Laparoscopic Transhiatal Esophagectomy For Esophageal Cancer
Traditional esophagectomy may be associated with mortality, considerable morbidity, and lengthy recovery. It is often performed in cancer patients who are typically older, have associated comorbidities, and are often malnourished, all factors that increase surgical risk. Minimally invasive esophagectomy has the potential advantages of being a less traumatic procedure with an easier postoperative recovery and fewer wound and pulmonary complications.
Laparoscopic esophagectomy and gastric pull-up for cancer or esophageal trauma have been reported as challenge but safe procedures that reproduce results of open surgery by several authors. A laparoscopic tailoring of a gastric tube with transhjatal mediastinal dissection and gastric pull-up was performed in a young psycotic man referred for rupture of the cervical esophagus caused by large foreign bodies ingestion and clinical signes of mild mediastinitis.
Methods : -A 2-stage procedure was performed. On emergency removal of the foreign bodies, double cervical esophagostomy and drainage were performed via a left lateral cervicotomy. After a 7 day ICU stay and complete recovery from the mediastinitis the patient underwent laparoscopic esophagectomy and gastric pull-up for reconstruction. All vascular pedicles but the gastroepiploic arch were divided. Stomach mobilisation was accomplished by ultrasonic dissection, the gastric tube fashioned by multiple linear stapler applications.
The hjatus was widened according to Pinotti and the dissection of the esophagus carried out bluntly and by ultrasonic dissection up to the Azygos vein level. The dissection of the upper esophagus was completed from the neck and the esophago-gastric anastomosis accomplished according to Orringer.
Results : -Postop course was uneventful. X-ray contrast swallow at postop day 9 showed good passage of contrast medium without leaks. Oral intake started right afterward. At 6-month and 12-month follow-up the patient was completely recovered with regular oral diet.
Conclusion : -Whatever the approach to mediastinal dissection of the esophagus, the laparoscopic tailoring of the stomach tube is a safe and advisable procedure for both cancer and trauma patients.
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