Transhiatal Esophagogastrectomy with Colonic Interposition

Abstract

Indications • Carcinoma of the esophagus and end-stage benign conditions where gastric conduit is not available/suitable • Salvage operation for prior failed esophageal replacement Contraindications • Colonic malignancy or extensive diverticulosis • Extensive diverticulosis and active diverticulitis Essential Steps 1. Upper midline abdominal incision and abdominal exploration. 2. Identify the segment of the colon for reconstruction and assess the mesenteric vessels. 3. Measure the length of the colon needed for interposition (from the left ear lobe to the xiphoid process using an umbilical tape). 4. Divide colon and mobilize mesenteric pedicle. Transhiatal esophagogastrectomy 5. Divide the gastrocolic ligament and divide the gastroepiploic and short gastric vessels to mobilize the greater curvature for subtotal versus total gastrectomy. 6. Assure adequate lymphadenectomy for carcinoma. 7. Divide the gastrohepatic ligament and divide the left/right gastric vessels to mobilize the lesser curvature. 8. Dissect hiatus and circumferentially mobilize the distal esophagus within the media stinum. 9. Perform cervical incision along the sternoclei-domastoid muscle and divide strap muscles. 10. Perform transhiatal mobilization of the intra-thoracic esophagus. 11. Mobilize and divide cervical esophagus. 12. Divide distal stomach/duodenum to complete gastrectomy and remove entire specimen. 13. Gastric drainage procedure (pyloromyotomy or pyloroplasty) or Botox injection to prevent delayed emptying. Colonic reconstruction 14. Deliver the conduit in an isoperistaltic fashion into the neck. 15. Perform stapled/sutured esophagocolonic anastomosis.