Thoracophrentomy

Overview

The left thoracoabdominal incision (Thoracophrentomy) affords excellent exposure for distal esophageal or proximal stomach surgeries. It is especially beneficial for complex reoperations in this region, which are often challenging due to substantial adhesions involving the stomach, diaphragm, and liver.

The left thoracoabdominal incision is used for (1) resection of carcinomas of the lower third of the esophagus or the esophagogastric junction; (2) resection of carcinomas of the middle third of the esophagus, where the tumor is located below the carina; and (3) complex esophageal repairs, most notably reoperative antireflux surgery. A left thoracotomy incision alone with diaphragm division may be adequate in difficult reoperations at the esophageal hiatus or in original repairs of severe hiatal hernias. The left thoracoabdominal incision, on the other hand, is a beneficial extension of this strategy to permit superior exposure and safer operation.

To perform complete esophagectomy with cervical esophagogastrostomy, the left thoracoabdominal incision might be paired with a left neck incision. Using this method, the left colon can be mobilized for use as a substitute conduit for the esophagus by somewhat caudal extension of the lower end of the incision. Finally, the left thoracoabdominal incision affords excellent exposure for complete gastrectomy. The incision makes Roux-en-Y reconstruction of the distal esophagus simple.

 

When Thoracophrentomy is Indicated?

The spleen, stomach, left hemidiaphragm, aorta, and esophagus are all accessible through the left thoracoabdominal incision. It allows for a single-incision approach, simpler mobilization of the stomach (or colon or jejunum) and left gastric lymph nodes, and the potential of a two-team approach with esophagectomies. It enables for early abdominal and thoracic evaluation to guarantee operability before moving further. The exposure does not stop at the distal esophagus. This incision is well tolerated by patients, which I feel is due to strict reapproximation of the diaphragm, chest wall, and costal margin.

• Gastric cancer: Stomach cancer is one of the most frequent malignancies globally, however it is less common in the United States. Only approximately 1.5% of stomach cancers are detected each year in the United States, where cases have been consistently dropping for the past ten years. In stomach cancer, also known as gastric cancer, cancer cells proliferate uncontrollably in the stomach. Cancer can develop in any part of your stomach. The majority of stomach cancer instances in the United States involve abnormal cell development at the junction of your stomach and esophagus (gastroesophageal junction). Cancer normally starts in the major area of your stomach in other nations where gastric cancer is more frequent.  

About 95% of the time, stomach cancer starts in your stomach lining and progresses slowly. Untreated, it can form a mass (tumor) and grow deeper into your stomach walls. The tumor may spread to nearby organs like your liver and pancreas.

• Esophageal cancer: Esophageal cancer is the world's tenth most frequent cancer. It begins in your esophagus, the lengthy muscular tube that transports food from your neck to your stomach. Esophageal cancer tumors may not create symptoms until the malignancy has spread. Early-stage esophageal cancer is treated surgically to remove tumors or alleviate symptoms. Chemotherapy, radiation therapy, and immunotherapy may be used to treat advanced or late-stage esophageal cancer. When they are unable to cure the cancer, they focus on extending people's lives, alleviating symptoms, and maintaining quality of life. Medical experts are developing medicines to help individuals with esophageal cancer live longer lives.
• Peptic ulcer disease: Peptic ulcer disease is a disorder in which painful sores or ulcers form in the stomach lining or the first section of the small intestine (the duodenum). Normally, a thick coating of mucus shields the stomach lining from the effects of its digestive fluids. However, several factors can weaken this protective barrier, allowing stomach acid to harm the tissue. Many persons with ulcers have no symptoms at all. Some persons who have ulcers experience stomach discomfort. This ache is usually felt in the upper abdomen. Food might help the discomfort go away or make it worse. Other symptoms include nausea, vomiting, and feeling bloated or full. It is important to know that there are many causes of abdominal pain, so not all pain in the abdomen is an “ulcer”.

The most common symptoms of ulcers are those associated with bleeding. Bleeding from an ulcer might be gradual and undetectable, or it can be life-threatening. Ulcers that bleed slowly may not cause symptoms until the patient becomes anemic. Anemia symptoms include weariness, shortness of breath during activity, and pale complexion. Rapid bleeding may manifest as melena, a jet black, highly sticky stool (sometimes compared to "roof tar"), or a substantial volume of dark red or maroon blood in the stool. People who have bleeding ulcers may vomit. This vomit may be red blood or may look like “coffee grounds”. Other symptoms might include “passing out” or feeling lightheaded. Symptoms of rapid bleeding represent a medical emergency. 

• Duodenal cancer: Duodenal cancer is characterized by a mass of irregular, rapidly growing cells (tumor) in the initial segment of the small intestine. This tumor may impede your gut from properly digesting food and from passing food through it. You may have no signs of duodenal cancer in its early stages. If the intestinal tumor develops, you may have digestive symptoms such as nausea, constipation, or abdominal cramps. Because your duodenum includes a range of cell types, a number of malignancies can begin there. 

The four primary kinds of duodenal cancer are as follows:

• Adenocarcinoma affects the cells that produce the chemicals, enzymes and other fluids that break down food.
• Carcinoid tumors are slow-growing tumors that often start in your gastrointestinal (GI) tract and spread throughout your body.
• Lymphoma starts in the immune system cells that fight infection.
• Sarcoma starts in your bones or soft tissues, such as your muscles or blood vessels. The most common type of GI sarcoma is a gastrointestinal stromal tumor.

 

Disadvantaged Contraindications

This approach is contraindicated in patients who have had previous operations involving the left chest, injuries, infections, or empyema. It also should not be considered for patients who cannot physiologically tolerate a thoracotomy.

 

How to Prepare Before Thoracophrentomy?

Because of the enormity of a thoracoabdominal esophagectomy, or any esophagectomy, it is critical to do a thorough selection and staging work-up before proceeding with surgical intervention. Although patients with widely disseminated disease and severe concomitant conditions are quickly excluded from surgical consideration, the majority of patients receive a systematic evaluation of resectability and a review of risk factors.

A contrast esophagogram and upper gastrointestinal endoscopy should be performed on individuals with esophageal cancer. Esophagoscopy with lesion biopsy is required to acquire a tissue diagnosis, confirm the absence of a second synchronous esophageal carcinoma, and provide a more precise estimate of the tumor's extent both grossly and microscopically by mucosal biopsy. Endoscopy can also detect Barrett's esophagus and assess potential gastric involvement.

CT imaging of the thorax and abdomen offers further information on invasion of surrounding tissues (such as the pericardium and diaphragm), tracheobronchial invasion, and mediastinal lymph node involvement. However, recent studies have found that CT imaging is only 50% accurate in detecting the presence of locoregional disease. CT imaging of the abdomen with contrast material can also help identify hepatic metastases.

Endoscopic ultrasonography (EUS) is extensively utilized for local esophageal cancer staging. It gives useful information about the degree of tumor invasion, probable nodal involvement, and the possibility of fine-needle aspiration of nearby lymph nodes. In esophageal cancer, accuracy in predicting T status with EUS is better than 80%, whereas accuracy in predicting N status is about 70%. In terms of T staging, EUS definitely outperforms CT and appears to be more accurate in predicting T4 disease.

PET imaging is becoming a more useful technique in assessing distant metastatic illness. PET scans play essentially little effect in determining T status, but the findings for metastatic disease are promising, with claims of higher than 90% accuracy. (PET imaging may also be useful in monitoring illness recurrence.)

An assessment of pulmonary and cardiovascular function is part of the preoperative risk factor evaluation. If the patient's respiratory condition is in doubt, pulmonary function tests should be performed. Smoking should be discontinued several weeks before surgery. A cardiovascular evaluation should also include a history and physical examination, as well as an ECG and, if necessary, a stress test or cardiac catheterization.

 

How Thoracophrentomy is Performed?

1. The patient is in full right lateral decubitus, with the left side elevated. Without any tilt, the hips are kept perpendicular to the operating table. Compression protection should involve the use of an axillary roll and pillows between the legs. The left arm is supported by an arm holder or a stack of folded bath blankets between the two arms, which are then orientated in a "prayer posture," and the entire left chest and abdomen are sterilely prepared and covered. The thoracic drape is intended for a complete posterolateral thoracotomy. Drapes are placed to the right of the midline and below the umbilicus on the abdomen.
2. If a complete esophagectomy is planned, the left arm is sterilely prepped and free draped with a sterile towel and gauze. After that, the left neck is prepared. The sterile field has expanded to embrace the left shoulder, arm, and neck. The free draped left arm is withdrawn upward at first to maximize exposure of the thoracoabdominal incision and then downward to expose the neck for isolation of the cervical esophagus and formation of the esophagogastric anastomosis. A significant benefit of this method is the single location, which permits simultaneous access to the abdomen, chest, and neck.
3. An oblique incision is made 2 fingerbreadths beneath the scapular point. This is brought parallel to the ribs and crosses the costal arch around one-third of the way from the xiphisternum to the costal arch's terminus. The incision has a small inferior curve as it reaches the midline of the abdomen. The incision is deepened to the chest wall, and the latissimus dorsi and serratus anterior muscles are divided.
4. By splitting the intercostal muscles flush along the top border of the eighth rib, the chest is entered in the seventh intercostal space. Divide the obliques at the inferior border of the costal edge to enter the abdomen. Although the rectus muscle is maintained and merely retracted towards the abdominal midline, the anterior and posterior layers of the rectus sheath are split.
5. A big Kelly clamp is then quickly passed deep to the costal edge. At this stage, the cartilage is severely divided using a knife. This technique frequently splits the musculophrenic archery as well (ie, one of the terminal branches of the internal mammary artery). At this time, the musculophrenic artery should be firmly ligated.
6. Using moist laparotomy sponges, the left lung is deflated and packed cephalad and anteriorly. A set of O-silk stay sutures are then inserted along the diaphragm's perimeter. These stay sutures appropriately position the diaphragm for subsequent precise closure. They are also useful for successively retracting the split margins of the diaphragm to improve exposure of the abdomen or chest. The diaphragm is then divided using electrocautery while remaining within the route defined by the stay sutures. A 1-in attachment of diaphragm must be left inserted to the chest wall to allow the secure closure of the diaphragm at the conclusion of the operation. The total length of this phrenotomy is approximately 15 cm, and it joins the apex of the line of incision in the abdominal obliques in the shape of the letter “T.”
7. Retraction of the stay sutures upward offers excellent access to the left upper quadrant of the abdomen. The whole stomach and esophagogastric junction are freely accessible. The triangle ligament can be separated, allowing the liver's left lateral section to be mobilized and retracted to the right. This exposure allows for the formation of a pyloroplasty or pyloromyotomy, as well as the Kocher technique if necessary. Also visible are the transverse colon, splenic flexure, and upper descending colon. A slight caudal extension of the incision exposes more of the descending colon, allowing for complete left colonic mobility and colonic interposition if needed.
8. Before commencing closure, a 28-F chest tube is advanced posteriorly and apically along the course of the esophagus. This tube is brought out through a separate stab wound inferior to the main incision, secured to the skin, and connected to a drainage apparatus.
9. Closure of the diaphragm is facilitated using the previously placed stay sutures. The divided margins of the diaphragm are approximated with a series of horizontal mattress 0-polyprolene sutures. A second layer of continuous 0-polyprolene sutures is then used to approximate securely the diaphragm. A Ustitch is used at the confluence of the lines of division of the diaphragm and abdominal oblique. The rectus sheath is closed with continuous 0-polyglactin sutures in the anterior and posterior layers. A continuous 0-polyglactin suture is used to close the peritoneum and abdominal obliques in one layer.
10. The ribs are approximated with a series of figure-of-eight. A 1-cm segment of the cut end of the costal margin is excised to prevent any override of the cartilage after closure.
11. A single figure-of-eight, polyglactin suture is used to stabilize the cut margins of the costal arch once the pericostal sutures are tied.
12. The fascia of the latissimus dorsi and serratus anterior muscles are approximated with continuous 0-polyglactin suture, respectively. Subcutaneous tissues are approximated with continuous 2-0 polyglactin sutures.
13. Skin is approximated with staples. Sterile dressings are applied, and the drapes are taken down. The patient should be rolled supine for reintubation with a single lumen endotracheal tube if necessary.

 

Post-Operative Care

The initial postoperative care is determined by the scope and duration of the procedure. In the case of a relatively simple procedure, quick extubation is possible. Otherwise, the author chooses to ventilate the patient electively overnight with the goal of extubation the next morning. The thoracic epidural catheter is crucial for achieving sufficient pain relief to allow for forceful coughing and secretion clearance. The chest tube is kept in place with -20 cm water constant suction.

The type of the procedure determines how long the chest tube is managed. When an esophagogastrectomy is performed, the chest tube is often sutured at the esophagogastric anastomosis. The author likes to leave this tube in place until the patient has undergone at least 48 hours of postoperative oral intake. This cautious strategy is used to provide for enough external drainage in the case of an anastomotic leak. Small leaks are sometimes missed on the first contrast esophagogram but become apparent after starting oral intake within a couple of days. When there is no evidence of an air leak and the fluid drainage is less than 200 mL per 24 hours, the chest tube may be withdrawn.

 

Conclusion

The Thoracophrentomy is used for the following procedures:

• Resection of carcinomas of the lower third of the esophagus or the esophagogastric junction. 
• Resection of carcinomas of the middle third of the esophagus, where the tumor is located below the carina. 
• Complex esophageal repairs, most notably reoperative antireflux surgery. 

In difficult reoperations at the esophageal hiatus or in initial repairs of severe hiatal hernias, a Thoracophrentomy alone with diaphragm division may be sufficient. The Thoracophrentomy, on the other hand, is an advantageous extension of this method that allows for more exposure and safer surgery.