Editing Oesophagectomy (section)

== '''Pre-operative decisions''' ==

* Extent of operation
** '''Radical en      bloc''' - as wide      as possible peri-tumoural resection with en bloc lymph node resection of      the middle and distal thirds of the posterior mediastinum
*** Borders: right and left       parietal pleura, aortic adventitia, vertebral bodies, posterior       pericardium, membranous airway at carina
*** Includes oesophagus, vagus       nerves, peri-oesophageal lymph nodes (levels 7 and 8), azygos vein,       thoracic duct, bilateral parietal pleura, base of bilateral inferior       pulmonary ligament, level 9 lymph nodes bilaterally, posterior       pericardium
** '''Two-field      lymph node dissection''' - WLE of the primary tumour + lymphadenectomy of the entire      posterior mediastinum + lymphadenectomy of upper abdominal nodes (coeliac      trunk + common hepatic + splenic artery + lesser curvature + lesser      omentum)
** '''Three-field      lymph node dissection''' - two-field dissection + cervical nodes (paraoesophageal + nodes      lateral to carotid + supraclavicular nodes). May offer a survival      advantage for supra-carinal tumours.
** Cancers at GOJ need an      oesophagectomy plus partial (or extended) gastrectomy
* Neoadjuvant chemoradiotherapy
** cN+
** cT3-4
* Operative approach
** Trans-thoracic
*** '''Two-hole       approach: Ivor Lewis'''  - most commonly done
*** '''Three-hole:       McKeown''' (right       thoracotomy, laparotomy, neck incision and cervical anastomosis)
*** Proximal and middle thirds       (supra-carinal), or suspicious paratracheal nodes - approach via right       thoracic cavity in open surgery - allows assessment of airway, azygos,       pericardium
*** Distal tumours and GOJ -       left thoracic cavity easier, since it facilitates reconstruction after a       total gastrectomy, and allows upper abdominal lymph node dissection, and       allows assessment of aorta, pericardium and crus
*** Need to deflate the lung on       the operative side
** Trans-hiatal
** Minimally invasive
*** Typically performed via a       right thoracoscopy regardless of location
*** Best for T1a or Barrett's       indications
*** Avoid in difficult cases -       bulky tumours with possible adherence to the membranous part of the       trachea, or after definitive chemoradiotherapy
* Location of anastomosis
** Dependent on location of      tumour -
** Cervical anastomosis      historically thought to leak more, possibly because it is in the      watershed region, further away from feeding blood vessels from the      stomach. However modern rates of leak are comparable.
** Cervical leaks are easier to      control than intra-thoracic.
** Try to keep it out of      radiotherapy field
* Type of anastomosis
** Hand sewn
*** Running absorbable (PDS?)
*** Posterior layer - full       thickness
*** Advance NGT into gastric       tube
*** Anterior in two layers
*** Usually covered with a       pleural flap to protect the chest cavity from an anastomotic leakage
** Circular stapled (more      expensive, more likely to cause stricture, easier, faster)
*** Sew anvil head into       oesophagus using 4/0 Prolene purse-string
*** Incision in top of gastric       tube to insert gun
*** Perforate with tip of gun -       posterior, away from longitudinal staple lines and greater curvature       vessels
*** Connect gun to head
*** Anastomosis in conventional       manner
*** Can add some reinforcing       sutures
*** Advance NGT into gastric       tube
*** Close hole in stomach with       stapler and inverting sutures
** Side to side now preferred      technique, to increase area of anastomosis - triangular/droplet-shaped
*** Can be hybrid       stapled/sutured
* Optimal number of nodes
** One source says aim 10 for      T1, 20 for T2 and 30 for T3
** Typical trans-thoracic      lymphadenectomy includes levels 8, 9, 7, 4R, and 5. That typically gives      >15 nodes.