Left Thoracoabdominal Approach for Carcinoma of the Lower Esophagus and Gastric Cardia

Left Thoracoabdominal Approach for Carcinoma of the Lower Esophagus and Gastric Cardia

Shoji Natsugoe, Masamichi Baba, Takashi Aikou

Introduction

Tumors located aborally to the carina, i.e., Barrett’s carcinoma or carcinoma of the esophagogastric junction, may be removed by a left-sided thoracotomy instead of the more usual right-sided access combined with an abdominal approach. The extent of lymphadenectomy is limited to the middle and lower mediastinum.

Indications and Contraindications

Indications

Tumors of the infracarinal esophagus

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Tumors of the esophagogastric junction

Contraindications

See chapter on “Subtotal Esophagectomy: Transhiatal Approach”

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High risk patients

Preoperative Investigation/Preparation for the Procedure

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See chapter on “Subtotal Esophagectomy: Transhiatal Approach”

Procedure

Access

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Spiral positioning of the patient with 45° elevation of the left thorax

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Rotating the operating table for the thoracic part/abdominal part

STEP 1 Thoracotomy

The skin incision is made obliquely from the epigastrium toward the sixth or seventh

intercostal space, and a good exposure of the mediastinum or abdomen can be achieved

by rotating the operating table. After 1cm of costal cartilage is resected, the left side of

the chest is opened. Distant and peritoneal metastases should be excluded prior to

thoracotomy.

STEP 2 Diaphragmatomy and mobilization of the colon

Para-aortic lymphadenectomy is performed by delivering the splenic flexure into the chest through an incision in the peripheral diaphragm. The descending colon is then mobilized down the left paracolic gutter to the base of the sigmoid colon mesentery.

After mobilization of the left kidney from the retroperitoneum as well as pancreas

and spleen, the left renal vein is identified.

STEP 3 Para-aortic lymph node removal

The para-aortic lymph nodes in the left lateral region are then dissected, and the right

lateral para-aortic lymph nodes are removed after performing a Kocher maneuver.

STEP 4 Lymph node removal of the upper abdomen

Lymph nodes of the hepatoduodenal ligament and around the common hepatic artery, left gastric artery and celiac trunk are dissected.

Mobilization of the stomach and transection of the duodenum (see chapter “Total

Gastrectomy with Conventional Lymphadenectomy”)

STEP 5 Lower mediastinal lymph node removal

Regarding the left intrathoracic approach, the left pulmonary ligament is divided and

the mediastinal pleura is opened. The pleura covering the lower thoracic esophagus is

incised, allowing the clearance of loose connective tissue together with the lower

thoracic paraesophageal, supradiaphragmatic, posterior mediastinal and intradiaphrag-

matic lymph nodes.

STEP 6 Reconstruction

There are several methods of reconstruction according to the tumor location and exten- sion. Roux-Y reconstruction by using an EEA instrument, as shown here, is an option for performing the esophago-jejunostomy.

See chapter on “Subtotal Esophagectomy: Transhiatal Approach” for standard

postoperative investigations and complications.

Tricks of the Senior Surgeon

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Kinking of the graft: this is a rare but dangerous complication, due to clinical symptomatic disturbance of the gastrointestinal passage by elongation, which requires surgical intervention and is performed by shortening of the graft.

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If the trachea is injured, use direct suture and pericardial flap.