Wolfram T. Knoefel, Rainer Schmelzle
Cervical esophagectomy for neoplasia includes removal of the cervical part of the esophagus combined with cervical lymphadenectomy and reconstruction by interposition of a free jejunal transplant with microvascular anastomoses.
Resection of a segment of up to 3 cm can be performed with primary anastomosis of the esophagus after adequate mobilization.
Indications and Contraindications
■ Cervical esophageal neoplasia
■ Benign esophageal stricture
Local irresectability (infiltration of larynx, trachea or vertebrae)
Florid gastroduodenal ulcer
Preoperative Investigation/Preparation for the Procedure
Clinical evaluation: Endoscopy:
CT scan or MRI:
Doppler ultrasound: PET scan: Laboratory test: Avoid:
Risk factors (alcohol, nicotine), previous radiation therapy, concomitant malignancy, Crohn's disease Recurrent laryngeal nerve status, cervical lymphadenopathy Esophagogastroduodenoscopy (EGD) to rule out multifocal lesions and gastroduodenal ulcer
Assessment of stage and resectability (include thorax and abdomen!)
Vascular status in the neck
Exclude further lesions
SCC antigen, coagulation parameters
Central venous line on the side of anastomoses, wall stents
For the cervical part a unilateral or bilateral (U-) incision at the medial margin of the sternocleidomastoid muscle is performed. It extends from the margo inferior of the mandible to the jugulum, where it meets with the contralateral side. For cervical-mediastinal lymph node dissection, the incision is combined with a partial or complete median sternotomy. For harvesting the transplant, a small upper abdominal transverse incision is sufficient.
Retraction is performed by hand held retractors of different shapes and sizes according to the anatomy. If available, a self-retaining retraction system will help.
After transection of the platysma, the sternocleidomastoid muscle is retracted and the omohyoid muscle is divided. Along with the internal jugular vein, the common carotid artery and the vagal nerve are identified along the entire length of the incision and a lymphadenectomy around these structures is performed. This preparation is facilitated by the use of a pair of fine bipolar scissors. The superior thyroid artery can be preserved for reconstruction. From the carotid artery the anterior longitudinal ligament is reached and the posterior dissection of the cervical esophagus is completed under vision. After mobilization of the left (or right) thyroid lobe the recurrent nerve and the parathyroids are identified and preserved. Injuries to the recurrent nerve should be repaired immediately. Autotransplantation of dissected parathyroids should be performed in the forearm if radiation therapy is an option.
Quite frequently a hemithyroidectomy facilitates the further procedure significantly. Now the posterior aspect of the trachea is dissected and after identification of the contralateral recurrent nerve the cervical esophagus is completely mobilized from the hypopharynx to the upper thoracic aperture or below.
Occasionally the identification of important blood vessels can only be guaranteed using intraoperative Doppler ultrasound. Especially following extensive tumor resections of the oropharyngeal region, vast alterations of the typical anatomy must be expected. Injuries of the thoracic duct can lead to the development of persistent fistulas associated with significant fluid loss, protracted by a previous radiotherapy.
In cases of extensive tumor growth that warrant resection, more extensive procedures may become necessary, e. g., larynx or trachea.
Before resection, place retaining sutures on the potential proximal and distal stump.
STEP 2 Transection of the esophagus
The cervical esophagus is transected and the nasogastric tube withdrawn to the level of the neck so that the specimen can be removed. Confirm free margins by frozen section on both sides. In case negative margins cannot be achieved, an esophagectomy should be performed.
STEP 3 Preparation of the jejunal loop
The jejunal loop is harvested after exploration of the abdominal cavity with sufficient arterial and venous length and lumen. If the mesentery is very thick, a meticulous removal of fatty tissue may enable diaphanoscope However, under diaphanoscopy an artery and a vein of sufficient length and lumen are identified. After clamping on the mesenteric side and excision of the graft, the artery is flushed with heparinized saline until the venous outflow is clear.
If the vascular pedicle or one of the vessels are too short, it becomes necessary to harvest a venous or arterial interponate. The primary source for viable venous inter-ponates is the forearm, whereas for the artery the saphenous vein can be employed. Vessels harvested from the arm or foot region are equally suitable for the arterial inter-ponate whereas the saphenous vein, due to its dimension and susceptibility to spasm, proves to be hardly suitable for venous interpositioning and should thus only be reserved for arterial lengthening. At times it is very difficult to differentiate between the artery and the vein in the intestinal flap. To avoid confusing the two, prior to harvesting, the artery or vein should be unmistakably marked.
An end-to-end jejunostomy is performed to reconstruct the bowel, and the abdomen is closed without drainage.
STEP 4 Vascular anastomoses
The venous and arterial anastomoses are now performed. First the vein is anastomosed.
Preferably a confluens of the major mesenteric vein with a smaller contributing vein is used on the side of the graft and the internal jugular vein on the other side. The incision in the internal jugular vein should be at least 3-4mm long. The anastomosis is performed under a magnification of at least x4, preferably with a microscope. Running sutures with non-resorbable, monofilament material, 7-0 or 8-0, are used. Before closure, the anastomosis is rinsed with heparinized saline.
The vein should only be anastomosed before the artery if an expedient progression of the operation is evident. Should delays occur, e.g., difficulties during the preparation or unforeseen anesthesiological circumstances in conjunction with unstable cardiovascular parameters, the artery should be anastomosed prior to the vein, allowing a perfusion of the intestinal flap with nutrient rich blood until peristalsis returns. If the nature of the delay prevents the anastomoses, the harvested intestinal flap should be stored in moist dressings. If desired, the metabolic rate of the temporary non-perfused flap can be decreased by cooling the flap. Routinely, there is no necessity for the use of organ preservation solutions.
The same technique is used for the artery. The anastomosis can be performed on the superior thyroid artery (often quite small), the thyrocervical trunk or the common carotid artery directly. Rarely other cervical branches like the lingual artery are used.
It is extremely important to avoid kinking and compression especially on the vein during placement of the graft into the neck, and during closure of the neck.
If the vascular reconstruction fails, either a second loop can be harvested or a gastric tube can be fashioned.
STEP 5 Esophagojejunal anastomoses
After reperfusion an adequate flow is confirmed. Then the lower and finally the upper esophagojejunal anastomoses are performed end-to-end or end-to-side after shortening the graft to an adequate length. These anastomoses are performed using 3-0 or 4-0 absorbable sutures in a single layer. It is important to grasp the entire thickness of the pharynx or esophagus, whereas the stitches in the jejunum are extramucosal. If the anatomy is demanding, e.g., a very low intrathoracic anastomosis, the suture can be performed in an interrupted fashion. The nasogastric tube is then placed through the graft into the stomach.
It is important to implant the graft in an isoperistaltic fashion to facilitate swallowing. Even under optimal conditions, it can take weeks before the graft gains normal transplant function.
STEP 6 Final aspects
The neck is drained sufficiently from both sides with at least one soft easy flow drain on each side. The neck is closed by loose interrupted subcutaneous and skin stitches.
For the postoperative follow-up, it is advantageous to ensure that parts of the jejunal graft are clinically visible. This can either be achieved by placing a few sutures in a manner such as to allow a division of the covering tissue or by configuring the flap so as to leave parts of the flap uncovered, serving as a "monitor" during the postoperative surveillance. Verification of the blood flow can be performed using Doppler ultrasound. As an adjunct, various tissue probes are available, facilitating the measurement of the oxygen partial pressure.
Standard Postoperative Investigations
■ Anticoagulation (PTT 60-70s)
■ Maintain mean arterial blood pressure of 70-80 mmHg
■ Monitoring of microcirculation and improved rheology
■ Daily Doppler ultrasound
■ Regular inspection of the flap on postoperative day 1 every hour
■ Venous thrombosis (reoperate immediately)
■ Arterial thrombosis (reoperate immediately)
■ Necrosis of the transplant (excise and drain by pharyngostomy or reconstruct with gastric tube or colon)
■ Salivary leak (drain adequately)
■ Lymphatic leak
■ Recurrent laryngeal nerve injury
■ Esophageal stenosis (dilate by endoscopy) (long term)
■ Poor swallowing function (long term)
Tricks of the Senior Surgeon
■ Be aggressive to reoperate if vascular status is questionable.
■ Avoid kinking of the vein by keeping it short.
■ Keep CVP high and perform adequate heparinization to avoid vascular problems.
■ Leave the neck open if the jejunum is congested after reperfusion but cover the vessels with tissue.
■ If the exposure for vascular reconstruction becomes difficult, perform a hemithyroidectomy.
■ Occasionally a partial sternotomy may enable a safer inferior esophageal anastomosis.
■ Lymphatic leak can be managed conservatively; only rarely the lymphatic duct must be ligated.
■ Exposure can be facilitated by division of the medial head of the sternocleido-mastoid muscle.
■ Previous surgery with resection of the internal jugular vein necessitates dissection down to the subclavian vein.
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