How to Do It Combined Total Gastrectomy, Total Esophagectomy, and D2 Lymph Node Dissection with Transverse Colonic Interposition
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Surg Today (2011) 41:1319–1323 DOI 10.1007/s00595-010-4412-z How to Do It Combined Total Gastrectomy, Total Esophagectomy, and D2 Lymph Node Dissection with Transverse Colonic Interposition for Adenocarcinoma of the Gastroesophageal Junction JEAN M. BUTTE, ENRIQUE WAUGH, HUGO PARADA, and HERNÁN DE LA FUENTE Department of Gastrointestinal Surgery, Instituto Oncológico Fundación Arturo López Pérez, Rancagua 878, Santiago, Chile Abstract in the para-aortic or porta hepatis nodes5 when an The surgical treatment of adenocarcinoma of the gastro- adequate D2 lymphadenectomy is not performed for esophageal junction (GEJ) is complex. A large tumor complete locoregional control. involving a substantial portion of both the esophagus and Proximal or distal positive margins have been associ- stomach requires complete resection with negative proxi- ated with local recurrence, resulting in a worse progno- mal and distal margins as well as D2 lymph node dissec- sis and diminished long-term survival.6 The incidence of tion. Some investigators have found that patients who do a microscopically positive proximal resection margin in not undergo radical resection have a worse prognosis; patients undergoing surgery with curative intent ranges however, more aggressive surgical treatments are associ- from 2.5% to 58%.7 This is attributed to direct submu- ated with increased morbidity and mortality. We describe cosal tumor extension or discontinuous periesophageal our operative technique designed for complete resection lymphatic permeation by cancer, often found as far as of tumors of the GEJ. We used this technique to operate 4–6 cm beyond the tumor. For these reasons, resection on nine patients, none of whom suffered anastomotic of the esophagus of up to 10 cm from the tumor is rec- leakage or necrosis of the colonic interposition graft. ommended by a number of different centers.8,9 The survival benefi ts of different operative approaches Key words Gastroesophageal junction tumor · Surgical have not been clearly demonstrated.10 Recently, Barbour treatment · Gastrointestinal reconstruction et al.7 reported a better outcome after total esophagec- tomy than after partial esophageal resection for GEJ cancers. Based on available data, the surgical approach should pursue an R0 resection with at least 15 lymph Introduction nodes extracted and preferably 5 cm of grossly normal esophagus above the tumor.7 Perioperative nutrition is The incidence of adenocarcinoma of the gastroesopha- also important for preventing complications.11 geal junction (GEJ) is increasing.1 Surgical resection This report describes our technique of total gastrec- is the treatment of choice whenever possible, but the tomy and total esophagectomy with transverse colonic prognosis remains dismal.2 The Siewert classifi cation3 interposition for GEJ cancer. This operation allows us of types I to III gastroesophageal junction adenocarci- to perform radical resection of the tumor with adequate noma has been useful in planning the type of resection proximal and distal negative margins, en bloc infracari- and the appropriate level of lymph node dissection. nal mediastinal lymph node dissection, a D2 lymph The operative approaches to GEJ cancers include node dissection, and a cervical anastomosis, while pre- transthoracic or transhiatal esophagectomy with proxi- venting intramediastinal leakage. mal gastrectomy (EPG), total gastrectomy with distal esophagectomy (TGDE), and proximal gastrectomy with distal esophagectomy (PGDE).4 Siewert types II and III cancers often involve lymph nodes at groups 1, Surgical Technique 2, 3, and 7, and nodal recurrence frequently develops Preoperative Workup Reprint requests to: H. De La Fuente Physical examination should focus on any signs of dis- Received: December 12, 2009 / Accepted: June 2, 2010 seminated disease such as supraclavicular lymph node 1320 J.M. Butte et al.: Resection of Gastroesophageal Junction Tumor enlargement. Upper endoscopy is performed to obtain The utilization of an isoperistaltic transverse colonic biopsies and defi ne intraluminal extension of the tumor. graft fed by the left colic artery and the Drummond Chest and abdominal computed tomography (CT) scans arcade is preferred. Next, en bloc inferior lymph node are mandatory to evaluate the extraluminal extent of mediastinal dissection with bilateral pleural resection the disease, including proximal tumor involvement, and up to the inferior pulmonary veins is performed. During to rule out metastatic disease. Positron emission tomog- this part of the dissection, it is critical not to injure the raphy/CT evaluation may be done to exclude dissemi- left bronchus and the right pulmonary and azygos veins. nation. Colonoscopy is done to rule out a second primary When the esophagus is free in the mediastinum, a cervi- malignancy. Cardiopulmonary examinations are done cal dissection is performed. according to the patient’s risk. Patients are admitted the day before surgery and Cervical Dissection ingest a mechanical bowel preparation to clean the A vertical left neck incision is made on the anterior colon. In the operating room, routine monitoring is border of the sternocleidomastoid muscle. The dissec- done with an arterial catheter and central venous access. tion continues through the platysma, and the omohyoid A sequential compression device is placed on the lower muscle is identifi ed and preserved. The internal jugular extremities for deep venous thrombosis prophylaxis, an vein and carotid artery are identifi ed and dissection is epidural catheter is inserted for postoperative analgesia, carried out medial to the vessels, to locate the lateral and a urinary catheter is also placed. side of the esophagus before it is mobilized completely. In some cases, it is necessary to cut the middle thyroid vein to facilitate exposure. At this stage, it is important Operative Technique to identify the left laryngeal recurrent nerve to prevent The patient is positioned supine on the operating table injuring it. The anterior wall of the esophagus is sepa- with the head turned to the right, to expose the left side rated from the trachea and dissection along the right of the neck. A small, soft pillow is placed between the side of the esophagus is carefully performed to preserve shoulder blades to raise the chest. After making a bilat- the nearby right laryngeal recurrent nerve. The cervical eral subcostal or midline laparotomy incision, complete esophageal dissection is completed by manual mobiliza- visual and manual abdominal exploration is performed tion. The cervical esophagus is cut between intestinal to rule out intraabdominal spread. An Omni-Tract clamps and a suture is placed in the distal side of the retractor (Integra, St. Paul, MN, USA) is used to provide divided esophagus to allow traction ascent of the colon adequate exposure. to the neck. The left triangular ligament of the liver and mobiliza- Mobilization of the stomach and esophagus com- tion of the lateral segments of the liver expose the GEJ pletes resection of the abdominal tumor. A cholecystec- and allow us to assess the extent of the primary tumor. tomy is performed. The duodenum is dissected and the It is important to ligate the triangular ligament to right gastroepiploic vessels are identifi ed, ligated, and prevent a bile leak. A GEJ dissection is then performed, divided. The right gastric vessels are also divided at their taking meticulous care to prevent liver fracture and origin, assuring complete retrieval of the groups 5 and bleeding from the diaphragmatic vessels. Electrocautery 6 lymph nodes. Infrapyloric division of the duodenum and Ligasure (Valleylab, Boulder, CO, USA) or a Har- is performed with a linear stapler and the suture line monic Scalpel (Ethicon, Somerville, NJ, USA) are used is invaginated with 3-0 absorbable sutures (polydioxa- in the mobilization of the GEJ and esophagus to mini- none or Monocryl). Dissection of the lymph nodes mize bleeding. along the hepatoduodenal ligament, common hepatic The phrenoesophageal ligament is opened, the artery, left gastric artery, and celiac trunk is performed. abdominal esophagus is dissected, and the diaphrag- The left gastric vessels are cut and ligated at their origin. matic hiatus is opened widely through a vertical phre- The fi nal mobilization is completed with a section of the notomy. The proximal extent of the esophageal tumor left gastroepiploic vessels and the short gastric vessels, in the mediastinum is defi ned by palpation. At this permitting splenic preservation. point, a decision must be made on the need to perform The specimen is extracted through the abdomen with total gastrectomy and esophagectomy. The upper limit its perigastric lymph nodes (groups 1, 2, 3, 4, 5, and 6) of the tumor will determine whether it is possible to and groups 7, 8, 9, and 12 (Fig. 1A,B) and frozen section perform an intramediastinal esophagojejunal anasto- biopsies are done of the proximal and distal margins. mosis or whether a total esophagectomy will be necessary. A total burso-omentectomy and colonic Transit Reconstruction with Colon Interposition mobilization are performed. These maneuvers permit After complete mobilization of the colon, an appendec- adequate evaluation of the vasculature of the colon and tomy is performed. Use of the isoperistaltic transverse help with the decision to continue with radical resection. colon perfused by the left colic artery is preferred. Iden- J.M. Butte et al.: Resection of Gastroesophageal Junction Tumor 1321 AB A Fig. 1A,B. Total gastrectomy, total