Endothoracic endooesophageal pull through

The endothoracic endooesophageal pull through operation is similar to the transhiatal operation insofar as a thoracotomy is avoided for cancers at the extreme ends of the oesophagus. Only the normal oesophageal mucosa is resected and not the whole organ. After the mucosectomy, the remaining oesophageal muscular tube serves as a distensible tunnel through which either the stomach or colon loop is pulled to the neck for primary anastomosis.

Basic science underlying operation

Normal oesophagus differs from the rest of the GI tract in that:

• Strong stratifies squamous epithelial lining
• Thick non fatty submucosa
• Distensible muscular coating without restrictive serosa
• Blood supply is fom the aorta, in branches that ramify and diminish in size rapidly allowing a relatively bloodless filed between mucosa and submucosa

Operation

Two parts

1 Mucosal stripping

    a Abdominal component

    b Neck component

    c Thoracic component

2 Pull through of oesophageal substitute.

Abdominal component

Upper midline incision

Inspection and decision about curability and operability

Mobilisation of stomach and Kockerisation of duodenum

Lower end of the oesophagus is mobilised to 8 to 10 cm above tumour. If the tumour is too high a decision has to be made of whether to perform a transhiatal or a thoracotomy.

The anterior surface of the oesopahgus is incised transversally too reveal the paler mucosal layer. A blunt finger dissection technique is utilised to free the plane

Neck component

The oesophagus is mobilised in the neck, usually via a left antersternocleidomastoid incision

The oesopahgus is incised down to the mucosa

A combination of sharp and blunt finger dissection is utilised until contact with a finger placed via the abdominal incision

The mucosa is cut and the specimen is delivered via the abdomen with sustained gentle traction.

Left antersternocleidomastoid incision

The mucosa of the cervical oesophagus being isolated

Thoracic component

In mid oesophageal tumour the mucosal stripping may need to be started in the mid oesopahgus, usually via a right thoracotomy and division of the azygos vein.

The incision in the oesophagus is sutured to the pleura merely to prevent the pull through from catching on the edges.

Pull through

The oesophageal muscular tube undergoes diffuse spasm post mucosal stripping, this has to be overcome before anything can pass thought its new lumen.

The NG tube is attached to the new oesophageal conduit. This is gently pulled through the oesophageal tunnel utilising gentle finger dilatation ahead of it, which occurs during oesophageal relaxation.

A standard neck anastomosis is then performed.

A post operative CXR is necessary to exclude a post operative pneumothorax.