Esophageal cancer resection

There are various surgical methods for esophageal cancer. The surgical approach, the anastomosis method, the choice of incision site and the position are not the same, each has its own advantages and disadvantages. A representative procedure combining endoscopic techniques with traditional esophageal surgery is VATS esophageal cancer resection. This operation was performed by thoracoscopic surgery to complete the thoracic esophageal free and lymph node dissection, free gastric and rupture of the esophagus by laparoscopic or abdominal incision, and esophageal and gastric anastomosis through the neck incision. VATS esophageal cancer resection has the common advantage of thoracoscopic surgery, and VATS esophageal cancer resection is feasible as a surgical method. However, VATS can not be used to replace conventional open thoracic esophageal cancer resection. The indications are mainly limited to some patients with early esophageal cancer and cardiopulmonary dysfunction who cannot tolerate thoracotomy. Treating diseases: esophageal cancer Indication After diagnosis of early esophageal or cardiac cancer, and part of the third stage of lower esophageal cancer, the lesion is long within 5cm, the general condition is still good, no distant metastasis, no serious damage to heart, lung, liver and kidney function or other Patients with surgical contraindications should actively seek surgical treatment, and those who are over 70 years old should be strictly selected. Esophageal cancer resection is applicable to: 1, early esophageal cancer is most suitable for thoracoscopic surgery. 2. Certain intermediate esophageal cancer (stage IIA). 3, some cardiopulmonary function can not tolerate patients with stage IIB or stage III esophageal cancer with conventional thoracotomy. Preoperative preparation In principle, it is the same as the preoperative preparation of other chest surgery, but the following issues should be emphasized: 1, for early esophageal cancer, such as x-ray sputum esophageal examination can not be affirmed or negative, should be done esophagoscopy to confirm the diagnosis. 2, for ECG examination and heart, lung, liver, kidney function tests. If heart, lung, liver or kidney dysfunction is present, extended surgery or other morning surgery should be considered depending on the condition and prognosis. 3, patients with hypertension, should be given short-term preparation of antihypertensive drugs, so that blood pressure as normal as possible. 4. If there is fluid and electrolyte imbalance, it should be corrected before surgery. 5, significantly anemia or malnutrition, a small number of multiple blood transfusions, so that hemoglobin increased to more than 109%. 6, for patients with severe esophageal obstruction, 3 days before surgery, the stomach tube should be inserted into the esophagus every night, rinse with warm water; if the obstruction is not heavy, drink 2 cups of warm water every night. 7. Give antibiotics 1 to 2 days before surgery. Surgical procedure 1, position, incision: right side lying, left chest posterolateral incision, resection of the sixth rib, can cut the fifth rib posterior segment at the same time, through the ribbed bed into the chest. 2. Exploring the tumor: The lungs are pulled forward and inward, and the posterior mediastinum is revealed. The size, activity, relationship with the surrounding organs, and local lymph node metastasis are carefully examined. If the tumor has invaded the hilar organ or aorta, or has a wide range of lymph node metastasis, it is not suitable for resection. If the tumor has a certain degree of activity, and there is no such sign, the longitudinal pleura is cut longitudinally, the lower ligament of the lower lung is separated, and the finger is inserted into the mediastinal incision to try to provoke it; if the lump moves with the finger, and can be in the lung The sliding between the door and the aorta and the spine indicates that the tumor has not been invaded, and can be removed; if the degree of activity is not obvious, the finger can be used to detect the relationship with the surrounding organs in the mediastinum, and if some gaps are still found, It is possible to indicate that the resection is performed. It is preliminarily believed that after the possibility of resection, the finger is used to explore the esophagus under the tumor site, and the esophagus is hooked out, and the soft rubber tube (preferably without a tape) is used for traction. Usually, from the diaphragm, in the future, the esophageal branch of the aorta will be separated and ligated, and then cut off 1 or 2, so that the tumor is partially separated, which is convenient for exploration and further clarification. This separation should be adequate. If the tumor is completely isolated at the beginning, it may be found that the abdominal cavity has been widely metastasized after the incision of the diaphragm, indicating that the tumor has not been used, but the tumor has been completely separated, the blood supply of the esophagus has been broken, and it has to be forced to undergo an ineffective resection. 3, incision of the diaphragm: between the liver and spleen with two tissue forceps lift the diaphragm, cut between the two clamps, and then extend in the radial direction, the front end to the near rib arch, the back end points to the esophageal hiatus. In order to reduce bleeding and avoid damage to the underarm organs, use your fingers to guide and lift them up while cutting, and cut the edges to stop bleeding. At the proximal hole, there is a branch of the infraorbital artery, and the thick wire should be used for 8-slot sewing one by one. A few stitches are left on both sides of the incision as traction. Then reach into the abdominal cavity to explore the bottom of the stomach, stomach curvature and small bend, liver, spleen, left gastric artery and abdominal aorta, omentum, mesentery and pelvic lymph node metastasis or tumor transplantation. If the transthoracic and abdominal exploration can be removed or palliative surgery, the diaphragmatic incision can be enlarged and the esophageal hiatus can be cut. 4, separate esophagus (1) Separation range: The esophagus is gradually separated from the bottom to the top of the tumor. All esophagus below the tumor and at least 5 cm long esophagus above the upper edge of the tumor should be separated and excised. Lymph nodes visible in the left lower ligament, hilar and esophageal tissue should be removed along with the esophagus. (2) Separation of tumors: The branch of the esophageal artery from the descending aorta and bronchial artery should be cut off between the two hemostatic forceps or the ligatures at both ends. Subsequent separation of the fibrous tissue surrounding the esophageal tumor continues to completely free the tumor site. (3) Avoid damage to the right pleura: When separating the tumor, avoid damage to the right pleura. If you accidentally tear the right pleura, you should suture it in time. However, if the tumor has invaded the right pleura or the right lung and needs to be partially removed, the right pleura does not need to be sutured, and the breathing control can be strengthened in time, and the gauze is temporarily inserted into the hole to prevent the blood from being inhaled into the contralateral chest cavity. If there is no tumor on the right side, but the pleural rupture is large and difficult to suture, it can also be temporarily filled with gauze. At the end of the operation, the gauze is taken out and opened for bilateral chest drainage or drainage only to the left chest. (4) Treatment of thoracic duct: The thoracic duct is located in the left posterior esophagus and below the aortic arch, between the descending aorta and the azygous vein. If it adheres to the tumor, it should be removed together with the esophagus, and the two ends of the esophagus should be double-ligated with thick wires. . If the chest is inadvertently damaged by surgery, it is also necessary to be firmly connected to avoid the leakage of milk from the rash and threaten life. (5) Separation of the esophagus behind the aortic arch: When separating, the lung can be atrophied and pulled forward and downward to reveal the top of the chest. The lower part of the esophagus was gently pulled down, and the esophagus in the upper part of the aortic arch was seen to move outside the pleura in the left posterior subclavian artery. Along the left edge of the left subclavian artery, the mediastinal pleura is cut from the bottom to the top of the chest. The esophagus above the aortic arch was then separated with a finger and wrapped around a soft hose. Above the aortic arch, the thoracic duct passes laterally across the esophagus into the neck and care should be taken to avoid injury. Then, with the right indicator pointing down from the aortic arch, the left index finger is pulled down from the aortic arch, and the esophagus is gently and bluntly separated in the direction of the aortic arch. When separating behind the aortic arch, it must be placed close to the esophageal wall to avoid damage to the deep thoracic duct and recurrent laryngeal nerve. If the tumor is located behind the aortic arch, if the separation is difficult, the anterior pleura of the aorta can be incised, and 1 to 2 intercostal vessels can be ligated and cut, and the aortic arch can be pulled forward to reveal the posterior esophagus for easy separation. 5, separation of the stomach: the assistant lifts the stomach by hand, but can not be pulled and pinched by force, it is not suitable to use the hemostasis to clamp the stomach wall, so as not to damage the blood supply and may lead to necrosis and perforation of the stomach tissue. (1) Separation of the omentum: The gastric ligament is separated on the side of the vascular arch of the gastric retinal artery. The omentum branches and the left gastric artery of the gastric retina were cut between the two forceps and ligated or sutured one by one. Then, continue to separate the gastric spleen ligament, cut and ligation of the short gastric artery. Sometimes the gastric spleen ligament is short. When separating, care should be taken to avoid vascular tear or damage to the spleen; in case of damage to the spleen or spleen, hemostasis should be repaired as much as possible. If there is difficulty, the splen can be removed. When separating, do not damage the blood vessel bow of the stomach, because there is no other blood supply at the bottom of the stomach. (2) Separation of the small omentum: Subsequently, the right thumb is used to extend from the already isolated stomach to the posterior wall of the stomach, and the avascular region of the gastric ligament is bluntly pierced in the distal side of the left gastric artery, and then broken. The hole is clamped, cut, and ligated to the stomach and liver ligament with a hemostatic forceps along the small curved vessel of the stomach. The other parts of the omentum are generally thin and have no important blood vessels and can be separated by fingers. When separating, the stomach can be lifted slightly, and the left gastric artery can be touched between the small curvature of the stomach and the upper edge of the pancreas. Remove the lymph nodes next to the blood vessels as much as possible, but care should be taken not to damage the celiac artery. Finally, the stomach and the lower end of the esophagus are lifted at the same time, and the tissues attached to the cardia and the reflexive peritoneum attached to the cardia are clamped, cut and ligated in batches. (3) Cutting the left gastric artery: The left gastric artery should be fully exposed and carefully operated to prevent accidents. The assistant hands up the stomach and lifts the root of the left gastric artery at the upper edge of the pancreas. After proper separation, place 3 pairs of reliable hemostats at the proximal end. Cut the blood vessels between the 2 and 3 forceps and retain the two clamps at the proximal end of the blood vessel to prevent the blood clamp from slipping off. The forceps are ligated and opened under the first forceps; the tongs are sewed between the ligature and the second forceps and the second forceps are opened to ensure the hemostasis. The third forceps left on the stomach side is also removed after the suture, and the needle should not be too close to the stomach wall to avoid sticking the ascending branch of the left gastric artery. After cutting the left gastric artery, the cardia and stomach are basically free. Later, according to the height of the anastomosis, the large and small curves of the stomach can be separated to a satisfactory level (generally should be divided into the gastric antrum), but the right gastric artery and stomach must be preserved. The right artery of the omentum. (4) Partial separation of the duodenum: If the tumor is located at a high position, sometimes the peritoneum of the duodenum is removed, and the posterior wall of the duodenum is bluntly separated to allow the stomach to be fully separated. Sufficient length to fit the esophagus at the top of the chest or neck. 6, cut off the cardia: for esophageal cancer above the lower pulmonary vein plane, if it does not prevent the removal of lymph nodes, try to keep the stomach. It is generally possible to cut the esophagus at the cardia without having to have a partial gastric resection. Then, two toothed hemostats were placed in the cardia and cut between the two jaws. The esophageal end can be closed with a thick thread to close the esophagus, and then put on a rubber finger or condom. The stomach end is made of 2 to 3 needles of full-thickness suture, and the fine line of the muscle layer is interrupted and inverted, and the stomach is closed. When the tumor position is high, the esophagus can also be cut at about 2 cm on the cardia. The distal end of the esophagus is ligated with a thick wire under the forceps, and then a purse is sutured at the fundus, and the stump is turned into the stomach to tighten the purse. The stump is turned into the stomach, the purse string is tightened, and the muscle layer of the intermittent pulp is sutured, and the stomach is temporarily retained in the abdomen. 7. Transfer the esophagus to the front of the aorta. The banding of the esophageal stump is lifted from the aortic arch and pulled upward. At the same time, the esophageal stump is pushed from the bottom up with the left finger. The esophagus is pulled out from the arch incision behind the aortic arch and moved to the aortic arch. In front. 8, esophagogastric anastomosis: according to the location of the lesion, size and the nature of the resection (radical or palliative) to determine the site of anastomosis. In the radical resection, most of the esophagus is removed, so it is often necessary to make an esophagogastric anastomosis on the aortic arch. However, when the tumor has obvious external invasion or lymph node metastasis, the resection is only for the relief of symptoms, it should be based on the premise of safe and smooth operation, and the scope of esophageal separation and resection should be appropriate, but not too broad. Sometimes the tumor position is low, although it is possible to anastomosis under the aortic arch, but due to the obstruction of the aortic arch, it is often difficult to make anastomosis close to the lower edge of the aortic arch. It is better to have an anastomosis on the arch. The blood supply of the esophagus above the aortic arch is almost entirely supplied by the esophageal branch of the inferior thyroid artery. When anastomosis is required on the aortic arch, the esophagus must be cut above the aortic arch to prevent the esophageal stump from necrosis due to insufficient blood supply. Easy to match, leaving the esophagus too long and causing adverse consequences. Esophageal end-to-side anastomosis embedding and contraction surgery: embedding the anastomotic site with the stomach wall and reducing the corpuscular body, can effectively avoid anastomotic leakage and reflux esophagitis, and reduce the postoperative gastric volume in the chest to reduce postoperative Respiratory compression symptoms and complications of the lungs; in addition, it is easy to operate, easy to master, and can shorten the operation time. (1) Resection of the tumor: a non-invasive forceps was placed at the selected resected esophageal site, and the esophagus of the lesion was removed distally from the forceps, and the free stomach was referred to above the plane of the aortic arch of the chest for anastomosis. (2) Incision of the muscular layer in the stomach wall: Select an anastomosis 2.5 cm below the highest point of the fundus, and should not be too close to the big curve of the stomach to avoid obstructing blood supply. First make a transverse incision commensurate with the esophageal diameter at the selected gastric anastomosis site. Only the muscle layer of the pulp is cut, and the edge of the incision is slightly separated, and the small blood vessels under the mucosa can be seen. The blood vessels are sutured with filaments on both sides of the incision, and then the stomach is lifted up to prepare for anastomosis with the esophagus. (3) suture of the posterior wall: in the posterior wall of the esophageal stump and the front of the fundus, the first row of sutures are sutured 3 to 4 needles, as far as possible to the high point, so that a longer esophagus is inserted into the stomach. Generally, it can be inserted into 3 to 4 cm, and has a valve function of preventing gastric juice from flowing back. Because the esophageal muscle layer is fragile, it is easy to tear and is easy to tear. Therefore, the needle should not be sutured through the muscle layer. The right needle can be sewn on the right subpleural connective tissue connected to the esophagus. On the anterior fascia adjacent to the esophagus, 1 to 2 needles on the posterior side between the left and right needles are sewn on the esophageal muscle layer and the connective tissue and the mediastinal pleura connected thereto. The gastric suture should pass through the sarcolemma but avoid penetrating the mucosal layer. The sutures are not ligated first. After all the sutures are completed, the assistant lifts the stomach and ligates one by one. Ligation should not be too tight to avoid tearing the esophageal wall. (4) Open the stomach to open the esophagus: first cover the protective tissue with a gauze pad, then cut the gastric mucosa between the sutures on both sides of the gastric mucosal incision, suck the stomach contents, and then clamp the esophagus with the esophagus clamp Partial resection. Finally, the esophageal septum opening is anastomosed to the gastric incision. (5) suture of the inner wall of the posterior wall: the two corners can be sutured as the traction, so that the stomach incision and the esophageal end are accurately aligned, and the second inner layer of the posterior wall is interrupted or continuous full-layer suture. The needle is 0.5 to 0.7 cm from the edge of the incision. Care should be taken to avoid retraction of the muscle layer and cause incomplete suture. The spacing of the sutures should not be too dense, and the ligation should not be too tight to avoid cutting the tissue. The knot is in the esophageal lumen. This layer of suture is unclear due to poor exposure or bleeding, so that the suture is inaccurate, making anastomotic leakage easily after surgery. Therefore, when each needle passes through the stomach wall or the esophageal wall, it must be clearly seen that the mucosa has been sewn and the bilateral mucosa have been closely closed, with no gaps or overlap. (6) Put into the stomach tube: After the anastomosis is completed, the anesthesiologist pushes the stomach tube and the duodenal nutrition tube downwards. The surgeon pulls out the duodenal nutrition tube from the anastomosis and uses it at the end. The thread hangs a sugar ball about 1cm in diameter (the outer part is covered with the finger of the waste glove, and 2 to 3 small holes are cut to facilitate the melting of the sugar ball, and the sugar ball is squeezed after the anastomosis, and the nutrient tube is introduced into the duodenum) Then, it is placed in the stomach separately from the stomach tube. (7) suture of the inner wall of the anterior wall: the anterior wall of the anastomosis is sutured with a thin wire for intermittent varus, the knot is hit in the cavity, or is not varused, the knot is beaten outside, and the mucosa of the esophagus and the stomach is satisfied. . (8) The outer wall of the anterior wall is sutured: the silk thread is passed through the left and right stomach walls of the anastomosis, and the pleura is passed through the upper corner of the mediastinal incision, but the esophageal muscle layer is not sewn. After the ligation, the anastomosis is buried by the stomach wall. . Then squeeze the sugar ball out of the stomach and feed the nutrient tube into the duodenum. (9) Sewing the corpus: In the end, the stomach is folded along the stomach and the needle is folded into a tube shape. 9. Close the chest: After the anastomosis is completed, the surgeon and the assistant wash the gloves, replace the suction head, remove the gauze pad around the anastomosis, and absorb the blood and flushing fluid in the chest cavity. Detailed examination of the absence of bleeding in the esophageal bed and the absence of rupture of the thoracic duct, and the absence of hemorrhage in the greater omentum and left gastric artery in the thoracic cavity, suture the posterior segment of the diaphragmatic incision around the stomach wall, taking care to preserve the circumference of the corpus, in order to avoid Causes local narrowing of the stomach. The remaining diaphragms were sutured with 8-wire suture to prevent postoperative paralysis. The closed thick drainage tube was placed in the 8th or 9th auxiliary room of the Yushou line, and the chest wall incision was layered.

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