Ann Thorac Surg 1997;64:867-869
© 1997 The Society of Thoracic Surgeons
How To Do It
Atraumatic Gastric Transposition After Transhiatal Esophagectomy
Robert J. Korst, MD,
Mithran Sukumar, MD,
Michael E. Burt, MD, PhD
Thoracic Service, Memorial Sloan-Kettering Cancer Center, New York, New York
Accepted for publication April 7, 1997.
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Abstract
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Transhiatal esophagectomy using the stomach for esophageal replacement requires that the gastric "neoesophagus" be transferred from the peritoneal cavity through the posterior mediastinum into the neck under blind conditions. This process is associated with stretching, tearing, and hematoma formation in the most critical portion of the gastric tube, that to be used for the anastomosis. A technique is described for this procedure that is simple to perform and, most importantly, completely atraumatic to the gastric conduit.
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Introduction
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Transhiatal esophagectomy using the stomach for esophageal replacement requires that the gastric "neoesophagus" be translocated through the posterior mediastinum into the neck for anastomosis to the cervical esophagus. The technique most commonly used to accomplish this task is that of suturing an instrument (most commonly a Penrose drain), which has been previously placed in the posterior mediastinum, to the most superior aspect of the stomach. The stomach is then advanced through the mediastinum using both traction on the affixed instrument and gentle manipulation through the diaphragmatic hiatus. This technique, however, causes stretching, tearing, and hematoma formation in the stomach, which occurs in the portion most remote from the blood supply and that used for the anastomosis. We describe a technique to accomplish gastric transposition that is simple to perform and completely atraumatic to the gastric conduit.
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Technique
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Once the native esophagus is dissected free from the posterior mediastinum and the stomach mobilized, a long heavy silk ligature is placed around the cervical esophagus leaving two ends of equal length. The esophagus is then divided proximal to this tie with an automatic stapling device. The esophagus is delivered into the abdomen along with both ends of the silk ligature. The silk tie is then divided close to the esophagus leaving the two ends behind in the posterior mediastinum. The ties must be long enough to protrude at least 10 to 20 cm from both the cervical and abdominal incisions. The esophagus and proximal stomach are then resected in standard fashion, leaving the gastric "neoesophagus" to be translocated up into the neck.
One of the cervical ends of the previously placed heavy silk ties is then ligated to the end of an 18F urinary catheter "distal" to the balloon. The other silk tie is left in the mediastinum as a spare, and the ends are retracted out of the field to prevent entanglement. The end of the urinary catheter is delivered into the abdomen from the neck by pulling the silk tie. The silk ligature is then divided, leaving the catheter in the posterior mediastinum.
Either a clear plastic intraoperative ultrasound bag or a laparoscopy camera cable covering sheath is then obtained and a segment approximately 50 cm in length is cut from the center. The balloon in the urinary catheter is inflated with 20 mL of saline solution, and the catheter is inserted into one end of the clear plastic sheath. A heavy silk ligature is placed over the sheath just proximal to the balloon to fasten the two together. Figure 1
demonstrates the urinary catheter in the posterior mediastinum with the attached clear plastic sheath. Approximately 25 mL of saline solution is then added to the inside surface of the sheath, which is then unrolled onto the stomach (Fig 2). The entire stomach is inserted into the plastic bag in this fashion in the correct orientation and the operator gently grasps the distal end of the sheath containing the stomach and makes a seal (Fig 3). Suction is then applied to the proximal end of the urinary catheter in the neck, which, in combination with the watertight seal made at the distal end, keeps the stomach inside the bag. The operator then feeds the bag containing the stomach into the diaphragmatic hiatus, ensuring that no twisting is occurring, while gentle traction is applied to the urinary catheter in the neck (see Fig 3). The sheath containing the stomach is advanced through the mediastinum from the abdomen to the neck in this fashion until the stomach is visualized in the cervical incision (Fig 4). At this point, the plastic sheath is incised in the region of the catheter balloon to release the suction and the bag is easily withdrawn, leaving the stomach in place in the posterior mediastinum. The cervical anastomosis is then performed in the usual fashion.
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Fig 1. . After transhiatal esophagectomy, a urinary catheter has been placed in the posterior mediastinum (see text). The stapled and divided cervical esophagus is seen in the neck. An unraveled laparoscopy camera sheath has been fastened to the distal end with a heavy silk tie and the balloon inflated. The gastric tube has been prepared and is ready for transposition to the neck.
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Fig 2. . The gastric tube is inserted into the plastic sheath with 25 mL of saline solution and the sheath is unraveled to cover the entire stomach.
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Fig 3. . Suction is applied to the catheter and the surgeon's hand provides a seal. Once the vacuum is created, the surgeon's hand is loosened and is used to gently guide the gastric tube through the mediastinum.
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Fig 4. . The urinary catheter is withdrawn from the cervical incision until the balloon is delivered into the neck along with the gastric fundus. The plastic sheath is incised to release the vacuum and is easily removed from the mediastinum leaving the gastric tube in excellent position.
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Comment
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Transhiatal esophagectomy, or esophagectomy without thoracotomy, is widely performed for the resection of this organ in both malignant and benign conditions. The most popular choice of conduit for reconstruction after this procedure is the stomach. A disadvantage of this technique, however, is that after mobilization of the stomach and ligation of the left gastric, left gastroepiploic, and short gastric vessels, the fundus survives on microvascular connections that may be prone to injury during any manipulation [1]. In addition, because a thoracotomy is not performed, the stomach must be transferred from the abdomen to the neck under somewhat "blind" conditions.
Numerous techniques have been described to accomplish gastric transposition, the most popular of which is that described by Orringer and Sloan [2]. Specifically, a Penrose drain is sutured to the most superior portion of the stomach and traction is applied to deliver the stomach into the neck. Placement of these sutures, however, commonly injures a gastric blood vessel, which frequently results in hematoma formation. Additionally, during gastric transposition, tension is focused on this critical region of the stomach where the anastomosis is to be performed, resulting in rupture of important microvascular connections, which in turn may impede anastomotic healing. Avulsion of clips or ties on the short gastric and left gastroepiploic vessels may also occur as the stomach is being transferred from the abdomen to the neck.
The technique described in this report for gastric transposition after transhiatal esophagectomy has several advantages. First, no sutures are placed in the fundus so the possibility of hematoma formation is remote. Second, when the stomach is manipulated up into the neck, any tension resulting from traction on the urinary catheter is distributed evenly throughout the entire stomach and not just on the fundus due to the vacuum created in the plastic sheath. Third, the use of the plastic sheath also prevents clips and ties on the stomach from catching on mediastinal structures as it is moved up into the neck. These advantages preserve the integrity of the gastric "neoesophagus."
In summary, we describe a technique for gastric transposition after transhiatal esophagectomy that is completely atraumatic, easy to perform, and not time-consuming. By eliminating trauma to the fundus of the stomach, this technique may help to reduce anastomotic complications of this procedure.
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Footnotes
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Address reprint requests to Dr Burt, Thoracic Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021.
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References
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- Liebermann-Meffert DMI, Meier R, Siewert JR. Vascular anatomy of the gastric tube used for esophageal reconstruction. Ann Thorac Surg 1992;54:1110–5.[Abstract/Free Full Text]
- Orringer MB, Sloan H. Esophagectomy without thoracotomy. J Thorac Cardiovasc Surg 1978;76:643–54.[Abstract]
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Abstract
Introduction
