Esophageal Resection

& Reconstruction
Yasser Elghoneimy M.D.
Assistant Professor of Cardiothoracic
Surgery
King Faisal University
2008
 Objectives
1. Indications of Esophageal resection
2. Common techniques of resection
3. Conduits used for reconstruction
4. Routes of Reconstruction
5. Complications of reconstruction
 Indications for Resection
• Carcinoma of the esophagus
• High Grade Dysplasia in Barrett
esophagus
• Destrcution of the esophagus by Caustic
injury
• Esophageal Dysfunction: Scleroderma,
Achalasia, Spasm
• Esophageal Perforation
• Recurrent GE reflux
 Indications For Reconstruction
• Resection of Esophagus/Stomach:
– Neoplasms
– Dysfunctional Esophagus
 Indications For Reconstruction
• Esophagectomy/Gastrectomy
Complications
– Fistula
– Stricture
 Indications For Reconstruction
• Failed Esophageal continuity Procedures:
– Dehiscence
– Stricture
– Dysfunction
 The surgical option is chosen on the
basis of:

• The nature of the condition:benign or

malignant.T
• The extent of the lesion.
• The presence of complications
 Incisions
• Dictated by Approach to Resection
– Upper midline laparotomy
– Right thoracotomy
– Left Thoracotomy
– Left Thoracoabdominal incision
– Left Neck incision
– Ivor-Lewis (Laparotomy/Right thoracotomy)
– McKewn (Right thoracomty/Laparotomy/Neck
incision)
 Rules for Anastomotic Technique
• Hand Sewn:
– Double layer
– Single layer
– Interrupted suture
– Continuous suture
– Combination
• Stapled
• End to Side
• Tension Free anastomosis
• Intact blood supply
Ivor-Lewis Technique

• Laparotomy/Right
Thoracootmy
Ivor Lewis – Phase I
Ivor Lewis – Phase II
Resection
Gastric Tube - Stapling
Gastric Tube - Stapling
Gastric Tube - Length
Proximal Esophagus
Anastomosis
Gastric Tube - Anastomosis
Gastric Tube - Posterior Mediastinum
Indications

• Midesophageal
carcinomas
 Indications

• High-grade dysplasia in Barrett esophagus.

• Destruction of the distal two-thirds of the
esophagus by :
– caustic ingestion, peptic stricture and ulcer,
• Persistent reflux esophagitis causing pulmonary
complications that fail to respond to antireflux
procedures.
• Perforation of the mid- to distal esophagus .
 Contraindications
• High esophageal carcinomas located
within 20 cm of the incisors.
• Patients with previous right thoracotomy
due to postoperative adhesion
Transhiatal Esophagectomy without
Thoracotomy
• Same Indications
• Safe procedure only
when
tracheobronchial or
aortic involvement is
Not suggested at CT .
Transthoracic Esophagectomy through a
Left Thoracotomy

Distal esophageal and gastroesophageal lesions

Conduits for Esophageal
Reconstruction

• Skin Tubes
• Stomach
• Colon
• Jejunum
• Combination
Skin Tube
Stomach
Stomach
Colon
Colon Redundency
Colon
Blood Supply of the Colon
Different Segment Grafts
Right Colon Interposition
Left Colon Interposition
Transverse Colon Interposition
Colon – Surgical Hints
Posterior Cologastric Anastomosis
Jejunum
Vascular Pedicle
Jejunum – Roux-en-Y
Jejunum – Free Graft
Jejunum – Free Graft
Jejunum – Identifying Free Graft Free
Graft
Jejunum – Free Graft Isolated
Jejunum – Free Graft Anastomosis
Combined Conduits
Combined Conduits
Combined Conduits
Combined Conduits
Routes of Reconstruction
• Posterior Mediastinal
(Esophageal Bed)
• Substernal
• Subcutaneous
Reconstruction Route Selection
Reconstruction Route
Subcutaneous Substernal
Complications of Reconstruction
Complications of Reconstruction
Complications of Reconstruction
 CONCLUSIONS
• 1st Goal of esophageal resection and
reconstruction is to have a viable
patient.
• 2nd Goal is to have GI tract that is in
continuity and functional
• A successful reconstruction:
– Last over a long period of time
– Provide a nutrition and quality of eating
– Be done safely
 CONCLUSIONS
• Surgeon must have a “Game Plan” with
several options and be felxibleduring
the operation.
• A team approach is essential for an
excellent outcome.
Thank You