By O. Moff. Kalamazoo College. 2019.

The glomus tumour or the glomangioma is a benign and circumscribed tumour blue or reddish in colour order minomycin with visa. Plain muscle fibres intervene between the lumen and the clumps of epitheloid cells order 100mg minomycin overnight delivery. Abundant nerve fibres mainly nonmyelinated variety are seen between the epitheloid cells and these are responsible for exquisite pain which is the most important symptom of suqh tumour discount generic minomycin uk. Pain is probably caused by dilated glomus vessels pressing on the numerous nerve endings cheap 100 mg minomycin fast delivery. Subungual sprouting granulation tissue resulting from chronic osteomyelitis of the distal phalanx. Localized cluster of dilated lymph sacs in the skin and subcutaneous tissues which cannot connect into the normal lymph system grows into lymphangioma. Occasionally the vesicles may be rubbed with the clothes, get infected and become painful. When excision is complete there is no chance of recurrence and cure is complete and permanent. A hamartoma is a developmental malformation consisting of a tumour-like overgrowth in which the tissues of a particular part of the body are arranged haphazardly, usually with an excess of one or more of its components. Common lesions included in this group are benign pigmented moles, majority of angiomas and neurofibromas. A very well known example of hamartoma is the isolated cartilaginous mass found in the substance of a lung. On section it is found to be composed of mature hyaline cartilage with clefts lined by respiratory epithelium and surrounding the cartilaginous mass there is connective tissue and smooth muscle. But usually only those on exposed areas like the skin and mouth will be recognized as early as this. Other tumours will be recognized late, though no doubt the original nidus was present at birth. It grows alongwith its surroundings, so there is no question of any connective tissue condensation. False neuromas are those which arise from the connective tissue covering the nerve fibre or from the nerve sheath. The sympathetic system originates from the neural crest and develops along 2 lines :— (a) Primitive neuroblasts and adult sympathetic cells which may give rise to tumours such as neuroblastoma and ganglioneuroma respectively, (b) Chromaffin tissue situated mostly in the adrenal medulla and may produce tumours known as pheochromocytoma. It must be remembered that whereas schwann cells are derived from the neural crest, neurilemmoma is ectodermal in origin. Neurofibroma arises from elements of perineurium and endoneurium and are mixtures of ectoderm and mainly mesoderm. Neurilemmoma is a benign, well encapsulated tumour which forms a single, round or fusiform firm mass on the course of one of the larger nerves. Multiple lesions may occur on the same nerve or may be distributed throughout the body. Such neurilemmomas are occasionally seen in the posterior mediastinum and in the retroperitoneal space. The long slender cells form twisted band and have elongated nuclei which show palisading arrangement or are arranged in whorls. Basically two types of tissue can be noticed in such a tumour — fascicular and reticular tissues. The fascicular tissue presents a solid complex appearance almost like an exaggerated tactile corpuscle, known as Verocay body. The reticular tissue consists of loosely arranged schwann cells in an open network of tiny cysts and reticulin fibres. The neurilemmoma is essentially a benign lesion and does not show any tendency to malignant transformation. This is a developmental disorder and is often considered as Hamartoma and not a typical tumour. Majority of the neurofibromas arise from endoneurium, the innermost connective tissue covering of the nerve fibre. The endoneurium is covered by perineurium and epineurium, which remain usually unaffected. Paraesthesia or pain likely to occur from pressure of the tumour on the nerve fibres. On examination, it is a smooth firm swelling of the skin and subcutaneous tissue which occurs along the course of a nerve. Both the area of sensation and the muscle power of the nerve involved should be examined. In such cases excision may accompany resection of the involved portion of the nerve and then end-to- end anastomosis of the divided nerve is performed. Type I is a relatively common disorder and 50% of patients give a definite family history. Typically these components are dispersed in a loose disorderly pattern, often in a loose myxoid stroma. Elongated serpentine Schwann cells predominate with their slender, spindle-shaped nuclei. It must be remembered that neurilemmomas composed entirely of Schwann cells which virtually never undergo malignant transformation. Malignant transformation is more common in large tumours attached to the large nerve of the neck and extremities. The cutaneous pigmentations, the 2nd major component of this syndrome, are present in over 90% of patients. Most commonly they appear as light brown macules with smooth borders often located overlying the nerve trunks. The most common associated abnormalities perhaps are skeletal lesions which include erosive defects due to contiguity of neurofibroma to the bone, scoliosis, intraosseous cystic lesions, subperiosteal bone cysts and pseudoarthrosis of the tibia. Other abnormalities found in neurofibromatosis are meningiomas, gliomas, pheochromo-cytomas and medullary thyroid cancers. Although some patients with these conditions have normal mentality, yet there is a tendency of reduced intelligence. Indications for excision are : (a) When one swelling is large enough, (b) When one swelling is painful, (c) When one is causing pressure symptoms, (d) When one is causing mechanical discomfort, (e) When there is suspicion of malignancy. This is hyperparathyroidism due to excessive parathyroid hormone secretion and it is characterized by pathological fracture, recurrent renal calculi and peptic ulcer. It is more commonly seen in connection with branches of the trigeminal nerve (5th cranial nerve). Clinically there is a big swelling with the overlying skin thickened and oedematous. The subcutaneous tissue becomes greatly thickened and fat is replaced by fibrous tissue. Other causes of elephantiasis are : (a) Filariasis, (b) Nodular leprosy (elephantiasis graecorum), (c) Occlusion of lymph drainage due to (i) excision of draining lymph nodes e. Neurofibroma may occur anywhere in the body but the followings require special mention : A. The first symptom is unilateral deafness, followed by tinnitus, vertigo and headache. Ultimately the tumour may press on the cerebellum causing cerebellar symptoms and signs with increased intracranial pressure. Dumb-bell shaped neuroflbroma — arising from the dorsal nerve root partly inside and partly outside the intervertebral foramen. There will be tingling and numbness particularly due to irritation by an artificial limb due to pressure on the neuroma. This is particularly liable to occur in fair and dry skinned people constantly exposed to sunlight. Exposure to sunlight seems to be an important aetiologic factor, that is why this lesion is usually confined to the face. Rodent ulcer is particularly prevalent in Australia and is confined to white people of the labour class whose skin is exposed to the bright sunlight of high actinic value. The tumour is frequently multiple and the multiple growths may be confined to one area or may occur in different areas. Multiple, basal cell carcinomas may develop in persons following prolonged administration of arsenic usually in the form of liquor arsenicalis. Such an ulcer has a typical rolled edge (not everted), often beaded and the floor showing scabbing over some areas and breaking at others.

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Bright signal on T1-weighted images appears to reflect the high protein or starch content of the mucoid material in the cyst purchase genuine minomycin on-line. Coronal T1-weighted image demonstrates a prolactin-secreting microade- noma (open arrow) as a focal area of decreased sig- nal in the pituitary gland purchase minomycin. Associated findings include displacement of the pituitary stalk contralaterally (curved arrow) and elevation of the upper border of the gland (straight solid arrow) generic minomycin 100mg online. Isointense or slightly hyperintense mass location of the mass as well as whether the internal on T2-weighted images order minomycin 100mg amex. Marked homogeneous carotid artery and its branches are encased by contrast enhancement. Unlike a pituitary adenoma, a suprasellar meningioma usually does not project into the intrasellar space. Hyperintense on T2-weighted and beyond into the optic radiations and appears images. Germ cell tumor Isointense to hypointense on T1-weighted Detection of a suprasellar germ cell tumor man- (germinoma/teratoma) images. Slightly to moderately increased signal dates close inspection of the pineal region because on T2-weighted images. Dermoid Heterogeneous texture as a result of the mul- Fatty components are common and produce high tiple cell types in it. Neuroma Isointense or hypointense lesion on T1- Prominent homogeneous contrast enhancement. Isointense to hyperintense Coronal scans may show extension of a mandibular lesion on T2-weighted images. It also can be an acquired abnormality with traumatic stalk transection and compression or destruction of the neurohypo- physis. More common neoplasms of the infundibulum are germinoma, lymphoma, leukemia, and other metastatic tumors. Non- neoplastic causes of infundibular enlargement include histiocytosis and sarcoidosis. On this coro- nal T2-weighted scan, the predominantly flow-void mass (A) extends into the suprasellar cistern and dis- places the pituitary stalk. Hyperintensity in the region of the tuber cinereum (arrows) indicates transection of the pituitary stalk. Usually shows intense, sensitive, and is the most common tumor of the homogeneous contrast enhancement. May occur in association with a usually isointense to brain on both T1- and T2- suprasellar germinoma. A few lesions have long T1 to the aqueduct, these tumors frequently cause hy- and T2, which may correlate with embryonal drocephalus. Usually shows minimal contrast en- teratomas are of mixed signal intensity and hancement (intense enhancement suggests malig- often contain cystic components and fat. Enhancing tumor (T) in the large isointense mass (arrowheads) that compresses pineal region of a young girl with paralysis the midbrain (arrow) and elevates the splenium of the of upward gaze, headaches, and nausea corpus callosum. The minimal dilata- tion of the third ventricle (arrowheads) and lateral ventricles (arrows) indicates mild hydrocephalus, which developed because of obstruction of the posterior portion of the third ventricle by the tumor. Variable con- parenchymal cells and usually confined to the post- trast enhancement. Indistinct tumor margins mass on T1-weighted images that becomes hy- suggest infiltration of adjacent structures. Glioma of nonpineal origin Low-density mass with poorly defined margins, Tumors arising from the thalamus, posterior hypo- minimal or moderate enhancement, and no thalamus, tectal plate of the mesencephalon, or calcification. May displace the normal calcified splenium that extend into the quadrigeminal cis- pineal gland. Pineal mass that is hypointense (arrowheads) on a sagittal T1-weighted image (A) and hyperintense (arrows) on an axial T2-weighted image (B). Air in in the pineal region causing obstructive hydro- the frontal horns (white arrows) resulted from a cephalus. A contrast-en- in the pineal region that arises from the hanced scan shows dilatation of the vein of incisura of the tentorium. Note acteristic flat border (arrows) along the the prominent feeding vessels of the choroid tentorium. Round pineal mass (ar- rows) that is markedly hypointense on a coronal T1-weighted image (A) and hyperintense on an axial T2-weighted image (B). Hypothalamic germinomas affect images, though it may be isointense on both men and women equally, unlike the strong male pulse sequences. Sagittal T1-weighted scans before (A) and after (B) administration of con- trast material in an 18-year-old man with diabetes insipidus show enhancing masses in the floor of the anterior third ventricle (straight black arrow) and pineal region (curved arrow). Most common presentation is solitary or multicentric, well-defined enhancing masses in the deep gray nuclei, periventricular white matter, or corpus callosum. It may be found incidentally in adults typically does not show contrast enhancement. Coronal (A) T1-weighted and (B) T2-weighted scans in a 5-year-old girl with precocious puberty show a midline hypothalamic mass (arrows) bulging into the inferior floor of the third ventricle. The lesion is isointense on both images and is centered in the region of the tuber cinereum. Inhomogeneous enhance- benign and has minimal tendency for invasion or ment may be seen. The lesion is generally hypointense on anywhere along the infundibular stalk from the T1-weighted images and hyperintense on T2- floor of the third ventricle to the pituitary gland. High signal intensity on T1- Craniopharyngiomas have two peaks of prevalence, weighted images can reflect high cholesterol one between 10 and 14 years of age and the other content or methemoglobin within a cystic mass. Coronal T1-weighted contrast onstrates a large clival mass with destruction of the sella image indicates that the complex mass contains cys- and invasion of the suprasellar region. Note the small tic components with marginal enhancement (short enhancing hypothalamic mass (arrow) representing arrow) and an intensely enhancing mural nodule (long 22 arrow). Sagittal T1-weighted contrast image shows a well-defined suprasellar mass (arrow). Initially isointense rela- tive to brain, the mass shows inhomogeneous enhancement. Coronal T1-weighted contrast image shows a lobulated suprasella tumor with in- trasellar extension. The tumor is formed predomi- nantly of multiple cysts with varying signal intensities that show thin mural enhancement (arrows). Encephalitis Extensive edema appears hyperintense on T2- Most commonly due to viral infection. It shows homogeneous and usually occurs in the third to fourth decades of contrast enhancement. Sagittal T1-weighted image shows a well- defined, homogeneously hyperintense suprasellar cyst (curved arrow) that displaces the optic chiasm upward (straight arrow). Coronal T1-weighted image shows a well-defined intra- and suprasellar lesion that displaces the optic chiasm upward (arrow- heads). The high signal intensity reflects the high concentration of mucopolysaccharides within the mass. Coronal T2-weighted image shows a hyperin- tense area in the thalamic-hypothalamic region (arrow) that corresponds to edematous changes. Charac- Transection, compression, or absence of the infun- teristic absence of normal infundibulum and dibulum and its neurohypophyseal tract results in high-signal-intensity tissue within the posterior the proximal build-up of neurosecretory granules sella on T1-weighted images. The bright signal associated with the phos- pholipid membranes of these hormone-carrying vesicles is thus displaced proximally and cannot be seen in its normal location in the posterior lobe of the pituitary gland at the back of the sella. The disease is caused by thiamine deficiency and is most commonly seen in alcoholics. It is associated with the classic triad of oculomotor dysfunction, ataxia, and encephalop- athy. Note the mamillary bodies (curved arrow), tuber cinereum (straight arrow), and infundibulum (arrowhead). Sagittal T1-weighted weighted image in a young boy with short stature image in an elderly alcoholic man shows striking atro- shows a hyperintense, oblong nodule (arrow) in the phy of the mamillary bodies. Pituitary tis- sue within the sella does not show high signal in its posterior portion, and there is no evidence of an in- fundibulum connecting the pituitary gland to the hy- pothalamus. Cessation of parenteral nutrition usually results in regression of the abnormal signal intensity.

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In case of relapses or continuous symptoms one must be careful to reassess the diagnosis as there are various diseases which may give rise to similar symptoms as ulcer cases e minomycin 50 mg online. If there is no improvement by proper medical treatment given for 6 weeks order 100mg minomycin free shipping, there is every reason that the medical treatment should be stopped and surgery is indicated order minomycin uk. When the ulcer fails to heal after rigid medical treatment for the prescribed period minomycin 50mg fast delivery, which is 2 months for gastric ulcer and 6 months for duodenal ulcer operation is required. When the patients want quick relief of their symptoms and do not want to carry on a prolonged trial of medical treatment surgery is indicated. When the history suggests that the ulcer is present for 5 years, it is unlike that the ulcer will heal without operation. When repeated pain has made the patient intolerable with frequent loss of work, surgery is indicated. When ulcer has produced obstruction in the form of hour-glass stomach or pyloric stenosis, surgery is indicated. When the ulcer is giving rise to haemorrhage in the form of haematemesis or melaena, operation is indicated. When the patient gives a history of previous perforation of ulcer, the treatment is straightway surgery. If after 6 weeks of medical treatment endoscopy does not show any sign of healing of gastric ulcer, four quadrant biopsy should be taken through endoscopy. All gastric ulcers above the age of 45 years should be considered as suspicious and endoscopic biopsy is a must. Unless a definite improvement by medical trial is achieved within one month, surgery is indicated. As the vagus nerve is responsible for the psychic phase of gastric secretion, its transection i. Vagotomy also decreases the motility of the gastric muscles, hence hampers gastric emptying. Antrum is responsible for producing gastrin — the gastric phase of gastric secretion. It must be remembered that women patients do not tolerate partial gastrectomy so well and this operation should better be avoided in their cases. Pentagastrin test is always performed to assess the gastric acid status of the individual. The operation is selected as follows :— When the maximal free acid is from 30 to 40 m. This operation involves excision of distal two-thirds of the stomach followed by anastomosis between the remnant of the stomach and duodenum. Vagotomy and Pyloroplasty, associated with frozen section biopsy of the gastric ulcer (if benign), is gradually gaining popularity. Highly selective vagotomy or proximal gastric vagotomy with excision of the ulcer is being performed in some centres. The supporters of this technique claim that it is either equal or even a better operation than Billroth I gastrectomy, as the gastric physiology is best maintained in this operation. In fact, about 5 to 7 cm of the nerves are excised so that this technique can be referred to as ‘Vagectomy’. The selective vagotomy is aimed at removal of all gastric fibres of the vagus nerves, keeping intact the hepatic and coeliac branches. The proximal gastric vagotomy or highly selective vagotomy is designed to denervate the acid secretory part of the stomach, keeping the vagal supply to the alkali secreting gastric antrum and other abdominal viscera, thus motility of the stomach is not hampered and drainage procedure will not be required. The peritoneum over the abdominal part of the oesophagus is transversely incised taking care not to damage the inferior phrenic vessels. If now, the operator passes his finger through this incision, his finger will enter the posterior mediastinum. The assistant is asked to pull the stomach down when the tense anterior trunk will be seen lying on the anterior surface of the oesophagus. About 5 to 7 cm of both these trunks are excised and remaining ends are tied with fine silk. The ligature pyloroplasty is made to avoid bleeding from the ascending oesophageal ves­ sels, which run up along with the nerves. The most important operative complication is gastric retention for which drainage operation is performed along with this operation. This operation is probably contraindicated to patients already suffering from severe diarrhoea. The reason may be a few intact vagal fi­ bres, which may be detected by Holland­ er’s insulin test and in this case reoperation should be performed to com­ plete vagotomy. One must keep in mind the possibility of Zollinger-Ellison syndrome in these cases. The hepatic branches of the anterior vagus are identified in the upper part of the lesser omentum. The dissection is started along with the anterior vagus nerve in the lesser omentum downwards to find out all the gastric branches which are ligated and divided one by one. Now for posterior selective vagotomy, an incision is made through the peritoneum at the angle of His. Right index finger is passed through the hole to reach behind the gullet and the right thumb is passed through the hole made in the lesser omentum. These two fingers will meet behind the oesophagus and will only be intervened by the so-called ‘mesentery’ in which will be lying the posterior vagal trunk. The tissues behind the posterior vagus nerve are burst through and a tube is inserted to include the gullet and the vagi. With the right index finger, the posterior trunk is pushed posteriorly and tissues in front of the finger are very minutely dissected to secure the gastric branches of the posterior vagus nerve. The last part of the oesophagus is now thoroughly exposed to clear any additional fibres, which may be left behind. The whole circumference of the cardia is examined and all residual vagal branches are divided, leaving behind a ring of bare muscles. These nerves are preserved and separated from the proximal gastric branches by passing forceps through the lesser omentum to the left of the nerve of Latarjet close to the gastric wall about 3 inches (7. It is very convenient to save the posterior nerve of Latarjet through the lesser sac, which is entered through the greater omentum at the middle part of the greater curvature. The proximal gastric branches are dissected, ligated and divided and the main nerve, which supplies the antrum and pylorus, is preserved. In this operation posterior truncal vagotomy is being performed alongwith anterior lesser curve seromyotomy. A few surgeons are performing seromyotomy in both anterior and posterior aspects of the lesser curve. The advantage of this operation is that the disturbance to the neighbouring structures is least and it can be performed by minimal access procedure also. In uncomplicated duodenal ulcer, this operation is often used along with the vagotomy. In gastric ulcer, some surgeons are liking this operation along with vagotomy and the ulcer is biopsied. As Palliative measure this operation can be performed in gastric carcinoma for the relief of pyloric obstruction. When the general condition of the patient is not good enough to carry out the operation, a long-continued milk-drip therapy is advisable for fortnight. For this, a Ryle’s tube is passed through the nostril of the patient into the stomach. The tube is connected with a milk reservoir, hung about 3 feet above the patient’s head. The milk is allowed to drop into the stomach at such a rate that five pints can be given in 24 hours. In patients with cachexia or upper gastro-intestinal bleeding, blood transfusion will be required. The patient’s blood is sent for grouping and crossmatching with a requisition of such amount of blood which will be required for the particular patient. By the time the blood is received, intravenous infusion of glucose-saline should be administered.

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This maneuver provides a few centimeters of extra esopha- gus generic minomycin 100 mg without a prescription, allowing the option of selecting the best length when the anastomosis is performed purchase minomycin 100 mg online. This drain with its two identifying hemostats is later used to draw the stomach up through the posterior mediastinum into the neck minomycin 100mg mastercard. If a laceration is encountered order minomycin amex, insert a 32F chest tube into the chest cavity on the side of the laceration, in the midaxillary line. Then insert moist gauze packing into the mediastinum to help achieve hemostasis while the stom- ach is being prepared. Exteriorize the stomach and attached esophagus by spreading it out along the patient’s anterior chest wall. Because the blood supply to the lesser curvature subse- quent to ligation of the left gastric artery is poor (Akiyama), the lesser curvature is excised, converting the stomach into a tubular structure (Fig. Now invert the entire should be located 3–5 cm down from the apex of the gastric staple line by means of a continuous 4-0 Prolene Lembert tube and above the level of the clavicle. Remove the identifying hemostat from the previ- back into the neck so it rests on the anterior wall of the gastric ously positioned Penrose drain that was brought down from tube. Make an incision in the anterior wall of the gastric tube the neck into the mediastinum. Suture this Penrose drain to in a vertical direction, the length being appropriate to the the most cephalad point of the gastric cardia using 3-0 silk diameter of the elliptical esophageal orifice, which is approxi- sutures. Place gentle Be certain that the esophagus and stomach are positioned cephalad traction on the proximal end of the Penrose drain such that there is no tension on the suture line. This stitch passes through the muscle layer of the and into the posterior mediastinum until the stomach has esophagus and then enters the cephalad margin of the gastric been manipulated into the neck. To avoid the possibility of incision 4 mm above the incision, entering the lumen of the gastric torsion, be certain that the staple line along the stomach. When tying these sutures, make the knot just tight lesser curvature is located to the patient’s right and the enough to afford approximation, not strangulation. The long-tailed suture second stitch through the left lateral wall of the esophagus at the junction of the Penrose drain and the gastric cardia into the lumen, again catching at least 4 mm of mucosa, and identify the medial aspect of the gastric tube. Confirm the bring the stitch into the stomach and out the center of the absence of torsion by inserting the right hand through the left lateral wall of the stomach. Do not tie this stitch; rather, hiatus and palpating the anterior surface of the stomach up clamp it in a hemostat and place the third stitch in the same to the aortic arch and with the left hand from the cervical fashion in the right lateral margin of the esophagus and stom- approach. Ask the assistant to apply hemostats to stitches two and apex of the cervical incision. Insert several sutures of 5-0 three and then to apply lateral traction to separate the two Vicryl to attach the gastric fundus to the fascia of the lon- stitches. This maneuver lines up the esophagus and stomach gus colli muscles on both sides of the neck. Insert interrupted deep bites of stomach or tie the sutures so tight that necro- sutures about 4 mm apart from each other. Cut the tails of all the sutures in the pos- phragm with interrupted 2-0 silk sutures but do not constrict terior anastomosis but retain the hemostats on stitches two the newly formed hiatus to the point where it obstructs and three. Maintain lateral traction on these two stitches and venous return from the gastric tube. Leave about three begin the anterior anastomosis by inserting the first stitch at fingers’ space between the diaphragm and the stomach. Bring Then insert enough interrupted 3-0 silk sutures between this stitch into the lumen of the stomach and bring it out of the muscle surrounding the hiatus and the stomach to pre- the stomach at 6 o’clock. Apply a hemostat to this stitch, vent the possibility of bowel herniating through the newly which serves as an anchor. Cover the pyloromyotomy inserting Lembert sutures and then invert the tissues as the with omentum. We frequently use the technique of successive and then return to the neck to perform the esophagogastric bisection (see Figs. When dividing the esophagus, cut the ante- rior flap of esophagus so it is at least 1 cm longer than the posterior flap, as illustrated in Fig. This maneuver con- Closure verts the anastomotic suture line into an ellipse instead of a circle and should result in a larger stoma. Close the neck muscles as high as is comfortable in the cervical inci- abdominal cavity without drainage using the modified sion. Using Babcock forceps, gently elevate the anterior wall Smead-Jones closure described in Chap. Close the skin with interrupted fine nylon, subcu- and superior location in the neck. This is seen especially in cases of anas- chest catheter on some type of underwater drainage for tomoses involving the cervical esophagus. Insert a large drainage tube into the right or left managing-your-practice/coding-billing-insurance/cpt. A prospective randomized compari- mediastinum reveals most gaps in the mediastinal pleura. Comparison of outcomes drainage exceeds 800 ml per day after the third postopera- following transhiatal or Ivor Lewis esophagectomy for esophageal carcinoma. Cervical esophagogastric anastomosis for ing cream via the jejunostomy catheter and observing an benign disease: functional results. Aggressive treatment of chylotho- rax complicating transhiatal esophagectomy without thoracotomy. Eliminating the cervical esophagogastric anastomotic leak with a side-to-side stapled anas- jejunostomy feeding tube at a rate of 60–90 ml/h for 4–6 h tomosis. Two thousand transhiatal esoph- interspace posterolateral thoracotomy under one-lung agectomies: changing trends, lessons learned. Gouge Indications Prepare for possible massive blood loss during the thoracic dissection. Esophageal stricture Always use a double-lumen endotracheal tube to facilitate End-stage achalasia quick collapse of a lung, should exposure be needed emergently. Preoperative Preparation Pitfalls and Danger Points Perform preoperative esophagogastroscopy and biopsy. Use computed tomography and endoscopic ultrasound for Inadvertent interruption of the right gastroepiploic artery or preoperative staging. Anastomotic leak Consider neoadjuvant treatment for lesions T2 or greater Injury to spleen or splenic vessels and/or for suspected lymph node involvement. Excessive bleeding Consider preoperative tube feedings in patients with signifi- Laceration of membranous trachea cant weight loss or other evidence of malnutrition, espe- Hypotension during mediastinal dissection due to compres- cially if candidates for neoadjuvant treatment. Trauma to the thoracic duct and resultant chylothorax Traction injury or laceration of the recurrent laryngeal nerve Undetected pneumothorax M. Choice of the tech- Department of Cardiothoracic Surgery, New York University nique is influenced by the surgeon’s experience and personal Langone Medical Center, 530 First Ave. The minimally invasive Ivor Lewis esophagectomy with Transhiatal and Transthoracic Portions a thoracoscopic approach offers a better visualization of the periesophageal structures, especially near the main airways Bleeding and transfusion requirements are less with the mini- and subcarinal areas. It is also less affected by patient height mally invasive approach, but it is important to note that even and body habitus, and it might facilitate more complete small amounts of bleeding can obscure the operative field and nodal dissection. Since the transthoracic approach allows may require conversion to an open procedure. Hence, the aor- dissection of the mid-esophagus under direct vision, it is toesophageal branches must be identified and clipped. The tho- Bleeding from the azygous vein and peribronchial arteries also racoscopic portion of the minimally invasive transthoracic must be avoided. Injury to the posterior membranes on the esophagectomy can be performed before or after the gastric bronchus and trachea must be carefully avoided, especially mobilization depending on the surgeon’s preference and the during lymph node dissection. Although the dissection can be done use in close proximity to the posterior membranous trachea or with the patient supine or slightly rotated (which minimizes main stem bronchus can lead to tissue damage resulting in air position change and operative time), it is much easier in leak, local ischemia, herniation of the gastric conduit, and sub- right-side up or prone position. Where available, robot assis- sequent development of a tracheogastric conduit fistula. Avoid this catastrophic complication by careful preoperative staging and careful dissection at the point where azygous vein crosses the esophagus to isolate the vein Abdominal Portion and completely control it with the appropriate stapling device. If injury of the azygous vein is suspected during a tran- The laparoscopic portion of an esophagectomy is designed to shiatal dissection, the right lung should be deflated and a fully mobilize the stomach so that it can be used for a thoracic right thoracotomy performed. The steps of this portion of the opera- Since microscopic extension of cancer can be found even tion are the same, regardless of whether a transhiatal or a trans- at considerable distance from the macroscopically visible thoracic approach is chosen for the esophageal dissection.

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