Esophageal Resection & Reconstruction

Yasser Elghoneimy M.D.Assistant Professor of Cardiothoracic

SurgeryKing Faisal University

2008

Objectives

1. Indications of Esophageal resection

2. Common techniques of resection

3. Conduits used for reconstruction

4. Routes of Reconstruction

5. Complications of reconstruction

Indications for Resection

• Carcinoma of the esophagus• High Grade Dysplasia in Barrett

esophagus• Destrcution of the esophagus by Caustic

injury• Esophageal Dysfunction: Scleroderma,

Achalasia, Spasm• Esophageal Perforation• Recurrent GE reflux

Indications For Reconstruction

• Resection of Esophagus/Stomach:– Neoplasms– Dysfunctional Esophagus

Indications For Reconstruction

• Esophagectomy/Gastrectomy Complications– Fistula– Stricture

Indications For Reconstruction

• Failed Esophageal continuity Procedures:– Dehiscence– Stricture– Dysfunction

The surgical option is chosen on the basis of:

• The nature of the condition:benign or malignant.T

• The extent of the lesion.

• The presence of complications

Incisions

• Dictated by Approach to Resection– Upper midline laparotomy– Right thoracotomy– Left Thoracotomy– Left Thoracoabdominal incision– Left Neck incision– Ivor-Lewis (Laparotomy/Right thoracotomy)– McKewn (Right thoracomty/Laparotomy/Neck

incision)

Rules for Anastomotic Technique

• Hand Sewn:– Double layer– Single layer– Interrupted suture– Continuous suture– Combination

• Stapled• End to Side• Tension Free anastomosis• Intact blood supply

Ivor-Lewis Technique

• Laparotomy/Right Thoracootmy

http://radiographics.rsnajnls.org/content/vol21/issue5/images/large/g01se03c3a.jpeg

http://radiographics.rsnajnls.org/content/vol21/issue5/images/large/g01se03c3b.jpeg

http://radiographics.rsnajnls.org/content/vol21/issue5/images/large/g01se03c3c.jpeg

http://radiographics.rsnajnls.org/content/vol21/issue5/images/large/g01se03c1x.jpeg

Ivor Lewis – Phase I

Ivor Lewis – Phase II

Resection

Gastric Tube - Stapling

Gastric Tube - Stapling

Gastric Tube - Length

Proximal Esophagus

Anastomosis

Gastric Tube - Anastomosis

Gastric Tube - Posterior Mediastinum

Indications

• Midesophageal carcinomas

Indications

• High-grade dysplasia in Barrett esophagus.• Destruction of the distal two-thirds of the

esophagus by :– caustic ingestion, peptic stricture and ulcer,

• Persistent reflux esophagitis causing pulmonary complications that fail to respond to antireflux procedures.

• Perforation of the mid- to distal esophagus .

Contraindications

• High esophageal carcinomas located within 20 cm of the incisors.

• Patients with previous right thoracotomy due to postoperative adhesion

Transhiatal Esophagectomy without Thoracotomy

• Same Indications• Safe procedure only

when tracheobronchial or aortic involvement is Not suggested at CT .

http://radiographics.rsnajnls.org/content/vol21/issue5/images/large/g01se03c6a.jpeg

Transthoracic Esophagectomy through a Left Thoracotomy

Distal esophageal and gastroesophageal lesions

Conduits for Esophageal Reconstruction

• Skin Tubes• Stomach

• Colon• Jejunum

• Combination

Skin Tube

Stomach

Stomach

Colon

Colon Redundency

Colon

Blood Supply of the Colon

Different Segment Grafts

Right Colon Interposition

Left Colon Interposition

Transverse Colon Interposition

Colon – Surgical Hints

Posterior Cologastric Anastomosis

Jejunum

Vascular Pedicle

Jejunum – Roux-en-Y

Jejunum – Free Graft

Jejunum – Free Graft

Jejunum – Identifying Free Graft Free Graft

Jejunum – Free Graft Isolated

Jejunum – Free Graft Anastomosis

Combined Conduits

Combined Conduits

Combined Conduits

Combined Conduits

Routes of Reconstruction

• Posterior Mediastinal (Esophageal Bed)

• Substernal• Subcutaneous

Reconstruction Route Selection

Reconstruction Route

Subcutaneous Substernal

Complications of Reconstruction

Complications of Reconstruction

Complications of Reconstruction

CONCLUSIONS

• 1st Goal of esophageal resection and reconstruction is to have a viable patient.

• 2nd Goal is to have GI tract that is in continuity and functional

• A successful reconstruction:– Last over a long period of time– Provide a nutrition and quality of eating– Be done safely

CONCLUSIONS

• Surgeon must have a “Game Plan” with several options and be felxibleduring the operation.

• A team approach is essential for an excellent outcome.

Thank You