Esophagogastrothoracic anastomosis

The cupula of pleura is referred to clinically as the thoracic top. The pleural wall layer protrudes from the upper thoracic cavity, and the part above the first rib is called the pleural apex and reaches the first rib neck plane. Viewed from the front, it is a plane at 3 cm above the upper third of the clavicle. From the seventh cervical vertebrae and their transverse processes and the first thoracic vertebral body to the medial edge of the first rib, there is a thickened fascia covering the pleural apex and the apex of the lung, called the pleural fascia (ligament), which contains Muscle fiber. Many important structures of the base of the neck are adjacent to the pleural top. Treatment of diseases: esophageal sarcoma Indication The main surgical indication for esophageal-hepatic left thoracic mechanical anastomosis is malignant tumor of the middle esophagus (esophageal cancer), especially the esophageal cancer with the tumor at the level of the aortic arch and the esophagus with the upper edge of the tumor exceeding the aortic arch level of 1.5-2 cm. Upper cancer. For these two esophageal malignancies, the esophagus-gastric end-to-side anastomosis was performed manually on the thoracic top of the thoracic esophagus. Whether the surgery was exposed or the proximal end of the esophagus was anastomosed to the end of the stomach, it was very Difficult, and the length of esophagectomy is often limited; such as the use of esophagus-gastric neck and neck anastomosis, not only increases the surgical trauma and operation time, but also the incidence of postoperative esophageal-gastric anastomotic leakage can be as high as 25%. In order to solve these problems, domestic Zhang Xiaogong has used domestically produced GF-I tube-type digestive tract anastomat for more than 100 cases of esophagus-gastric left thoracic anastomosis since 1983. No postoperative intrathoracic esophagus-gastric anastomotic fistula occurred in 1 case. Pathological examination showed that the positive rate of proximal esophageal tumor cells was 7.1%. The main advantage of this surgical method is that it can increase the length of resection, greatly reduce the incidence of anastomotic leakage, improve the quality of surgery, and shorten the operation time. The main disadvantage is that the positive rate of residual tissue in the proximal end of the esophagus is relatively high. Therefore, if the upper edge of esophageal cancer exceeds the aortic arch level by more than 2 cm, esophageal-gastric neck anastomosis should be used. Surgical procedure 1. The patient takes the right lateral position, the left chest and the posterolateral thoracic incision, and enters the chest through the sixth ribbed bed or the sixth intercostal space. 2, routine exploration and free tumor segment esophagus. 3. Cut the left diaphragm between the liver and the spleen, and the stomach is free by conventional methods. The freeness of the stomach should be sufficient to ensure that there is no tension when the fundus migrates to the top of the chest. 4. The esophagus is transected at the esophagogastric junction, and the two ends are sterilized with iodine and ethanol. The lateral end of the cardia was treated with a medium-needle needle through the 7th silk thread to make a pulp layer. The suture line was temporarily not knotted. The distal end of the esophagus was first ligated with a 7-gauge thread, then wrapped with an esophageal band and cut from the upper triangular section of the esophagus. Lead out. 5, ligation of the thoracic duct at a low position of about 5cm on the sputum to prevent postoperative chylothorax. 6. Lift the esophageal segment of the tumor from the upper triangular region of the esophagus, use the blunt and sharp separation method to separate the upper part of the esophagus along the esophageal space, and cut the parietal pleura at the top of the chest to increase the exposure of the surgical field. In the upper part of the esophagus, all the esophageal arteries encountered are clamped, cut and ligated one by one, and the upper part of the esophagus is released above the level of the first rib circle, so that the upper edge reaches the level of the lower edge of the esophagus as much as possible. Increase the length of the tumor-free esophagus and reduce the residual tissue of the esophagus. 7. About 1.5cm from the upper edge of the esophageal tumor, use two Allis clamps to clamp the muscular tissue of the anterior wall of the esophagus. Use the electric knife to cut the whole layer of the anterior wall of the esophagus and use the suction device to remove the food. The contents of the lumen are pulled up the stomach tube to the esophagus of the neck. The anterior wall of the esophagus was sterilized with ethanol. 8. Insert the longitudinal incision of the anterior wall of the upper esophagus into the abutment of the stapler. When inserting into the nail seat, the movement should be light and slow, and gradually insert it into the tumor-free esophageal lumen at the top of the chest above the first rib circle. Avoid rough operation and excessive force, so that the esophageal muscle layer on the upper part of the esophagus and the upper part of the esophagus The mucosal layer is torn. According to the size of the upper esophageal lumen, the type of the stapler should be correctly selected. The general patient can choose the 26th stapler; the individual esophageal lumen is large, you can choose the 28th stapler. If the 26th stapler is too small to be placed, the procedure should be changed to esophageal-gastric left neck anastomosis. 9. When the abutment is inserted into the upper part of the esophagus and reaches the top of the chest, use a small round needle to wear the 7th silk thread near the lower edge of the nail base to make a purse string running through the full layer of the esophageal wall and tighten the knot. The whole layer of the esophageal wall is fixed on the central rod for one week without slipping. If necessary, it is close to the upper edge or the lower edge of the ligature of the purse string and then ligated with the 7th wire. Note that the purse string must be sutured in the esophageal wall where the naked eye is observed and palpated as no tumor. 10. The tumor esophagus was cut transversely at a distance of about 0.5 cm from the lower edge of the purse stringing line. Surgical specimens and mediastinal lymph nodes (thoracic paratracheal lymph nodes, lower axillary lymph nodes, paraesophageal lymph nodes, posterior mediastinal lymph nodes, and diaphragmatic lymph nodes) and abdominal lymph nodes (parathyroid lymph nodes, left gastric lymph nodes, small stomach curvature) Lymph nodes, large curved lymph nodes, splenic lymph nodes and splenic lymph nodes, etc. were sent to pathological examination, and the esophagus margin was disinfected with ethanol. 11. The stapler device with the plastic knife seat and the nail frame is inserted into the stomach cavity through the incision of the cardia to the large curved side of the "highest point" of the fundus, so that the knife seat and the nail frame abut against the stomach wall; The avascular area of the stomach wall of the staple frame is made with a sharp blade to make a 0.5 cm long puncture, cut through the full layer of the stomach wall, and the central rod is inserted into the stapler body through the incision. 12. Tighten the screw knob at the end of the stapler body to adjust the distance between the knife holder and the staple holder and the abutment until the "highest point" of the fundus is in close contact with the end of the esophagus, so that the two are ready to be fitted. ), but do not hit the stapler temporarily. 13, from the "highest point" of the fundus and the proximal end of the esophagus contact surface (equivalent to the esophagus - gastric anastomosis around the upper and lower edge of 0.5 ~ 0.7cm, with a small round needle filament line interscribing sclerosing muscle suture 6 ~ 8 stitches. The spacing of each needle should be substantially equal, distributed around the proximal end of the esophagus (front, back, left, right); the sutures are not knotted, and are clamped with mosquito clamps. 14. Loosen the safety brake of the stapler, grasp the handle, and fire the stapler to complete the mechanical anastomosis of the esophagus-gastric thoracic top. Loosen the knob at the end of the stapler and gently withdraw the stapler body and the center rod from the incision of the cardia; the suture line of the sarcoplasmic layer that has been pre-sewn around the anastomosis is tightened one by one and the distance is about 0.3 cm. Suture. At this point, the esophageal-gastric anastomosis is completely retracted to the pleural plane above the chest wall; to prevent tension in the anastomotic area, the stomach bottom and the pleural incision pleural incision edge can be sutured 4 to 5 stitches to make the stomach The bottom is suspended from the top of the chest. 15. Insert the gastric tube into the antrum of the stomach and fix it. 16. Tighten the purse-string suture of the cardia incision and tie it, close the door of the cardia, and sew the stomach slightly. 17. Intermittently suture the diaphragmatic incision, fix the chest and stomach, and reconstruct the esophageal hiatus. 18. Rinse the chest cavity, install the chest drainage tube to connect the drainage bottle (water seal bottle), and the operation is over. The esophagus-gastric thoracic mechanical anastomosis is safe and reliable, and is significantly better than manual anastomosis. Especially in patients with aortic arch tortuosity almost close to the thoracic top, the advantages of mechanical anastomosis of the esophagus-gastric thoracic top are more prominent, and it is very difficult to perform thoracic esophageal-gastric anastomosis by hand suturing. It is impossible to match, and the procedure can only be changed to esophagus-gastric neck anastomosis. In this regard, the esophagus-gastric thoracic mechanical anastomosis can replace a part of the esophagus-left gastric neck anastomosis, which is an advancement of esophageal-gastric intrathoracic anastomosis, and has clinical value. complication Intrathoracic anastomotic leakage and benign anastomotic stenosis are two major complications associated with mechanical anastomosis of the esophagus (intestine). According to domestic reports, the incidence of anastomotic leakage is 1.3% to 2% after mechanical anastomosis of the esophagus and stomach. The incidence of benign stenosis of anastomotic stoma is 0.9% to 22%, which occurs mostly from 6 months to 1 year after surgery. The size of the stapler has a certain relationship with the anastomotic stenosis, that is, the esophagogastric anastomosis is performed with a small stapler, and there is a tendency for benign anastomotic stricture after surgery. The anastomotic stenosis is treated by dilatation, and the caliber of the anastomosis can generally reach the normal size. In some patients, the narrow anastomosis can naturally expand to the normal range.