Esophagectomy and Reverse Gastric Tube: Gavriliu I
This operation is indicated in patients with cancer of the proximal half of the thoracic esophagus, without metastatic extension below the diaphragm. The procedure shown here is a Beck-Jianu-Gavriliu reverse gastric tube.
The indications for routine, simultaneous, or delayed one-sided or bilateral neck dissection in the absence of macroscopically recognizable lymph node metastases remain unresolved. Studies, mostly by Japanese authors, give validity to the concept of radical neck dissection in operable and hopefully curable cancers of the cervical and thoracic esophagus. It would appear, however, that one-stage radical esophagectomy, creation of a substitute organ, and classic or modified neck dissection(s) represent a formidable challenge for these often nutritionally compromised patients, as well as for one team or even several teams of surgeons.
The concept of sentinel node mapping and biopsy—so successfully used in operations for melanoma and breast cancer—may help in solving this dilemma. For an elongated organ such as the esophagus, spanning three anatomical spaces—the neck, mediastinum, and abdomen—and lacking the protective cover of a serosa, the lymphatic drainage can be unexpectedly erratic. Although the various patterns of drainage to the three potential lymph node basins are statistically well established for any tumor level, the knowledge that in a small number of patients all three locations are possible, could be interpreted as the need to radically excise all three lymphatic basins for any curative operative attempt—an almost impossible task in an operation as demanding as is the excision and replacement of the esophagus. Therefore, the intraoperative detection, biopsy, and histological examination of sentinel nodes below the diaphragm and above the clavicles could be of great value in proving the absence or presence of metastatic disease. A clear upper abdominal lymphatic basin would establish the performance of a reverse gastric tube on a secure basis. Clear or only unilaterally involved cervical lymphatic basins would justify the withholding of radical neck dissections or establish the approach on the side of identified metastatic disease for both the lymph node dissection and the esophago-substitute anastomosis. Since the thoracic esophagus is always excised—either by thoracotomy or thoracoscopy—a complete dissection of fatty and fibrous tissues in the posterior mediastinum, around the trachea, main bronchi, pericardium, and pulmonary vessels and aorta, on the side exposed by the approach, should be part of the excision, as far as the density of vital organs in this area allows an "en bloc” dissection.
The reverse gastric tube has a rich and dependable blood supply, requires only a slender channel to pass through in either substernal or posterior mediastinal position, and readily reaches the neck. The staple-constructed gastric tube transports food efficiently and empties readily into the stomach.