Lymphadenectomy Radical excision of the stomach and associated lymph nodes is widely practi ced in Japan and specialist Western Centers. Gastric cancer with lymph node metastases may remain a loco-regional disease and radical excision with lymphadenectomy can be justified o n the following grounds: (cid:142)(cid:3) Optimal pathological disease staging and estimate of prognosis (cid:142)(cid:3) Improved loco-regional control (cid:142)(cid:3) Prolonged su rvival and possible cure. The pattern of lymphatic spread has been carefully documented in rela- tion to the primary tumor and divided into three tiers based on the relative incidenc e of nodal disease. (cid:142)(cid:3) N1 (perigastric tier) (cid:142)(cid:3) N2 (nodes along main arterial supply to the stomach) (cid:142)(cid:3) N3 (distant nodal stations away from the stomach). The amount of nodal dissection performed is represented as D1, D2 or D3 depe nding on how many tiers are removed. There is strong support- ing evidence that a D2 gastre ctomy should be the standard surgical pro- cedure for gastric cancer, although the case for this approach remains unproven in randomized trials. The morbidity of more extensive D3 re sections, particularly if the distal pancreas or spleen needs to be re- sected, appears to outweigh the potential benefits. The N1, N2, N3 and metastatic (M) nodes for gastric cancer subsites are shown in Table 6.1. RADICAL SURGERY FOR GASTRIC CANCER1 203 Table 6.1 Nodes for gastric cancer subsites No. Location LMU/MUL MLU/UML LD/L LM/M/ML MU/UM U 1 Right paracardial 1 2 1 1 1 2 Left paracardial 1 M 3 1 1 3 Lesser curve 1 1 1 1 1 4sa Short gastric 1 M 3 1 1 4sb Left gastroepiploic 1 3 1 1 1 4d Right gastroepiploic 1 1 1 2 2 5 Suprapyloric 1 1 1 3 3 6 Infrapyloric 1 1 1 3 3 7 Left gastric artery 2 2 2 2 2 8a 2 2 2 2 2 Anterior common hepatic artery 8b 3 3 3 3 3 Posterior common hepatic artery 9 Coeliac artery 2 2 2 2 2 10 Splenic hilum 2 M 3 2 2 11p Proximal splenic artery 2 2 2 2 2 11d Distal splenic artery 2 M 3 2 2 12a 2 2 2 3 3 Left hepatoduodenal ligament 12b,p Posterior hepatoduo- denal lligament 3 3 3 3 3 13 Retropancreatic 3 3 3 M M 14v 2 2 3 M M Superior mesenteric vein 14a M M M M M Superior mesenteric artery L, lower; M, middle; U, upper, D, distal. Gastroenterostomy A Roux-en-Y gastro-enterostomy is almost always employed, as it is associ ated with lowest degree of bile reflux. Bilroth 1 reconstruction after subtotal gastrectomy produces maximal bile reflux into the gastric remnant. Bilroth II and Polya (retro-colic l oop gastro-jejunostomy) re- constructions were frequently carried out for benign peptic ulc er surgery but also produce bile reflux and in symptomatic patients require revision to a R oux-en-Y configuration. Loop gastro-jejunostomy continues to be employed for palliative byp asses, as there is only one anastomosis. It may be combined with a division of the stomach above the site of the malig- nant obstruction to prevent future in-growth into the anastomo sis as a \200\230Divine exclusion \200\231. CHAPTER 6 Upper gastrointestinal surgery 204 Indications (cid:142)(cid:3) Reconstruction after gastric resection (cid:142)(cid:3) Draina ge procedure after peptic ulcer surgery (cid:142)(cid:3) Obstructing/inoperable gastric/duo denal/pancreatic malignancy (cid:142)(cid:3) Revision of previous peptic ulcer surgery (cid :142)(cid:3) By-pass surgery for morbid obesity. Roux-en-Y reconstruction (cid:142)(cid:3) Divide the proximal jejunum just beyond the DJ fl exure. Divide the mesenteric vessels to provide a mobile well-vascularised distal segment. Create a retro -colic window in an avascular part of the transverse mesocolon. (cid:142)(cid:3) Perform a stapled oesophago-gastrostomy if reconstruction is carried out a fter total gastrectomy. Place a 2/0 Prolene purse string in the esophagus either by hand ap plication between stay sutures or by using a purse string instrument. Secure an appropriate size circular gun head (usually 28mm diameter) in place. Insert the gun into the open end of the Roux loop from the left hand side of the patient and create an end-side anastomosis taking care not to twist the mesentery or catch additional tissue in the anastomosis. (cid:142)(cid:3) Keep the blind end of the jejunum as short as possible and closed with a l inear stapler. Oversewn with 2/0 Vicryl. Occasionally, the blind end is deliberately kept l ong so as to create a side-to-side pouch reconstruction. (cid:142)(cid:3) Employ a hand sewn continuous two-layer anastomosis after subtotal gastrec tomy between the lowest part of the gastric remnant and the Roux loop using 2/0 PDS or Vicr yl. An end-side anastomosis is usually too narrow and a side-side anastomosis is preferred. (cid:142)(cid:3) Close the blind end of the Roux loop with a linear stapler and oversew it. In constructing the anastomosis this blind end is positioned on the patient \200\231s righ t hand side (in contrast to total gastrectomy) so that there is dependent drainage from the stomach. (cid:142)(cid:3) After completing the gastro-jejunostomy, secure it beneath the colon and i ncorporate closure of the window in the transverse mesocolon. (cid:142)(cid:3) Perform the distal Roux anastomosis 40 \200\22350cm distally as a side-to-end jejuno-jejunostomy using one or two layers of 2/0 PDS or Vicryl. Loop gastro-jejunostomy (cid:142)(cid:3) Identify a mobile proximal jejunal segment. The re trocolic route is the shortest and associated with the best position for drainage. (cid:142)(cid:3) Perform the anastomosis along the lower greater curve in two layers with 2 /0 Vicryl or PDS with 5 \200\22310cm of iso-peristaltic jejunum. Then secure the gastro-jej unostomy below the transverse mesocolon. This page intentionally left blank CHAPTER 6 Upper gastrointestinal surgery 206 Preoperative preparation for oesophagectomy Indications (cid:142)(cid:3) Malignancy (cid:14 2)(cid:3) End-stage benign disease (cid:142)(cid:3) Occasionally emergency resection requir ed for corrosive injury/perforation or spontaneous rupture. Staging malignant disease Endoscopy (cid:142)(cid:3) Site/size of tumor (cid:142)(cid:3) Di latation for improved nutrition (cid:142)(cid:3) Insertion of feeding naso-gastric tube (ci d:142)(cid:3) Histological diagnosis (cid:142)(cid:3) Suitability of oesophageal replacemen t (stomach/colon). Exclude distant/unresectable disease (cid:142)(cid:3) CT thorax/abdomen (cid:142)(cid:3) Endoscopic ultrasound (cid:142)(cid:3) PET scanning (cid:142)(cid:3) Bone scintigraphy (cid:142)(cid:3) Laparoscopy (cid:142)(cid:3) Bronchoscopy. Re-stage after neo -adjuvant treatment (cid:142)(cid:3) Assess fitness for surgery (cid:142)(cid:3) Full blood count/electrolytes/liver function tests (cid:142)(cid:3) Pulmonary function tests (cid:142 )(cid:3) Arterial blood gasses (cid:142)(cid:3) Exercise test (cid:142)(cid:3) ECG (cid:142 )(cid:3) Cardiological/respiratory consultation (cid:142)(cid:3) Nutritional assessment and hyperalimentation (cid:142)(cid:3) Anesthetic assessment \200\224single lung anesthesia/th oracic epidural. Preparation for surgery (cid:142)(cid:3) Stop smoking (cid:142)(cid:3) Control of dental ca ries (cid:142)(cid:3) Thrombo-embolic prophylaxis (cid:142)(cid:3) Intravenous broad-spectr um antibiotic cover (cid:142)(cid:3) Cross match four units of blood (cid:142)(cid:3) Inten sive care/high dependency bed availability (cid:142)(cid:3) Colon preparation if required f or a conduit (cid:142)(cid:3) Psychological preparation and counseling. Rationale for radical surgery and lymphadenectomy (cid:142)(cid:3) Optimal staging (cid:142 )(cid:3) Improved loco-regional control (cid:142)(cid:3) Improved cure rate. This page intentionally left blank CHAPTER 6 Upper gastrointestinal surgery 208 Left thoracic subtotal oesophagectomy Some thoracic surgeons favor this approach for lower and middle third oesophageal tumors. It is contraindicated for malignancy above the aortic arch for which a right-sided three-phase approach is required. The theo- retical advantage is that tumor operability is assessed as the initial part of the procedure, although with m odern imaging inoperability in the chest is rare. Disadvantages include poor access to the abdomen and insufficient mediastinal access to nodal tissue and the thoracic duct. Left thoraco-laparotomy Position of patient Right lateral position. Procedure Make an oblique incision from the left hypochondrium over the costal margin along the 7th rib to its posterior angle. Divide the thoracic wall muscles with diathermy and op en the pleural space at the upper border of the 7th rib. (cid:142)(cid:3) Collapse the lung . (cid:142)(cid:3) Divide the costal margin and detach the diaphragm from the ribs peripherally, avoiding phrenic nerve damage. (cid:142)(cid:3) Open the peritoneum along the main incision from rectus sheath to costal m argin and exclude distant/unresectable disease (Fig.6.3). (cid:142)(cid:3) Mobilize the esophagus and adjacent tissue from the hiatus upwards. (cid:1 42)(cid:3) Preserve the left recurrent laryngeal nerve as the esophagus is freed by blunt dissection around the aortic arch. (cid:142)(cid:3) Pass a tape around the esophagus at this point to aid retraction and dissect into root of the neck, identified by the 1st rib. (cid:142)(cid:3) Mobilize the stomach in a similar fashion to that described for the abdominal Lewis-Tanner approach (see following section). (cid:142)(cid:3) Divide the gastro-splenic, gastro-colic and gastro-hepatic ligaments with preservation of the right gastric and gastro-epiploic vessels. (cid:142)(cid:3) Ligate the left gastric vessels and divide separately and carry out a pyloroplasty. (cid:142)(cid:3) Kocherise the duodenum to gain length. (cid:142)(cid:3) Divide the upper e sophagus above the aortic arch after stay sutures have been applied. (cid:142)(cid:3) Divide the proximal stomach with a linear stapler across the lesser curve towards the fundus to create a gastric tube and deliver the specimen. (cid:142)(cid:3) Oversew the gastrotomy line with 2/0 PDS. (cid:142)(cid:3) Pass the high p oint of the fundus up to the apex of the thorax and suture it to the oesophageal stump. (cid:142)(cid:3) Repair the diaphragm and costal margin with continuous 1 Nylon. (cid:142)( cid:3) Insert apical and basal underwater seal chest drains and re-expand the lung. (cid:142)(cid:3) Approximate the ribs with interrupted 0 Vicryl and close the muscle in layers with 1 PDS and clips to skin. LEFT THORACIC SUBTOTAL OESOPHAGECTOMY1 209 Left cervical incision Mobilize the esophagus as previously described and fashion an end-to - side oesophago-gastric anastomosis with interrupted 2/0 PDS. Insert a 24Fr Wallace \200 \223Robinson drain adjacent to the anastomosis. Close the wound in layers with 2/0 Vicryl a nd subcutaneous 3/0 Monocryl to skin. Spleen Lung Coeliac axis Left gastric artery Fig. 6.3 Thoraco-abdominal approach for lower-third oesophageal carcinoma CHAPTER 6 Upper gastrointestinal surgery 210 Transhiatal oesophagectomy Rationale Transhiatal oesophagectomy has fewer pulmonary complic ations when com- pared to the transthoracic approach, although with no significant reductio n in mortality. The esophagus is resected by blunt dissection with anastomosis of the condu it through a neck incision. Major blood loss can occur and there is sub-optimal lymphadenec tomy producing a higher local recurrence rate. Modern retractors facilitate more dissection under direct vision and many thoracic surgeons favor this approach, particularly for benig n disease. Abdominal phase Exclude distant or unresectable disease through a midline incisi on. Carry out routine gastric or colonic mobilization as previously described to allow tens ion free passage up to the neck. Divide the phreno-oesophageal liga- ment. Mobilize the low er 5 \200\22310cm of esophagus and tumor checking that there is no fixation to the aorta or tracheo-bronchial tree. Stop the mediastinal dissection and perform a pyloroplasty. Cervic al phase (cid:142)(cid:3) Make a 5cm oblique left cervical incision parallel to the sterno-cleidomastoid centered at the level of the cricoid cartilage. (cid:142)(cid:3) Divid e the platysma and omohyoid and ligate the inferior thyroid ar- tery and divide it. (cid:142)(cid:3) Retract the carotid sheath laterally and the larynx and trachea medially avoiding damage to the recurrent laryngeal nerve in the tracheo- oesophageal groove. (cid:142)(cid:3) Mobilize the esophagus posteriorly by blunt dissection from the pre-verteb ral fascia into the superior mediastinum. Dissect the esophagus free by sharp dissection fr om the trachea avoiding damage to the posterior membranous aspect. Once encircled with a sl ing, the cervical and upper thoracic esophagus can be mobilized to the level of the carina by further blunt dissection. Mediastinal phase (Fig. 6.4) (cid:142)(cid:3) Now pass a hand through the hiatus and free t he esophagus by blunt finger dissection. Carry out sequential division of the posterior attachment to the a orta and the anterior connection to the tracheo- bronchial tree. Finally, mobilize the esop hagus from its lateral pleural adhesions. Much of this can be achieved under direct vision with adequate retraction and synchronous dissection from the neck. (cid:142)(cid:3) If ther e is uncontrollable blood loss pack the area and convert to an open thoracotomy. (cid:142)(cid:3) Penetration of either pleural space necessitates tube thoracotomy. (cid:14 2)(cid:3) Divide the proximal esophagus in the neck and suture a drain to the distal cut en d and bring this out in the abdomen. Then excise the specimen and prepare the colonic or ga stric conduit, suturing it to the drain and passing it up into the neck. Anchor the conduit to the pre-vertebral fascia in the neck. (cid:142)(cid:3) Insert a feeding jejunostomy and close the abdomen with 1 PDS and clips to skin. TRANSHIATAL OESOPHAGECTOMY1 211 Anastomosis (Fig. 6.4) (cid:142)(cid:3) Fashion an end-to-end oesophago-gastric or oesophag o-colic anastomosis with interrupted 2/0 PDS as previously described. (cid:142)(cid:3) Insert a 24Fr Wallace \200\223Robinson drain adjacent to the anastomosis a nd close the wound in layers with 2/0 Vicryl and subcutaneous 3/0 Monocryl to skin. A B Fig. 6.4 Transhiatal mobilization of esophagus CHAPTER 6 Upper gastrointestinal surgery Abdominal & right thoracic subtotal oesophagectomy Abdominal and right thoracic subtotal oesophagectomy This is the Ivor Lewis or Lewis \200 \223Tanner procedure, commonly used for middle and lower third of the oesophageal tumors. R econstruction is usually carried out with a gastric pull-up anastomosed at the apex of the thorax. 212 Abdominal phase Position of patient Supine. Procedure (cid:142)(cid:3) Exclude distant and unresectable disease via an upper midline in cision. Use modern fixed retracting devices to enhance gastric and hiatal exposure. (cid:142)(cid:3) Mobilize the stomach as previously described with preservation of the righ t gastric and gastro-epiploic vessels. Carry out a varying degree of lymphadenectomy. No dr ains are usually required. Close the abdomen with mass closure with 1 PDS and clips to skin . Thoracic phase Position of patient Left lateral position. Procedure (cid:142)(cid:3) Perform a postero-lateral thoracotomy with diathermy. Retract th e inferior aspect of the scapula upwards and enter the thorax through the 5th or 6th interc ostal spaces (the 2nd rib is at the apex of the sub- scapula space). Divide the intercostal muscles above the rib and col- lapse the lung. Excise the neck of the lower rib to allow a controlled fracture and better exposure. Ligate the intercostal vessels and destroy the ne rve to decrease postoperative pain. (cid:142)(cid:3) Exclude distant or unresectable disease. Divide the right pulmonary ligament up to the inferior pulmonary vein. Ligate the arch of the azygous vein and divide it in continuity with 2/0 Vicryl. Develop the plane be- tween the azygos vein and the aorta with en bloc excision of the thoracic duct and para-aortic nodes. Ligate oesophageal aorti c branches with 3/0 Vicryl and skeletonise the antero-lateral descending thoracic aorta. Di s- sect the esophagus medially from the lung hilum and pericardium taking all nodes en bloc . Pass a tape around the esophagus to aid retraction. Expose proximally the right and left main bronchi with en bloc excision of carinal, bronchial, and para-tracheal nodes, avoiding damage to the posterior membranous aspect of the tracheo-bronchial tree. (cid:142)(cid:3) Ligate the thoracic duct just above the diaphragm to prevent chylotho- rax . Excise para-oesophageal tissue en bloc with mediastinal pleura posteriorly and inferiorly , exposing the left lung. Continue oesophageal mobilization to meet the trans-abdominal dis section (Fig. 6.5A, B). Divide the final pleural attachments to allow entry of the stomach into the thorax. ABDOMINAL & RIGHT THORACIC SUBTOTAL OESOPHAGECTOMY1 213 (cid:142)(cid:3) Withdraw the NG tube. Apply oesophageal stay 2/0 Vicryl sutures and transe ct the esophagus at the apex of the thorax. Divide the proximal stomach along the lesser cu rve with associated abdominal nodes and fashion a gastric tube. Carry out a gastro-oesophag eal anastomosis as previously described (Fig. 6.5C). (cid:142)(cid:3) Insert apical, basal and left pleural (sometimes) underwater seal drains. Approximate the ribs and close the wound with interrupted 0 Vicryl. Close the muscle in two layers with 1 PDS and apply clips to skin. A B C Fig. 6.5 Right thoracic resection of the esophagus with gastric interposition CHAPTER 6 Upper gastrointestinal surgery 214 Three stage oesophagectomy Some surgeons prefer to expose/divide and anastomose the esophag us in the neck. The additional resection of the esophagus is not much more than that achiev ed by the Ivor Lewis technique although this tech- nique is required for proximal tumors so that an adequate proximal resection margin can be achieved. The procedure is commonly refe rred to as a \200\230McKeown \200\231 oesophagectomy. It involves the same initial approac h as an Ivor Lewis oesophagectomy but with complete dissection of the thoracic esophagus up to the thoracic inlet. The additional of a left or right neck approach is then carried out for the additional resection. In Japan a bilateral cervical approach is employed for middle third and upper third squamou s cell carcinomas in order to perform radical cervi- cal lymphadenectomy. This latter appro ach is seldom used in the West based upon the lower incidence of cervical nodal disease for lower third adenocarcinomas and the associated additional morbidity mainly from recurrent laryngeal nerve injury. Carcinoma of the hypopharynx and upper cervical esophagus are usually dealed with by head a nd neck surgeons employing a pharyngo- laryngo-oesophagectomy with free jejunal graft inter position. This page intentionally left blank CHAPTER 6 Upper gastrointestinal surgery 216 Gastric interposition as an oesophageal substitute Indication The stomach is usually the fi rst choice as an oesophageal substitute. It is well vascularised, simple to mobilize into t he thorax or neck with good functional results. Additionally, only one anastomosis is requi red. It is common to use the posterior mediastinal route through the oesophageal bed. Retro -sternal (anterior mediastinal) or pre-sternal (subcutaneous) routes are longer, non-anatom ical and seldom employed. Incision Upper midline. Procedure (cid:142)(cid:3) Exclude distant or unresectable disease. (cid:142)(cid:3) Retrac t the greater omentum/transverse colon from the stomach and divide the gastro-colic omentum below the right gastro-epiploic arcade centrally, entering the lesser sac. Continue dissection towards the fun- dus and left gastro-epiploic pedicle a nd then inferiorly to expose the origin of the right gastro-epiploic vein after division of the crossover vessel to the middle colic vein. Separate the hepatic flexure from the duode num and Kocherise it to the midline exposing the IVC and aorta. This allows the pylorus to swing up to the hiatus providing maximum gastric length. (cid:142)(cid:3) Divide the lesser omentum close to the liver and preserve the right gastric artery inferiorly as it emerges from the common hepatic artery. Ligate the hepatic branch of the vagus as there may be a significant as- sociated vessel. Preserve any large a berrant hepatic artery. Now divide the gastro-splenic ligament, ligate the short gastric ve ssels away from the fundus with 3/0 Vicryl. Elevate the stomach and divide the lesser sac a dhesions over the pancreas. Ligate the left gastric vein in continu- ity with 3/0 Vicryl an d divide it. Divide the origin of the left gastric artery and transfix it with 3/0 Vicryl. Carry out an en bloc partial D2 nodal clearance of the left gastric, common hepatic and spl enic arter- ies. Resect the coeliac nodes with skeletonisation of the abdominal aorta up to the hiatus. Take the crura and cuff of diaphragm en bloc with the esophagus. Carry out fur ther transhiatal dissection into each pleural space to allow the correct planes for thoraci c en bloc excision of the mediastinal pleura. (cid:142)(cid:3) The stomach should now be completely mobile. Carry out a Heineke \200\223Mikulicz pyloroplasty with interrupted Gambee 2/0 Vicryl sutures. Skeletoni se the lesser curve in the abdomen by dividing the lesser omentum and left gastric tissue a bove the right gastric pedicle. It is common practice to fashion a feeding jejunostomy. Clo se the abdomen with monolayer PDS. GASTRIC INTERPOSITION AS AN OESOPHAGEAL SUBSTITUTE1 217 (cid:142)(cid:3) Once resection of the esophagus is complete, pull the stomach through to the apex of the thorax or neck for anastomosis. Depending on the extent of gastr ic involvement, excise a varying degree of the lesser curve and proximal stomach to create a gastric tube. Perform the anastomosis in the posterior fundus at the high point of the st om- ach, well away from the resection line to ensure no compromise of blood supply as previ ously described. CHAPTER 6 Upper gastrointestinal surgery 218 Colonic interposition for oesophageal replacement Indications (cid:142)(cid:3) When the sto mach is absent, rendered ischaemic, or damaged by caustic injury (cid:142)(cid:3) Where tumor extent requires resection of whole stomach (cid:142)(cid:3) Fo r extra-anatomical bypass (sub-sternal or subcutaneous routes) (cid:142)(cid:3) Surgical pr eference (particularly vagal preserving procedures). Preoperative preparation (cid:142)(cid:3) Colonoscopy to exclude inflammatory bowel disease /severe diverticulosis/malignancy or multiple polyp formation (cid:142)(cid:3) Mesenteric angiography to assess adequacy/pattern of colonic blood supply and identify which section of colon to use (usually an iso- peristaltic left colonic segmen t based upon the left colic pedicle) (cid:142)(cid:3) Colonic preparation with Picolax/Kleenprep. Position of patient Supine. Incision Long midline. Procedure (cid:142)(cid:3) Exclude distant or unresectable disease and detach the omentum f rom the transverse colon. Mobilize the splenic and hepatic flexures and the ascending and d escending colon to the midline so that the whole colon is free on its mesentery. Bring the apex of the left colonic loop based upon the ascending branch of the left colic artery to t he xiphisternum and marked it with a 2/0 Vicryl stitch. Measure the distance from the xiphi sternum to the mandible and mark this length proximal to the first stitch, usually at the s plenic flexure. Ligate the marginal vessels and di- vide them at this point. Divide the tra nsverse mesocolon by ligating the middle colic pedicle below its bifurcation to preserve an y arcade. (cid:142)(cid:3) Prepare the site of the proximal oesophageal anastomosis (usually in the l eft neck) and divide the right colon with a linear stapler. Tie the resec- tion line to a l ong drain and insert the colon into a bowel bag for atraumatic traction up into the neck. P erform the proximal anastomosis with interrupted 2/0 Vicryl full-thickness sutures. Straigh ten the colon without mesenteric twisting and secure it inferiorly to the diaphragm. COLONIC INTERPOSITION FOR OESOPHAGEAL REPLACEMENT1 219 (cid:142)(cid:3) Now divide the distal colon 10cm below the diaphragm. If the vagi are divi ded and the stomach denervated then a better functional outcome is gained by an additional proximal two thirds gastrectomy and end-to- end colo-gastric anastomosis to the antrum in t wo layers with 2/0 PDS (Fig. 6.6). Carry out a Heineke \200\223Mikulicz pyloroplasty. If a vagal preserv- ing procedure has been performed then the stomach is retained with a posteri or end-to-side colo-gastric anastomosis using a circular stapling device through a small an terior gastrotomy. Insert an NG tube in ei- ther event. Restore colonic continuity with an end-to-end colo-colic anastomosis in two layers with 2/0 PDS. Insert a feeding jejunostomy for nutritional support. Colo-oesophageal anastomosis Colo-gastric anastomosis Colo-colic anastomosis Fig. 6.6 Right colonic interposition from cervical esophagus to antrum with colo- colic ana stomosis CHAPTER 6 Upper gastrointestinal surgery 220 Oesophageal anastomosis after subtotal oesophagectomy The oesophageal remnant is anastomose d to the conduit used for recon- struction, usually stomach or occasionally colon. Jejunum is rarely used for replacement except as free graft after pharyngo-laryngo- oesophagectomy for hypo-pharyngeal and proximal cervical tumors. Oesophago-gastric or oesophago-colic anastomoses are hand sewn or stapled in the neck or up per thorax. The outcome is similar and surgical preference/approach dictates the selection of anastomotic technique. Cervical anastomoses have a higher leak rate, although a neck lea k may not produce as severe clinical consequences as an intra-thoracic leak. Circular stapl ed anastomoses produce a higher stricture rate than sutured anastomoses, particularly if gu ns smaller than 25mm are used. Irrespective of technique, anastomoses should be tension-fre e, have good blood supply with close application of epithelial margins. Trauma from non-cru shing clamps should be avoided. Stapled oesophageal anastomosis (cid:142)(cid:3) Prepare the oesophageal remnant by NG tube withdrawal, aspiration, and insertion of a 2/0 Prolene purse string. Pass a double-ended straight needle suture thr ough a purse string clamp (Fig. 6.7) applied across the esophagus before transection. Divid e the esophagus close to the margin of the clamp. Alternatively, use a small round- bodied needle to place the Prolene purse string by hand at 5 \200\2237mm intervals with 5mm bites circumferentially, the esophagus being held open by multiple full thickness 2/0 Vicryl stay sutures. Insert the head of the gun and the purse string secured around its neck (Fig. 6.8 ). (cid:142)(cid:3) If a gastric tube is used, insert the staple gun through the proximal r esec- tion margin and site the anastomosis posteriorly at the high point of the stomach, aw ay from the gastrotomy line so as not to compromise the blood supply. Pass the spike throug h and secure the gastric wall with a 2/0 Vicryl purse string suture around the neck of the gun. After firing the gun inspect the completeness of the donuts (Fig. 6.9). Advance the NG tube and close the gastrotomy line with a linear stapler and oversew it with 2/0 PDS. Vari ations of this approach can be used to produce end-to- end or end-to-side oesophago-colic a nastomoses in the thorax or neck. Sutured oesophageal anastomosis (Fig. 6.10) (cid:142)(cid:3) The simplest approach is a sin gle layer of interrupted full-thickness 2/0 Vicryl or PDS sutures. (cid:142)(cid:3) First form the gastric tube completely and make a 2cm incision at the site where a stapled anastomosis would be fashioned. Place lateral stay sutures and suture the posterior wall initially with the knots internally. In the thorax the whole row is plac ed first and then the esophagus parachuted down with sequential ligation of the sutures. Th en com- plete the anterior row with knots externally and avoid redundant tis- sue from size discrepancy. A similar technique can be used to fashion end-to-end oesophago-colic anastom oses. OESOPHAGEAL ANASTOMOSIS AFTER OESOPHAGECTOMY1 221 Oesophageal anastomosis after oe- sophagectomy Fig. 6.7 Purse string clamp across the esophagus 5 \200\2236cm proximal to the tumor Fig. 6.8 Staple gun in the gastric conduit with the staple head in the proximal cut end of the esophagus CHAPTER 6 Upper gastrointestinal surgery 222 Fig. 6.9 Gastric and oesophageal donuts with the staple head Fig. 6.10 Sutured oesophago-gastric anastomosis This page intentionally left blank CHAPTER 6 Upper gastrointestinal surgery 224 Complications following oesophagectomy Early complications (cid:142)(cid:3) Hemorrhage (cid :142)(cid:3) Pneumonia/acute respiratory distress syndrome (ARDS) (cid:142)(cid:3) Pneumoth orax/pleural effusion (cid:142)(cid:3) Thrombo-embolic complications (cid:142)(cid:3) Anast omotic leak (cid:142)(cid:3) Chylothorax (cid:142)(cid:3) Recurrent laryngeal nerve palsy ( cid:142)(cid:3) Gastric outlet obstruction (if no pyloroplasty performed) (cid:142)(cid:3) Mortality (5 \200\22310%). Late complications (cid:142)(cid:3) Anastomotic stricture (particularly for stapled anastom oses) (cid:142)(cid:3) Post-thoracotomy pain (cid:142)(cid:3) Dumping (cid:142)(cid:3) Post -vagotomy diarrhea (cid:142)(cid:3) Reflux (cid:142)(cid:3) Cancer recurrence (loco-regiona l and/or metastatic). Chapter 7 225 s7 Colorectal surgery, appendix, and small bowel A. K. Agarwal, J. Shenfine, H. El-Khalifa, and David J. Leaper Fissure-in-ano 226 Hemorrhoi ds 228 Fistula-in-ano 234 Pilonidal sinus 238 Rectal prolapse 240 Acute anorectal infection (abscess) 244 Appendicectomy 246 Excision of Meckel \200\231s diverticulum 252 Ileostomy 2 54 Colostomy 260 Bowel resection and anastomosis 264 Right hemicolectomy 270 Left hemicolec tomy 274 Transverse colectomy 280 Sigmoid colectomy 282 Total colectomy 284 Anterior resect ion 286 Proctocolectomy and ileostomy 292 Abdomino-perineal excision of rectum 294 Restorat ive proctocolectomy 298 Hartmann \200\231s procedure 300 Procedures for large bowel obstruc tion 302 CHAPTER 7 Colorectal surgery 226 Fissure-in-ano A linear ulcer occurring below the dentate line. May be due to increase in a nal resting pressure from overactivity of the internal anal sphincter causing hypoperfusion and fissuring at sites of \200\230watershed \200\231 vascular supply. They occur in the a nterior and posterior midline and are more common in the posterior midline. Consider possib le underlying pathology such as Crohn \200\231s disease, infection, trauma, or malignancy. Use of bulk laxatives, stool softeners, and topical application of local anesthetic assist in the spontaneous healing of most acute fissures. Topical glyceryl trinitrate 0.2% or Dilt iazem 2% applied locally, reduce anal pressure and achieve healing in 50 \200\22370% of all fissures. Lateral internal sphincterotomy Indication Surgery is indicated when medical therapy fails. Anal dilatation has been abandoned in favor of lateral internal sphincterotomy because the latter process is more controlled and incontinence is less common. Position of patient Lithotomy. Procedure This is done as a day procedure under general anesthesia. (cid:142)(cid:3) Perfor m a digital rectal examination and sigmoidoscopy. (cid:142)(cid:3) Introduce a bivalve anal speculum. Open it gradually to put the fibers of the internal sphincter on the stretch. (cid:142)(cid:3) Ask the assistant to apply traction to perianal skin. (cid:142)(cid:3) Pal pate the intersphincteric groove in the 3 o \200\231clock position. (cid:142)(cid:3) Infilt rate local anesthetic with 1:200 000 adrenaline in the groove and make a 1cm incision along the groove. (cid:142)(cid:3) The lower border of the internal sphincter is identified as a white band. Using blunt ended scissors develop the intersphincteric and submucosal planes. Divide the i nternal sphincter to the level of the dentate line. (cid:142)(cid:3) Excise any skin tag or hypertrophied internal papilla. (cid:142)(cid:3) Ap ply pressure to achieve haemostasis. Leave the wound open. Flap repairs may be used for rec urrent fissure after sphincterotomy and where risk to continence is high. Postoperative complications (cid:142)(cid:3) Incontinence (cid:142)(cid:3) Recurrence/persi stence (cid:142)(cid:3) Bleeding/haematoma. FISSURE-IN-ANO1 227 Fig. 7.1 Lateral internal sphincterotomy Divided internal sphincter Posterior fissure Fig. 7.2 Lateral internal sphincterotomy: technique and result CHAPTER 7 Colorectal surgery 228 Hemorrhoids Degeneration of the supporting structures of the three anal cushions causes the m to prolapse leading to development of hemorrhoids. The majority of patients present with intermittent, small rectal bleeds and require no treatment other than reassurance and dieta ry advice but thorough evaluation is necessary to exclude other pathologies such as inflamm atory bowel disease and malignancies. Examination should include inspection of the perineum , digital rectal examination, proctoscopy and sigmoidoscopy, and full colonic examination m ay be required by colono- scopy or barium enema. Injection sclerotherapy Indication Persist ent haemorrhoidal bleeding or small anterior mucosal prolapses. The aim of the procedure is to cause submucosal fibrosis. Position Left lateral. Procedure Done as an outpatient proce dure. (cid:142)(cid:3) Draw up 10 \200\22315ml of 5% phenol in almond oil into a Luer lock syringe with a shouldered Gabriel needle. (cid:142)(cid:3) Pass a proctoscope and identify the left lateral, right anterior, and righ t posterior internal hemorrhoids. (cid:142)(cid:3) Inject 3 \200\2235ml of the solution under vision into the submucosa above each haemorrhoid. The correct plane of injection is indicated by elevation of the mucosa. Review the patient at six weeks and repeat the procedure if necessary. Rubber band ligation Indication Persistent haemorrhoidal bleeding and prolapsing. The aim of the procedure is t o fix the mucosa thereby preventing prolapse. Contraindication Anticoagulation and immunoco mpromise. Position Left lateral. Procedure Done as an outpatient procedure. (cid:142)(cid:3 ) Pass a proctoscope and identify the internal hemorrhoids. Non-suction banders require an assistant to keep the proctoscope in position. (cid:142)(cid:3) Grasp the mucosa above the haemorrhoid and draw it into the barrel of the loaded ligator. Suction banding frees the surgeon \200\231s left hand to hold the proctosco pe in position whilst applying suction to draw the mucosa into the bander. It is important to make sure before releasing the band that the grasping or suction on the mucosa does not cause pain. If it does, apply the banding to a more proximal position above the anorectal r ing. hemorrhoids1 229 Fig. 7.3 Equipment for injection sclerotherapy Fig. 7.4 Equipment for rubber band ligation Site for injection/rubber band ligation Fig. 7.5 Site for injection/rubber band ligation CHAPTER 7 Colorectal surgery 230 Warn the patient that it is usual to feel some rectal discomfort and a desire to defaecate for the next 2 \200\2233 days and that a small amount of bleeding or the passage of a \200 \230blackberry-like \200\231 thrombosed pile is common between 4 \200\22310 days. Review th e patient at six weeks and repeat the procedure if necessary. Haemorrhoidectomy Indication (cid:142)(cid:3) Prolapsing hemorrhoids with symptomatic external hemorrhoids (pain, swelling). (cid:142)(cid:3) Second degree hemorrhoids (reduce spontaneously) and third degree hemorrho ids (needing to be reduced manually) that do not respond to out-patient procedures. (cid:142)(cid:3) Fourth degree hemorrhoids (which remain prolapsed permanently). Position L ithotomy or prone jack-knife with general anesthetic. Procedure Usually done as an inpatient. (cid:142)(cid:3) Prepare the skin, towel up and sha ve the perineum. Insert a bivalve anal speculum and assess the position and size of the hem orrhoids. Start with the most posterior lying haemorrhoid so that blood does not obscure vi sion. (cid:142)(cid:3) Apply artery forceps to the skin at the edge of the external haemorrhoid a nd incise the skin with cutting diathermy. (cid:142)(cid:3) Continue the dissection medially with diathermy and insert the bivalve speculum once the anal margin is reached. (cid:142)(cid:3) Continue to carefully separate the internal haemorrhoidal tissue from the white internal sphincter muscle fibers using diathermy. (cid:142)(cid:3) Achieve haemos tasis with diathermy during this dissection. (cid:142)(cid:3) Divide mucosa at the apex of the haemorrhoid with diathermy or by transfixing with 2/0 Vicryl. (cid:142)(cid:3) Repeat the procedure to excise the hemorrhoids in other positions, taking care to keep skin bridges between excisions to avoid anal stenosis. During the operation re peatedly remove and reinsert the speculum to avoid overstretching the sphincter. (cid:142)(cid:3) At the completion of the procedure an anal pack is not required. Stool softeners may aid postoperative pain. Perform digital rectal examination and proctoscopy 4 \200\2236 weeks after discharge. The above description is of an open technique using diathermy. In the closed technique the skin edges and the mucosa are sutured together. Postoperative complications (cid:142)(cid:3) Incontinence/major incontinence (cid:142)(cid: 3) Acute urinary retention (cid:142)(cid:3) Recurrence/persistence (cid:142)(cid:3) Stenosi s (cid:142)(cid:3) Bleeding/haematoma. hemorrhoids1 231 Haemorrhoid dissected off the internal sphincter Internal sphincter muscle fibers Fig. 7.6 Haemorrhoidectomy CHAPTER 7 Colorectal surgery 232 Circular stapled haemorrhoidectomy (see also p366) A new technique where a circular staplin g device introduced per-anally is used to excise a rim of rectal mucosa above the hemorrhoi ds. The result is the prolapsed haemorrhoidal tissue is drawn back into a more physiologica l position and its blood supply is interrupted. The procedure claims to be less painful and allows rapid post operative recovery. Perianal haematoma Haematoma due to rupture of an anal venule. Surgery is indicated if the patient presents early with a painful lump. Incise the skin over the swell- ing and evacuat e the clot. This can be done under local or general anesthesia. Thrombosed or strangulated hemorrhoids Conservative treatment is usually successful. Immedi ate surgery, if under- taken, should be under antibiotic cover and carried out by an experi enced surgeon. hemorrhoids1 233 Prolapsed mucous membrane drawn into the casing Fig. 7.7 Circular stapled haemorrhoidectomy \200\224insertion of stapling device Staple line Fig. 7.8 Circular stapled haemorrhoidectomy \200\224final result CHAPTER 7 Colorectal surgery 234