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Open Radical En Bloc Esophagectomy

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Abstract

The poor outcome of patients following conventional esophagectomy for cancer is partly due to the high rates of locoregional failure. Despite the controversy over its efficacy, we believe that radical en bloc esophagectomy maximizes locoregional control and provides the most thorough staging information. En bloc resection involves a wide resection of tissues surrounding the esophagus with a two-field or three-field lymphadenectomy. With an experienced surgical team and careful patient selection, the procedure can be done with low mortality and similar morbidity compared to conventional transthoracic or transhiatal esophagectomy. From our studies, extensive lymphadenectomy appears to have a favorable impact on survival, especially in patients with nodal metastases. En bloc esophagectomy should be recommended for patients with stage II or greater disease with good performance status and adequate cardiopulmonary reserve. This chapter details each step of this operation and summarizes our experience.

Keywords

  • Radical esophagectomy
  • En bloc esophagectomy
  • Open resection

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Correspondence to Nasser K. Altorki M.D. .

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Key Operative Steps

Key Operative Steps

  1. 1.

    Perform right fifth interspace thoracotomy.

  2. 2.

    Incise mediastinal pleura over the anterior azygos vein from the azygos arch to the aortic hiatus and leftward across the aorta and to the opposite pleura.

  3. 3.

    Ligate the thoracic duct at the aortic hiatus and where it crosses over to the left side.

  4. 4.

    Resect azygos arch en bloc with the operative specimen.

  5. 5.

    Clear the hilar and subcarinal nodes.

  6. 6.

    Resect a patch of pericardium en bloc with esophagus if the tumor is adherent to the pericardium.

  7. 7.

    Divide bilateral pulmonary ligaments.

  8. 8.

    Thoracic lymphadenectomy with clearance of all nodal tissue including right and left paraesophageal, parahiatal, para-aortic, subcarinal, and bilateral hilar lymph nodes.

  9. 9.

    Dissection of the third field begins in the thorax including the superior mediastinal lymph nodes and the nodes along the right and left recurrent laryngeal nerves.

  10. 10.

    Complete the third-field dissection with a cervical incision removing the lower deep cervical lymph nodes.

  11. 11.

    Laparotomy requires an upper abdominal midline incision.

  12. 12.

    Enter the lesser sac through the avascular plane between the omentum and colon.

  13. 13.

    The omentum is resected and the short gastric vessels are divided.

  14. 14.

    Retroperitoneal tissues along the superior border of the pancreas are swept up to the esophageal hiatus.

  15. 15.

    The left gastric artery is divided.

  16. 16.

    The common hepatic artery lymph nodes are dissected and swept towards the specimen.

  17. 17.

    The lesser curvature lymph nodes are included with the specimen.

  18. 18.

    Retrieve the esophagus from the prevertebral space in the neck.

  19. 19.

    Divide the esophagus and retrieve the specimen in the abdomen.

  20. 20.

    Dissect the lymph nodes posterior and lateral to the carotid sheath along with the supraclavicular lymph nodes.

  21. 21.

    In the abdomen create the gastric conduit.

  22. 22.

    Perform cervical esophagogastrostomy, completed posteriorly with side-to-side stapled technique and anteriorly with 3–0 absorbable running suture.

  23. 23.

    Place feeding jejunostomy tube.

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Lee, P.C., Altorki, N.K. (2015). Open Radical En Bloc Esophagectomy. In: Kim, J., Garcia-Aguilar, J. (eds) Surgery for Cancers of the Gastrointestinal Tract. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-1893-5_4

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  • DOI: https://doi.org/10.1007/978-1-4939-1893-5_4

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