Oesophagectomy (Ivor-Lewis)

1.Double lumen tube. Conduct a laparotomy and assess resectability. Determine adequacy of right gastric and right gastroepiploic vessels.
2.Mobilize the stomach by dissecting the omentum off the transverse colon as well as the gastrohepatic omentum. The left lobe of liver may also require mobilization by dividing the left triangular ligament.
3.Divide the left gastric from the undersurface; and then the left gastro-epiploeic and short gastric vessels (preserve the arcade of the lesser and greater curves of the stomach, i.e. the main trunks of the right gastric and right gastro-epiploic)
4.Sweep the nodes en bloc with the vessels.
5.Perform a Kocher manouvre to mobilise the duodenum, this will give mobility to the right gastric vessels. Occasionally, the right gastric will need to be sacrificed for greater mobility.
6.Divide the phreno-oesophageal ligament and mobilize the cardio-oesophageal junction. You may need to divide the right crus to ensure there is no constriction of the gastric tube. Loosely suture the tube to the distal resection margin so you can retrieve it later.
7.Perform a pyloromyotomy by making an incision longitudinally across the pylorus.
8.Fashion a jejunal feeding tube before closing the abdomen. Make a trephine in the abdominal wall at a suitable site, insert a Fraser forcep from inside out and bring the feeding in through the abdominal wall. Place a pursestring at a suitable site in the jejunum, making an enterotomy, inserting the jejunal feeding tube heading distally and then tying the pursestring. Place a further pursestring to invert the previous one and then tunnel the feeding tube within an invagination longitudinally sequentially heading proximally along the jejunum with interrupted Lembert sutures. Finally suture the jejunum with feeding tube in situ to the abdominal wall in the three quadrants superiorly opposite the jejunal invagination (i.e. on the proximal side). This tube is to remain in situ for 3/52.
9.Perform a mass closure of the abdominal wall and close skin.
10.Turn the patient over to the left lateral position for a right posterolateral thoracotomy in the 5th intercostal space. The space is usually just below the inferior angle of the scapula.
11.Divide through skin, subcutaneous tissue, latissimus. Reflect any fibres of serratus off the 6th rib without division.
12.By lifting up the scapula, you can count the ribs to confirm the right intercostal space (usually the 2nd rib is the highest palpable rib). Elevate the periosteum over the 6th rib with a periosteal elevator.
13.Divide the intercostals at the upper margin of the 6th rib and resect a 2-3cm fragment of rib posteriorly.
14.Insert a Finochietto retractor to separate the ribs and enter the pleural cavity asking the anaesthetist to now ventilate the opposite lung.
15.Retract the lung antero-superiorly with an Allison lung retractor and make an incision in the mediastinal pleura. Dissect and ligate the azygos vein to gain better access to the oesophagus. Mobilize the oesophagus up to 10 cm above the tumour. Secure the tumour by ligating the oesophagus above and below using umbilical tape.
16.Bring the mobilized stomach into the chest and fashion the neo-oesophageal tube using a GIA80 (green cartridge 4.8mm staples). Reinforce the staple line with a continuous Cushing suture.
17.Perform an end-to-side oesophago-gastric anastomosis using either a hand-sewn 4/0 PDS in two layers or a CEEA28 circular stapler via a gastrotomy. Oversew all staple lines.
18.Check for a chyle leak – administer cream via the feeding jejunostomy at the conclusion of the abdominal phase to aid identification of the thoracic duct, which is routinely ligated.
19.Place two intercostal catheters and close the thoracotomy with 1/0 ethibond (figure of 8 sutures) and vicryl to reconstitute the latissimus and subcutaneous tissue/ skin. An alternative is to bury the rib by suturing the intercostals above and below the thoracotomy

Leave NGT in situ for 1/52 and perform a GG swallow prior to starting oral intake.

Complications: ACRGS
1.Anastomotic leak <5%, early – re-explore, late – conservative treatment unless gastric resection line
2.Chyle leak 2-3%, transhiatal upto 10% - Test the fluid for fat, decreased serum lymphocytes (CD4). Treat conservatively if after 1 week, early leaks and prolonged leaks require re-operation to ligate the thoracic duct. High amount of leaks lead to loss of lymphocytes, immunosuppression (pneumocystis) and nutritional deficiency.
3.RLN palsy in cervical anastomosis (rare in Ivor-Lewis).
4.Gastric outlet obstruction – prevented by routine use of a pyloroplasty. Reflux I also common. Dumping symptoms resolve after 12 months.
5.Stricture (benign) related to stapled (higher rate) or handsewn.
6.Other- operative mortality of 5-10% overall with overall 20% 5YS, significant respiratory complications in 25-50%.