Resection Specimens

The surgical techniques for resecting oesophageal tumours fall into two broad categories: those which employ a chest incision (thoracotomy) and those which do not (transdiaphragmatic hiatal procedures). The type of procedure used depends on the general level of health of the patient, any previous operations, the preference of the operating surgeon, the position of the tumour in the oesophagus (see Table 1.1) and the choice of oesophageal substitute, i.e., stomach, jejunum or colonic interposition. Ideally the surgeon should strive for a 5 cm longitudinal margin of clearance with adenocarcinoma and 10 cm for squamous carcinoma.

a) Ivor Lewis technique - in this operation upper abdominal and right thoracotomy incisions are made. The proximal stomach is divided and the oesophagus is transected proximal to the tumour. The distal stomach is then raised into the chest and an oesophagogastric anastomosis is fashioned.

b) Thoracoabdominal oesophagectomy - a continuous incision extending from the midline of the upper abdomen running obliquely across the rib margin and posterolateral aspect of the chest wall is made. The left diaphragm is divided and this gives access for potential en bloc resection of the oesophagus, stomach, gastric nodes and, if required, the spleen and distal pancreas. An oesophagojejunal or oesophagogastric anastomosis is fashioned in the neck.

c) Transhiatal oesophagectomy - depending on whether a total or distal oesophagectomy is to be performed, two variations of this procedure are used:

- 'Two-field approach' - the entire oesophagus and stomach is mobilised via upper abdominal and oblique neck incisions. The cervical oesophagus is divided and anastomosed to stomach, which had been mobilised and raised high into the posterior mediastinum.

- Distal oesophagectomy with proximal gastrectomy - (for distal oesophageal/junctional tumours). Only an upper abdominal incision is used, with the distal oesophagus being mobilised and an oesophagogastric anastomosis fashioned in the chest.

Although transhiatal resection for diseases of the thoracic oesophagus used to be uncommon, it is now more commonly used, reducing the physiological insult experienced with a thoracotomy.

Whenever possible the stomach should be used in the anastomosis and with appropriate mobilisation the stomach will reach the neck in virtually all patients. If the tumour is limited to the OG junction, the entire greater curvature of the gastric fundus (shaded area in Figure 1.3), including the point which usually reaches most cephalad to the neck (* in Figure 1.3), may be preserved while still obtaining a 4-6 cm gastric margin distal to the malignancy.

Table 1.1. Choice of surgical procedure in oesophageal neoplasia

Proximal 1/3 tumours

Pharyngo-oesophagectomy.

Middle 1/3 tumours

Ivor Lewis technique

Thoracoabdominal oesophagectomy

Two field transhiatal oesophagectomy

Lower 1/3 tumours

Ivor Lewis technique

Thoracoabdominal oesophagectomy

Transhiatal oesophagectomy

Barrett's

Transhiatal oesophagectomy

Figure 13. Transhiatal oesophagectomy with limited proximal gastrectomy.

There are several benefits in performing a total thoracic oesophagectomy with cervical anastomosis: maximum clearance of surgical margins is obtained while the risk of mediastinitis, sepsis and GOR that can be seen with an intrathoracic anastomosis is diminished.

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