Cancer esofago

Notas del editor

1. FIGURE 39-1. Normal anatomy of the esophagus.
2. FIGURE 39-35. Comparison of endoscopic ultrasonographic image with layers of gut wall. The first layer, hyperechoic, represents the interface between the endoscope and superficial mucosa. The second layer, hypoechoic, represents the lamina propria and muscularis mucosae. The third layer, hyperechoic, represents submucosa and the interface between submucosa and muscularis propria. The fourth layer, hypoechoic, represents the muscularis propria. The fifth layer, hyperechoic, represents the interface between serosa and surrounding tissues. (From Rice TW, Zuccaro G Jr: Endoscopic esophageal ultrasound. In Pearson FG, Cooper JD, Deslauriers J, et al [eds]: Esophageal Surgery, 2nd ed. Philadelphia, Churchill Livingstone, 2002, p 124.)
3. FIGURE 39-2. Arterial blood supply of the esophagus. (Adapted from Hagen JA, DeMeester TR: Anatomy of the esophagus. In Shields TW, LoCicero J III, Ponn RB [eds]: General Thoracic Surgery, 5th ed, vol 2. Philadelphia, Lippincott Williams & Wilkins, 2000, p 1599.)
4. FIGURE 39-3. Venous drainage of the esophagus. (Adapted from Hagen JA, DeMeester TR: Anatomy of the esophagus. In Shields TW, LoCicero J III, Ponn RB [eds]: General Thoracic Surgery, 5th ed, vol 2. Philadelphia, Lippincott Williams & Wilkins, 2000, p 1599.)
5. FIGURE 39-4. Innervation of the esophagus. (Adapted from Hagen JA, DeMeester TR: Anatomy of the esophagus. In Shields TW, LoCicero J III, Ponn RB [eds]: General Thoracic Surgery, 5th ed, vol 2. Philadelphia, Lippincott Williams & Wilkins, 2000, p 1599.)
6. FIGURE 39-34. Concept of lymphatic pathways. Owing to the embryonic development of the lymphatic pathways from two sources, the branchiogenic and the body mesenchyme, lymph drains toward two different directions. There is bidirectional flow at the tracheal bifurcation, which is the area of embryologic tissue transition. This feature is consistent with clinical observations. The knowledge of lymph flow and the corresponding lymph node distribution is essential in understanding potential spread of malignancy. (From Liebermann-Meffert D: Anatomy, embryology, and histology. In Pearson FG, Cooper JD, Deslauriers J, et al [eds]: Esophageal Surgery, 2nd ed. Philadelphia, Churchill Livingstone, 2002, p 17.
7. FIGURE 39-33. Primary tumor status (T) is defined by depth of tumor invasion. Regional lymph node (N) status is defined by the absence (N0) or presence (N1) of regional nodal metastases. HGD, high-grade dysplasia. (From Rice TW: Esophageal carcinoma: Diagnosis and staging of esophageal carcinoma. In Pearson FG, Cooper JD, Deslauriers J, et al [eds]: Esophageal Surgery, 2nd ed. Philadelphia, Churchill Livingstone, 2002, p 687.)
8. FIGURE 39-30. Adenocarcinoma of the esophagogastric junction. (From Rice TW, Zuccaro G Jr: Flexible esophagoscopy. In Pearson FG, Cooper JD, Deslauriers J, et al [eds]: Esophageal Surgery, 2nd ed. Philadelphia, Churchill Livingstone, 2002, p 153.)
9. FIGURE 39-37. Use of endoscopic ultrasound allows real-time imaging of lymph nodes within 5 cm of the esophagus, including subcarinal nodes, providing direct access for fine-needle aspiration.
10. FIGURE 39-36. A T2 esophageal carcinoma. Top, A T2 tumor as seen by endoscopic ultrasound. The hypoechoic (black) tumor invades the hypoechoic (black) fourth ultrasound layer (muscularis propria) but does not breach the boundary between fourth and fifth ultrasound layers (arrows). Bottom, A T2 tumor invades but does not breach the muscularis propria. (From Rice TW, Zuccaro G Jr: Endoscopic esophageal ultrasound. In Pearson FG, Cooper JD, Deslauriers J, et al [eds]: Esophageal Surgery, 2nd ed. Philadelphia, Churchill Livingstone, 2002, p 688.)
11. FIGURE 39-38A. A, CT shows diffuse esophageal thickening (arrow). B, FDG-PET shows increased emission in the region of the esophagus. C, CT-PET fusion images show precise anatomic location of the lesion. (Courtesy of Jeremy J. Erasmus, M.D., MD Anderson Cancer Center, Houston, TX.)
12. FIGURE 39-38C. A, CT shows diffuse esophageal thickening (arrow). B, FDG-PET shows increased emission in the region of the esophagus. C, CT-PET fusion images show precise anatomic location of the lesion. (Courtesy of Jeremy J. Erasmus, M.D., MD Anderson Cancer Center, Houston, TX.)
13. FIGURE 39-41. A to C, Overview of transhiatal esophagectomy with gastric mobilization and gastric pull-up for cervical-esophagogastric anastomosis. (A to C, Adapted from Ellis FH Jr: Esophagogastrectomy for carcinoma: Technical considerations based on anatomic location of lesion. Surg Clin North Am 60:275, 1980.)
14. FIGURE 39-42. Mobilization of the stomach for either substernal gastric bypass or esophageal replacement after transhiatal esophagectomy. The gastric and right gastroepiploic vessels are preserved, a Kocher maneuver and pyloromyotomy are performed, and the divided cardia is stapled and oversewn. (Adapted from Orringer MB, Sloan H: Substernal gastric bypass of the excluded thoracic esophagus for palliation of esophageal carcinoma. J Thorac Cardiovasc Surg 70:836-851, 1975.)
15. FIGURE 39-49. Overview of left thoracotomy (A) and esophageal mobilization with gastric pull-up (B) for intrathoracic anastomosis (C). D, The completed low intrathoracic esophagogastric anastomosis is shown. The remaining distal stomach has been mobilized into the chest through the diaphragmatic hiatus and the stomach suspended from the prevertebral fascia with several sutures. The anastomosis is constructed away from the suture line of the gastric transection. The edge of the diaphragmatic hiatus has been sutured to the stomach to prevent herniation of abdominal viscera. The diaphragmatic incision is closed with everting horizontal mattress sutures followed by a running whipstitch of nonabsorbable suture. (A to C, Adapted from Ellis FH Jr, Shahian DM: Tumors of the esophagus. In Glenn WWL, Baue AE, Geha AS, et al [eds]: Thoracic and Cardiovascular Surgery, 4th ed. Norwalk, CT, Appleton & Lange, 1983, p 566, with permission of the McGraw-Hill Companies. D, Adapted from Orringer MB: Surgical options for esophageal resection and reconstruction with stomach. In Baue AE, Geha AS, Hammond GL [eds]: Glenn’s Thoracic and Cardiovascular Surgery, 5th ed. Norwalk, CT, Appleton & Lange, 1991, p 793, with permission of the McGraw-Hill Companies.)
16. FIGURE 39-47. Total thoracic esophagectomy and proximal partial gastrectomy performed for adenocarcinoma limited to the esophagogastric junction and adjacent stomach. Such tumors may be resected with a 4- to 6-cm gastric margin, thereby preserving the entire greater curvature aspect of the gastric fundus and that point (asterisk) that reaches most cephalad to the neck. A proximal hemigastrectomy for such a tumor wastes valuable stomach (stippled area) that can be used for esophageal replacement and contributes little to the “cancer operation.” (Adapted from Orringer MB, Sloan H: Esophagectomy without thoracotomy. J Thorac Cardiovasc Surg 76:643-654, 1978.)
17. FIGURE 39-44. After completing the transhiatal esophagectomy for a localized distal third carcinoma, the surgical stapler is used to fashion a gastric tube from the greater curvature, resecting as much stomach as possible distal to gross tumor. The remaining stomach is then positioned in the posterior mediastinum in the original esophageal bed and is anastomosed to the cervical esophagus. (Adapted from Orringer MB, Sloan H: Esophageal replacement after blunt esophagectomy. In Nyhus LM, Baker RJ [eds]: Mastery of Surgery. Boston, Little, Brown, 1984.)
18. FIGURE 39-50. Overview of right thoracotomy (A) with esophageal resection, gastric mobilization (B), and intrathoracic anastomosis (C) for midesophageal tumor. D, The azygos vein has been divided and the esophagus encircled and dissected away from the posterior membranous trachea. E, Completed high intrathoracic esophagogastric anastomosis at the apex of the right chest is shown. The gastric fundus has been suspended from the prevertebral fascia. (A to C, Adapted from Ellis FH Jr: Esophagogastrectomy for carcinoma: Technical considerations based on anatomic location of lesion. Surg Clin North Am 60:273, 1980; D and E, Adapted from Orringer MB: Surgical options for esophageal resection and reconstruction with stomach. In Baue AE, Geha AS, Hammond GL [eds]: Glenn’s Thoracic and Cardiovascular Surgery, 5th ed. Norwalk, CT, Appleton & Lange, 1991, p 794.)
19. FIGURE 39-45. After transhiatal esophagectomy and pyloromyotomy, the stomach is mobilized through the posterior mediastinum, the fundus is sutured to the cervical prevertebral fascia, and an end-to-side esophagogastrotomy is performed. (Adapted from Orringer MB, Sloan H: Esophagectomy without thoracotomy. J Thorac Cardiovasc Surg 76:643-654, 1978.)
20. FIGURE 39-46. A, The stapler is closed, thereby approximating the jaws; but before firing it, two suspension sutures are placed on either side between the anterior stomach and the adjacent esophagus. B, When the knife assembly of the stapler is advanced, the “common wall” between the esophagus and the stomach is cut and a 3-cm-long side-to-side anastomosis is created. Corner sutures are then placed at either side of the gastrotomy. C, The gastrotomy and remaining open esophagus are approximated in two layers. (A to C, Adapted from Orringer MB, Marshall B, Iannettoni MD: Eliminating the cervical esophagogastric anastomotic leak with a side-to-side stapled anastomosis. J Thorac Cardiovasc Surg 119:277-288, 2000.)
21. FIGURE 39-57. Esophagectomy with interposition of antiperistaltic segment of left colon. A, Incisions used in performance of esophagectomy, cervical esophagostomy, pyloromyotomy, and gastrostomy. B, Extent of esophageal resection (shaded area). C, Preparation of segment of left colon (shaded area) for interposition based on middle colic artery (note sites of vascular interruption, which maintain the integrity of the vascular arcade). D, Completed operation. (A to D, Adapted from Ellis FH Jr: Esophagogastrectomy for carcinoma: Technical considerations based on anatomic location of lesion. Surg Clin North Am 60:265-279, 1980.)
22. FIGURE 39-58. Roux-en-Y reconstruction of the distal esophagus after distal esophagectomy and total gastrectomy for tumor involving the cardia of the stomach. (Adapted from Akiyama H: Total gastrectomy and roux-en-Y reconstruction. In Pearson FG, Deslauriers J, Ginsberg RJ, et al [eds]: Esophageal Surgery. New York, Churchill Livingstone, 1995, p 736.)