminal arte-rial branches over the whole length of the isolated loop is the only guarantee of adequate blood supply.

Cervical oesophagojejunal anastomosis

It is rarely possible to reach as far as the neck with a loop of intestine. In this case, transposition via the anterior medi-astinum is preferable. An end-to-side (oesophagus to jejunum) cervical oe-sophagojejunal anastomosis is preferable, created with a manual, single-layer running suture using a 4/0 monofila-ment thread.

Intrathoracic oesophagojejunal anastomosis

Transposition of a loop of jejunum into the chest, particu-larly if very long, entails the risk of twisting the blood vessels.To minimise this eventuality, which could lead to ischaemic necrosis of the loop, it is advisable to perform the surgical

resection and reconstruction procedure via a simultaneous midline laparotomy and anterolateral thoracotomy. This allows direct vision of the loop while it is being trans-posed into the chest and is certain to prevent twisting of the blood vessels. An end-to-side (oesophagus to jejunal loop) oesophago-jejunal anastomosis is created in the chest using a stapling device with a diameter compatible with that of the oesopha-gus. The technical details of this anastomosis are identical to those described for the thoracic oesophagocolic anastomo-sis.

Distal anastomosis

Intestinal continuity is restored with an end-to-side or side-to-side jejunojejunal anastomosis using manual, dou-ble-layer suturing.

Surgical preparation of the jejunum

Transillumination of the mesentery with light placed in front of the surgeon is very helpful in identifying the course of the jejunal vessels and then choosing which segment of the small intestine to use. Usually it is the second or third jejunal loop that is cho-sen. Normally, two jejunal arteries need to be ligated in or-der to obtain a sufficient length to reach at least as far as the azygos vein in the chest. Having ligated the jejunal arteries and veins while pre-serving the bordering arcade, the latter is ligated and re-sected. The intestinal wall is sutured and resected with a linear stapling device. The vasculature of the isolated loop must be assessed about twenty minutes after the ligation and resection of the bordering arcade so that the initial phase of arterial spasm, which occurs when the jejunal arteries are ligated, disap-pears. The colour of the jejunal loop is not a good criterion for assessing whether the isolated intestine has a good blood

fig.1 - A vascular network of the jejunum that is not favorable to prepare long jejunal loops.

fig.2 - More favorable distribution of the jejunal arteries to prepare a long isolated jejunal loop.

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ANATOMY OF THE COLONANATOMY OF THE COLON

ANATOMY OF THE COLON

The colon is a segment of intestine that starts from the ileocaecal valve and ends at the sacral promontory. It is ar-ranged like a frame within the abdominal cavity and is made up of an ascending segment on the right (caecum and as-cending colon), a transverse segment and a descending one on the left (descending colon) and the sigmoid. (fig.1) The ascending and descending portions of the colon are attached to the lateral abdominal wall by anatomical adhe-sions to the peritoneal reflection, known as the Toldt mem-brane. The superior mesenteric artery provides the blood sup-ply to the ascending and transverse colon via the ileocolic, right colic and middle colic arteries. (fig.2)

The inferior mesenteric artery and its ascending branch (left colic artery) supply the descending colon. These two systems communicate with each other via the marginal arc of Riolan, which is the origin of the marginal branches for the colon wall. If the arc of Riolan has a normal anatomy, a long segment of colon can be prepared, isolated by dividing the middle colic and right colic pedicles without impairing the blood supply. The venous vascular network is depicted in the fig.3.

fig.2 - Arterial network of the colon.

fig.1- The colon in its anatomic position in the abdominal cavity.fig.3 - Venous network of the colon.

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ph.1 - Incision of Toldt’s membrane to start the mobilisation of the colon on the left side.

Surgical preparation of the colon

The colon is prepared by isolating a segment with a very good blood supply, long enough to replace the oesophagus that is to be removed.

* A first cardinal principle is therefore that it is unwise to resect an oesophagus affected by either a malignant or be-nign lesion, before the colon has been prepared and has proved to have a suitable length and vasculature for the purpose.

* A second cardinal principle is that the colon must be iso-lated along its whole length, for various reasons:• To assess the blood supply • To decide which segment of the colon (ascending, trans-

verse or descending) to use• To help create the colocolic anastomosis for restoration

of bowel continuity

Isolation generally starts at the level of the descending-sigmoid junction and continues towards the splenic flexure. (ph.1) The Surgeon keeps the colon slightly tractioned in a ver-tical direction with his left hand and the Assistant retracts the Toldt reflection towards the left using forceps. (ph.2) The Surgeon then uses scissors or coagulation to gently separate the mesocolon from the insertion of Toldt’s peri-toneal reflection. (ph.3) Dissection with scissors is easy as long as it remains within the correct anatomical plane be-cause there are no important vascular structures here. Dissection continues laterally as far as the splenic flex-ure and then the same manoeuvre is performed from the left iliac fossa, this time to separate the renal fascia from the mesocolon. (ph.4) The reflection of the renal fascia is shown by a thin white line, which is sometimes not easy to identify. It is important to stay within the plane of separation between the renal fascia and the mesocolon because this will keep the dissection above the plane of the left ureter so that it is not damaged. When dissection of the descending colon is complete, the greater omentum can conveniently be separated from the transverse colon. The Assistant uses his left hand to traction the transverse colon gently caudad, while tractioning the greater omentum in the opposite direction with his right hand; this reveals the line of insertion of the greater omentum on the colon, which is usually avascular. Resection is done quickly by elec-trocautery. (ph.5) It can sometimes be difficult to mobilise the splenic flex-ure because of its proximity to the spleen. Therefore, as well as preserving the whole vascular arcade of the colon, the splenic blood vessels also need to be spared. Before tractioning the transverse colon it is advisable to

ph.2 - Retraction of the Toldt’s peritoneal reflexion with graspers facilitates the dissection.

Choosing the colon

The segments of colon that can be used as an oesopha-geal substitute are the right one (ileum and ascending co-lon) or the left one (transverse and descending colon). Assuming that the anatomy of the colon and its vas-culature are normal and that the colon has to substitute the oesophagus in an isoperistaltic position, the following observations can be made:

The ascending colon

• The vasculature of the ascending colon and the last ileal loops consists of the ileocolic vessels, which need to be rotated upwards counter to the natural anatomical arrangement, with the risk of creating an angle in the ileocolic vein and thereby impeding venous return.

• The diameter of the caecum and ascending colon may occupy a lot of space in the mediastinum.

The descending colon

• The descending colon is supplied by the inferior mesen-teric artery via the left colic artery and venous outflow is via the inferior mesenteric vein, both of which remain in their anatomical position when the colon is mobilised.

• The arc of Riolan is always close and parallel to the wall of the colon, which is ideal for keeping it straight.

• Excellent venous outflow is maintained via the inferior mesenteric vein.

• The transverse and descending colon are of a uniform size.

According to opinions expressed in the literature and that of the Author, the transverse and descending colon are preferable as a substitute for the oesophagus.

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ph.5 - The insertion of the gastrocolic ligament and of greater omentum is coagulated to completely free the transverse colon.

ph.4 - The phrenocolic ligament is resected. ph.6 - The same maneuvers are repeated along the ascending colon where the Assistant holds the colon and the Surgeon resects the peri-toneal reflexion.

ph.3 - The Gerota’s fascia is visible and it is separeted from the mesocolon carefully.

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ph.8 - The colon has been completely dissected from the caecum to the sigmoid colon and it is delivered out of the abdominal cavity making possible a careful study of the vascular supply to the colon.

ph.9 - Clamping the vascular pedicles it is necessary to assess the possibility to obtain a long isolated segment of the colon suitable to sub-stitute the oesophagus.

check that there are no adhesions with the splenic capsule. If there are, it is best to coagulate them so that even minimal traction cannot trigger bleeding from the spleen. The splenic flexure of the colon is held in place by the splenocolic ligament, which has a good blood supply and should therefore be resected appropriately, and suitably co-agulated. Dissection of the ascending colon and the right colic flex-ure does not usually present any particular difficulties be-cause the latter is less closely attached posteriorly than the descending colon. In this case, the Assistant keeps the colon tractioned to the left and the Surgeon gently lifts the Toldt reflection and separates the mesocolon from the right lateral abdominal wall. (ph.6) At the right colic flexure attention should be paid to the duodenum. (ph.7) Once the colon has been isolated from the caecum to the sigmoid, it is delivered out of the abdominal cavity; the continuity of the arc of Riolan can then be assessed and the vascular pedicles to be ligated and resected can be chosen. (ph.8) One insuperable anatomical problem is discontinuity of the vascular arcade (3-5%) in the middle colic vessels, which may not have a common trunk before dividing into

right and left branches. If it is necessary to use the trans-verse colon as far as the right colic flexure, then obviously this could not be done and the possibility of using the ileum and ascending colon should be assessed. Bringing the colon out of the body makes it easier to measure the segment of colon required as a substitute for the oesophagus. In this connection it is useful to note the following principles:• The colon is measured not along the colon wall but along

the arc of Riolan.• It is essential to measure out an “extra” 10 cm or so of

colon rather than run the risk that, once resected, the colon will not reach as far as necessary.

Gentle vascular clamps are used for test clamping of the artery of the splenic flexure, the middle colic artery and, if necessary, the right colic pedicle and finally the arc of Riolan. (ph.9) There should be an interval of about twenty minutes be-fore the most distal arterial flow becomes stable because clamping is followed by a phase of spasm. It is also advisable to check that the arterial pressure is normal for the patient and that it remains stable throughout the procedure.

ph.7 - Attention has to be paied non to damage the duodenum

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ph.11 - The colon is positioned on the anterior chest wall to verify its lenght and the perfect blood supply observing pulsation of the small marginal arteries at is extremity.

ph.10 - When the vascular pedicles have been ligated the colon can be sutured and sectioned.

The criterion for assessing a good blood supply to the colon that is to be transposed should not be the colour of the wall but obvious pulsation of the small marginal arteries as far as the predetermined end of the colon. When a good blood supply to the colon has been dem-onstrated the clamped vascular pedicles are ligated and re-sected at the point where they were clamped. Once the arc of Riolan has also been ligated and resected, a linear surgical stapler is applied to the colon wall to close and resect it. (ph.10) The colon is then positioned on the anterior chest wall for final evaluation of its length and vasculature. (ph.11)

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Cervical oesophagocolic anastomosis

An end-to-side (oesophagus to colon) oesophagocolic anastomosis is created. An incision is made along the taenia coli with a length equivalent to the diameter of the lumen of the oesophagus using a scalpel blade so as not to damage the vasculature of the mucosa. The anastomosis is created manually in the neck with a running suture using a slow-absorption monofilament with a needle at both ends. The first pass is made at one end, knotting internally about halfway along the suture thread. The running suture is placed first on the posterior wall as far as the opposite corner and the thread is kept in traction by an assistant. The second needle is passed out of the lumen of the anastomosis so as to complete the suturing of anterior wall of the anastomosis. The ends of the suture thread are knot-ted together and the anastomosis is completed. A small-cal-ibre nasogastric tube is advanced to about ten centimetres below the anastomosis. An Easy-Flow type drain is put in place behind the anas-tomosis.

Intrathoracic mechanical oesophagocolic anastomosis

An oesophagocolic anastomosis in the chest is prefer-ably created with a stapling device. A clamp is placed above the oesophageal stenosis so as to avoid reflux and traction the oesophagus and, a few centimetres proximally, an incision is made about halfway round the circumference of the oesophagus by electrocau-tery. (ph.12) If necessary, sequentially larger dilators are inserted through this incision, taking care not to lacerate the oesoph-ageal mucosa. Next, a stapling device is chosen with a diameter com-patible with the lumen of the oesophagus to be used and the anvil is inserted into the oesophagus. (ph.13) The first purse-string suture is made around the oesoph-agus, taking up the full thickness of the oesophageal wall with four stitches and using strong suture thread. (ph.14) This is tied around the pin of the stapler head. A second suture is placed two or three millimetres from the first by the same method, and tied. The oesophageal wall is resected below the two purse-string sutures, taking care not to cut the suture thread. (ph.15) The stapling device is introduced from the end of the co-lon and its collar is brought out from the antimesenteric wall. (ph.16) The two ends of the stapler are connected together and the anastomosis is created. (ph. 17-18)

Routine methods are used to check that the doughnuts of oesophageal and colon wall are intact. A linear stapler is applied to the end of the colon and this is closed about three centimetres from the anastomo-sis. The staple line is oversewn with interrupted sutures and secured to the parietal pleura. A nasogastric tube is advanced to about ten centimetres below the anastomosis.

Intrathoracic handsewn oesophagocolic anastomosis (see page 152)

When a mechanical anastomosis is not advised because of oedematous esophageal wall or its thickness or rigidity a handsewn anastomosis is suggested. The upper section of the colon is sutured to the medias-tinal pleura and the colon opened longitudinally for a length equal to the esophageal diameter. A running suture is usually made using a 4/0 absorbable monofilament armed at both extremities with a 26 millime-ter needle in a single layer. First the posterior wall of the anastomosis is performed picking about 4 millimeter of both esophageal and colic wall every 4 millimeter of distance each from the other. The anterior wall of the anastomosis is performed in same way.

Distal anastomosis

A distal anastomosis can be created using the stomach or jejunum. An anastomosis between colon and stomach is usually created if the colon has been transposed because of a be-nign oesophageal stenosis in a young patient. An anastomosis between colon and jejunum is created where the stomach has also had to be removed because caustic substances have been ingested or for cancer of the cardia. An important stage, common to all cases, is the choice of the point on the colon where the anastomosis is to be made, and the preservation of the vascular arcade. The point on the colon where the anastomosis is to be created must be chosen such that the colon is not redun-dant and therefore reaches the anastomosis in a straight line. The blood supply to the colon wall needs to be removed for about ten centimetres, taking the greatest care to pre-serve the vascular arcade. It is therefore advisable to use suitable coagulation, stay-ing close to the colon wall, which will then be removed in any case. (ph.19) The colon is resected proximally where the wall has a

good blood supply and an anastomosis is made between it and the anterior wall of the stomach (ph.20) or the jeju-num. In both these cases the anastomosis is preferably creat-ed by the manual technique, with a double layer of sutures using a 4/0 absorbable monofilament. Having removed the part of the colon with no blood sup-ply, the colocolic anastomosis is created, either manually or by using a linear or circular stapling device.

ph.12 - A clamp is placed on the oesophagus above the stenosis and it is opened to consent, if necessary, dilation of its wall.

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ph.13 - The anvil of the circular stapler chosen is introduced into the oesophagus.

ph.14 - A first pursestring suture is performed and tied. A second one is made in the same way three millimetres above the first one.

ph.15 - The oesophageal wall is resected just below the purse-strings taking care not to cut them.

ph.16 - The stapler is introduced from the extremitiy of the colon.

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ph.17 - The oesophagocolic anastomosis is then created.

ph.18 - A larger view of the anastomosis performed with the stapler.

ph.19 - When preparing the colon for the cologastric anastomosis the blood supply needs to be removed from its wall. The greatest care must be paied not to damage the vascular arcade.

ph.20 - The cologastric anastomosis is preferably handsewn on the anterior wall of the stomach.

ph.1 - The azygos vein is ligated and sectioned to allow a complete access to the posterior mediastinum.

ph.2 - The azygos vein is dissected from its ligature downwards to facilitate identification of the thoracic duct.

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SURGERY OF THE OESOPHAGUS SURGERY OF THE OESOPHAGUSOESOPHAGECTOMY FOR CANCEROESOPHAGECTOMY FOR CANCEROESOPHAGECTOMY

OESOPHAGECTOMY THROUGH RIGHT THORACOTOMYOESOPHAGECTOMY THROUGH RIGHT THORACOTOMY

Transthoracic oesophagectomy as the first step of sur-gery in an elective oesphageal resection for cancer is indi-cated in the following situations:

• Carcinoma of the upper thoracic oesophagus requiring anastomosis in the neck area

• Carcinoma of the oesophagus for which resectability is not certain at preoperative staging

Patient position

When performing a total oesophagectomy and recon-struction with an anastomosis in the neck area the position of the patient will have to be changed during the procedure.During the thoracotomy the patient is positioned on the op-erating table in left lateral decubitus with the chest perpen-dicular to the table. A suitably prepared towel roll is placed under the chest directly below the scapula, to raise the right side of the chest and make it more accessible to the Surgeon. The patient is suitably secured to the operating table.In the abdominal and cervical phase, used for preparing the stomach and performing the oesophagogastric anastomo-sis, the patient is in the supine position. A towel roll is placed under the patient’s shoulders, thereby allowing greater ex-tension of the neck. The patient’s head is turned to the right in maximum rotation and extension and held in this position with a suitable strap fastened to the operating table.

Anaesthesia

General anaesthesia is administered by double-lumen endobronchial tube, to block right lung ventilation during the thoracotomy and make it easier to dissect the oesophagus.An epidural catheter is positioned at T4-T5 for effective in-traoperative and postoperative anaesthesia.

Approach

The initial approach is via a right thoracotomy in the fifth intercostal space because this gives the best view of both the upper and lower mediastinum. When the oesphageal resection has been completed the patient is placed in the supine position as described above.

OESOPHAGECTOMY THROUGH RIGHT THORACOTOMY

Surgical technique

Right thoracotomy

Once the thoracotomy has been performed, dissection of the oesophagus starts with ligation and resection of the azygos vein where it crosses through the posterior medias-tinum and flows into the superior vena cava. (ph.1) Traction is applied to the proximal ligature, through grav-ity, by a Péan-type surgical instrument. This makes it easy to visualise the space between azygos vein and aorta, where the thoracic duct is sited. The right bronchial artery is ligated together with the azy-gos vein or separately. Dissection of the oesophagus can be started at any point but it is advisable to begin some distance away from the tu-mour. However, in the case of an exploratory thoracotomy to check the resectability of the neoplasm, a cautious ap-proach, around the tumour site, is needed. This will prevent excessive devascularisation of the oesophagus, which could lead to necrosis if the tumour proves non-resectable.In general, however, the dissection starts level with the low-er mediastinum. The inferior pulmonary ligament is resected using mono-polar or ultrasonic coagulation. Dissection then continues in an upward direction, sepa-rating the pericardium from the anterior wall of the oesoph-agus as far as the tracheal bifurcation. At this point the oesophagus can be gently tractioned upwards and forwards with sponge forceps (ph.2) thus fig. the mediastinal pleura towards the azygos vein, which is incised level with the ligature on that vein. The thoracic duct is identified (ph.3) within the loose cellular tissue between azygos vein and aorta. The thoracic duct is traced downwards and displaced anteriorly so that it can subsequently be removed en bloc with the oesophagus. The thoracic duct is closed off with metal clips (ph.4) a few centimetres away from the diaphragm. Dissection then continues along the anterior wall of the aorta, from which two or three small oesphageal arteries arise (ph.5) which are coagulated by ultrasonic device, tak-ing care to keep away from the aortic wall so as not to cause heat damage. At this point the left mediastinal pleura becomes visible and can be easily moved away. Dissection of the inferior middle mediastinum is completed by excision of the lymph nodes near the carina of the trachea. The trachea and left main bronchus must be revealed in order to avoid damage to the membranous wall. Following the dissection plane of the pericardium, the lymph nodes are isolated and removed en bloc, taking care to coagulate a small artery that would otherwise cause trou-blesome bleeding. (ph.6)

ph.3 - The thoracic duct is easily identified in its anatomic site between the aorta and the azygos vein.

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ph.4 - The thoracic duct is clipped above the diaphragm and sectioned.

ph.5 - The oesophageal dissection along the aorta allows the identification of the oesophageal vascular supply coming directly from the aorta. They are coagulated using an ultrasonic device.

ph.6 - The lymph nodes of the tracheal bifurcation are removed carefully for a correct staging of the disease.

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The tissue remaining between left bronchus and aorta is coagulated, preferably by ultrasonic device, taking extreme care to preserve the left bronchus. (ph.7) The complex anatomy of the upper oesophagus makes dissection tricky and fascinating, and the lymphadenectomy has to be performed along the right and left recurrent laryn-geal nerves. The posterior pleura is incised using electrocautery along the prevertebral plane inferiorly as far as the ligature on the azygos vein and superiorly as far as the subclavian vessels. Anteriorly, the resection line follows the right vagus nerve. (ph.8) Dissecting the oesophagus from the trachea is straight-forward and is done on an avascular plane, similarly to dis-section from the prevertebral plane. Very great care must be paid to the left tracheoesopha-geal groove, in which the left recurrent laryngeal nerve lies. A forceps applies traction to the oesophagus posteriorly and downwards, and the Assistant uses a sponge on a stick to move the trachea forward, pushing against the cartilagi-nous rings on the left side rather than on the membranous wall, so as to preserve it. (ph.9) It is usually easy to locate the recurrent nerve; this is done by careful scissor-tip dissection. (ph.10)

ph.8 - The right vagus nerve is dissected. Coagulation is applied at least 1 cm away to avoid its damaging by heating.

ph.7 - Also lymph nodes along the left main bronchus are removed paying attention to not damage the membranaceous wall of the bronchus itself.

ph.9 - The oesophagus is tractioned posteriorly and the trachea gently pushed anteriorly. The identification of left recurrent nerve is so fa-cilitated.

Coagulation - whether monopolar, bipolar or ultrasonic - must never be used near the nerve, to avoid heat damage.Once the nerve has been revealed (ph.11) the lymph nodes are removed for histological examination. The right recurrent laryngeal nerve runs below the right subclavian artery and is harder to see. Gentle traction on the right vagus nerve (ph.12) with an elastic loop may help greatly. When the nerve has been revealed the lymph nodes can be excised. (ph.13) At this point the whole length of the oesophagus is iso-lated and can be left in situ for subsequent removal via the neck incision. A drain is positioned in the pleural cavity and the thora-cotomy is closed.

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ph.10 - The left recurrent nerve indicated by scissors is clearly visible.

ph.11 - A lymph node along the left recurrent nerve is removed avoiding carefully any kind of coagulation in the vicinity of the nerve and clipping when necessary of small vessels is suggested.

ph.12 - A gentle traction is applied on the right vagus nerve to facilitate the identification of the right recurrent nerve that is located close to the right subclavian artery.

ph.13 - Clipping of small vessels is advised close to the nerve and coagulation applied far from it.

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ph.14 - When the stomach has to be transposed to the neck its tubulisation is a little bit different from when it has to be transposed to the thorax. The tube is maintained larger to allow a better vascularization of the gastric fundus. The first linear stapler is applied 4-5 cm above the pylorus.

Laparotomy

A medial laparotomy is used for preparation of the stom-ach, which substitutes the oesophagus till the neck.. Gastrolysis is performed in exactly the same way as for re-construction of the thoracic oesophagus. Note that it is important to extend the oesophageal hia-tus sufficiently, resecting the diaphragm vertically after ligat-ing the inferior phrenic vein. Once the stomach has been completely isolated the gas-troesophageal junction is resected between clamps and the lower oesophagus is sutured. The construction of the gastric tube is different from the procedure to partially replace the oesophagus. When the stomach is completely released it is retrieved onto the anterior chest wall and its vasculature is carefully inspected. To replace the oesophagus, the whole stomach can be used, removing just a small part of the lesser curvature, or a narrower gastric tube can be formed, retaining part of the stomach wall along the greater curvature. We prefer to construct a gastric tube, which retains the intermediate portion of the stomach wall so as to ensure a better blood supply to the fundus of the stomach where

it meets the cervical oesophagus, while also ensuring opti-mum detorsion. The vascular arcade of the lesser curvature is divided four or five centimetres above the pylorus. Then the stapler is used to start constructing the gas-tric tube. The Assistant maintains gentle traction along the greater curvature of the stomach, taking care to preserve the right gastroepiploic arcade. (ph.14) This first application of the linear stapler is important be-cause it allows to eliminate the angle of the gastric antrum with the best elongation of the stomach. When the stapler is used subsequently the Assistant should maintain gentle traction on the gastric fundus and the stomach wall proximal to the pylorus, to produce the longest possible tube. (ph.15) The staple line is about five or six centimetres from the line of the greater curvature of the stomach, as far as the left paracardial region. (ph.16) The prepared gastric tube looks well vascularised and reaches easily the neck. The mechanical suture line is oversewn along its en-tire length with a continuous suture for further protection against possible fistulas. (ph.17)

ph.15 - The distance of the tubulisation line from the greater curvature is about 5-6 cm.

ph.16 - The gastric tube is well vascularised and it reaches easily the neck site.

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ph.17 - The line of mechanical suturing is covered by a running suture using an absorbable monofilament to prevent bleeding and possible leaks.

Left cervicotomy

A left neck incision is made along the anterior border of the sternocleidomastoid muscle and the technical stages of the neck incision procedure are as described elsewhere. Having placed a Beckman-type retractor the Assistant medialises the thyroid with dissector sponges mounted on Péan forceps rather than Farabeuf-type retractors, which could damage the left recurrent nerve although the latter type is used to lateralise the left carotid and the jugular vein. (ph.18) The infrahyoid muscles are resected to enlarge the op-erating space and the trachea is moved to the right. (ph.19) The cervical oesophagus is carefully isolated to preserve the left recurrent nerve. To make this task easier, triangular-jaw forceps (ph.20) are used to draw the oesophagus to the left; coagulation should not be used, to avoid heat damage to the recurrent nerve itself. Scissors are used for careful dissec-tion. Particular attention must be paid to the point where the right side of the oesophagus is dissected and it is necessary to remain over the oesophageal wall in order to preserve the right recurrent nerve. When the cervical oesophagus has been isolated, the entire oesophagus is pulled into the neck and then resected with a scalpel so as not to compromise the blood supply. (ph.21) One important technical detail is that the oesophageal mucosa should be kept longer than the muscular coat.. This will allow the oesophageal and gastric mucosa to be cor-rectly apposed when the anastomosis is made. Three holding sutures are inserted into the oesophageal stump. (ph.22) The stomach can be delivered into the neck by using a specially designed instrument. This long forceps is intro-duced through the neck incision and pushed in as far as the abdominal cavity through the posterior mediastinum. The gastric tube, which can if preferred be given a plastic coating, is fastened by a suture to the loop of the forceps and can then be delivered into the neck by gentle traction. While applying traction to the instrument, the surgeon uses his left hand to push the stomach into the mediastinum, checking that it stays in its axis. The main advantage of using the forceps illustrated is that they make it easy to avoid twisting the tube on its axis, which would lead to tube ischaemia. The apex of the stomach is secured to the prevertebral fascia to avoid traction on the anastomosis in the immediate postoperative period. A small longitudinal incision about one and a half centi-metres long is made on the stomach wall in order to create an end-to-side oesophagogastric anastomosis. (ph. 23) The oesophagogastric anastomosis is produced in a sin-gle layer using a 4/0 monofilament absorbable suture with a

double needle. The suture normally starts from the left with the Surgeon positioned to the right of the patient and the thread is knotted about halfway along its length. (ph. 24-25) The sutures are positioned about 4 mm from the edge of both the stomach and oesophageal walls and great care is taken to appose the mucosae gently. (ph.26) The sutures are spaced about three millimetres apart. When the posterior wall of the anastomosis has been completed, the suture thread is held in tension by an Assis-tant and a nasogastric tube is passed through the anastomo-sis under direct vision (ph.27). Then the anterior wall of the anastomosis is produced with the other half of the thread and its needle. The extramucosal suture technique is used. Once the anterior wall is also completed, both ends of the threads are knotted together. (ph.28) A suction drain is positioned at the back of the oesopha-gus and the wall is sutured in layers. (ph.29) A drain is also positioned in the abdominal cavity under the left lobe of the liver and the abdominal wall is sutured in layers.

Postoperative management

The patient is extubated as soon as possible and trans-ferred to intensive care for the shortest possible time consis-tent with stabilising respiratory and cardiovascular function. The nasogastric tube is maintained with gentle suction, with lavage to remove any blood clots from the stomach cavity. Respiratory physiotherapy is recommended to aid expec-toration and routine measures should be taken to prevent thrombosis. Analgesia is maintained via the epidural catheter and, if necessary, further pain relief is administered intravenously or intramuscularly. The chest drain, which is used only to expand the lungs, can be removed at an early stage, as can the abdominal drain. The patient is maintained on total parenteral nutrition until the tenth postoperative day when a radiological exami-nation of the anastomosis is carried out with water-soluble contrast medium. Then the nasogastric feeding tube can be removed and the patient can gradually resume feeding by the oral route.

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ph.19 - Coagulation of prethyroid muscles and their section is advised to achieve a better view.

ph.20 - The left recurrent nerve is identified.

ph.21 - The muscle wall of cervical oesophagus is sectioned by scalpel to limitate ischemia due to coagulation and paying attention to keep the mucosal layer longer than the muscle one.

ph.18 - When dissecting the cervical oesophagus the thyroid is displaced medially using soft wisps to avoid any trauma to the left recurrent nerve. Rigid instruments have to be avoided.

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ph.24 - The first suture is from outside to inside on the stomach …

ph.25 - … and from inside to outside on the oesophagus.

ph.22 - Three holding sutures are applied on the oesophagus to keep it open during performing the anastomosis.

ph.23 - The stomach that has been already fixed to the prevertebral fascia is opened longitudinally using coagulation.

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ph.27 - A nasogastric probe is passed through the anastomosis to maintain the stomach empty during the first postoperative days.

ph.28 - The oesophagogastric anastomosis has been completed.

ph.29 - A drain is positioned behind the anastomosis.

ph.26 - Then a running suture is performed in a single layer using a 4/0 absorbable monofilament.The sutures are positioned about 4 mm from the edge of the stomach and oesophagus.

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