Limited Resection of the Gastroesophageal Junction with Isoperistaltic Jejunal Interposition

Asad Kutup, Emre F. Yekebas, Jakob R. Izbicki

Introduction

Limited en bloc resection of the gastroesophageal junction includes complete removal of the esophageal segment with metaplastic mucosa, the lower esophageal sphincter and a part of the lesser gastric curvature and formation of a neofundus. Since even early adenocarcinomas of the distal esophagus (T1b) seed lymph node metastases in up to 20% of patients, removal of the lymph nodes of the lesser curvature, the hepatic and splenic arteries, the celiac trunk, the para-aortal region, and the inferior mediastinum is an essential part of the operation.

In patients with early tumors, staged as uT1a or b on preoperative endosonography or severe dysplasia in the distal esophagus (Barrett's esophagus), a limited resection of the proximal stomach, cardia and distal esophagus with interposition of a pedicled isoperistaltic jejunal segment offers excellent functional and oncological results.

Indications and Contraindications

Indications ■ Severe dysplasia in the distal esophagus (Barrett's esophagus)

■ Distal adenocarcinoma of the esophagus (stage T1a and b) (UICC 2005)

■ For palliative reasons (stenotic tumor with severe dysphagia or profuse hemorrhage in selective patients)

Contraindications ■ Esophageal carcinoma staged T2 and more

■ Long Barrett's segment above the carina

Preoperative Investigations/Preparation for the Procedure

■ Esophagogastroscopy with extensive biopsies

■ Endosonography of the esophagus

■ Computed tomography of the chest and abdomen

■ Abdominal ultrasound

■ Pulmonary function test

■ Orthograde cleansing of the intestines

Positioning

■ Supine position with hyperlordosis

Procedure Access

■ Upper transverse incision with median T-shaped

■ Insertion of Rochard retractor to elevate costal margin

STEP 1 Exposure of the inferior posterior mediastinum; diaphanoscopy

The left liver lobe is completely mobilized and the lesser omentum is incised just medial to the anterior and posterior gastric vagal branches. A longitudinal median diaphragmal incision enables exposure of the inferior posterior mediastinum. The distal esophagus is then mobilized including the paraesophageal tissue. The vagal nerves are divided.

Intraoperative esophagoscopy identifies the cranial limit of the Barrett's segment by diaphanoscopy. This also marks the proximal limit of resection.

A lymphadenectomy around the splenic and hepatic artery is performed, the left gastric vein is divided, and the left gastric artery is divided at the celiac trunk. Then the celiac trunk and the para-aortic region above the celiac trunk are cleared from lymphatic tissue (A, B).

STEP 2 Transection of the esophagus

Approximately 1 cm proximal to the cranial limit of the Barrett's segment, a pursestring clamp is placed and the esophagus is divided.

Removal of the cardia and lesser curvature is performed by placing multiple linear staplers down to the border between antrum and body. Thus, a neofundus is formed.

In case an advanced tumor stage is encountered, possible extension of the operation including transhiatal esophagectomy or esophagogastrectomy should be performed.

Jejunal Interposition

STEP 3 Transposition of the proximal jejunum segment; esophagojejunostomy

A 15- to 20-cm-long segment of the proximal jejunum is isolated and is transposed with its mesenteric root to the diaphragmatic region through the mesocolon and behind the stomach. Care has to be taken while dissecting the vascular pedicle of this jejunal interposition to provide adequate length. It is imperative to form an isoperistaltic jejunal interposition which should be pulled up retrogastric and retrocolic. The proximal anastomosis is then performed by a circular stapling device as a terminolateral esophagoje-junostomy. The stapler is introduced into the end of the jejunal interponate (A-1 ).

After firing of the anastomosis, the blind end of the loop is then resected and closed by a linear stapler and then oversewn (A-2).

A-1

STEP 4 Jejunogastrostomy

Close to the base of the neofundus the gastric stapler line is removed over a distance of 3-4cm and a terminolateral or laterolateral jejunogastrostomy is performed. The remaining gastric suture line is oversewn. A terminoterminal jejunojejunostomy reconstructs the enteric passage. Drainage of the mediastinum is warranted by two soft drains from the abdomen. Finally an anterior and/or posterior hiatal repair is performed.

Standard Postoperative Investigations

■ Daily check the drains for insufficiency of the intrathoracic esophagojejunostomy Postoperative Complications

■ Insufficiency of the esophagojejunostomy or the intra-abdominal anastomosis

■ Mediastinitis

■ Pancreatitis

■ Peritonitis

■ Pleural empyema

■ Necrosis of the transposed jejunal segment

■ Delayed gastric emptying

Tricks of the Senior Surgeon

■ Intraoperative endoscopy in any case of long-segment irregularities or evidence of multicentric lesions.

■ Insertion of the stapler device through the oral end of the pedicled jejunal segment.

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