Thoracic stage and access
The surgical intervention begins with access to the mediastinal organs. For this, a right-sided lateral thoracotomy is performed, with the optimal level being the 5th–6th intercostal space.
After opening the chest cavity, the lung is retracted ventrally (anteriorly) to expose the operative field. Then the surgeon incises the mediastinal pleura along its entire length—from the level of the diaphragm to the cupula of the pleura—granting direct access to the esophagus.
Mobilization of the organ
At the mobilization stage, it is important to carefully separate the esophagus along with the tumor mass, surrounding adipose tissue, and regional lymph nodes.
If the neoplasm is localized in the upper or middle third, it becomes necessary to operate in the area of the azygos vein arch. It is carefully isolated, secured with ligatures, and transected. During the dissection of the esophagus, all blood vessels supplying it are sequentially ligated and transected. For convenience during subsequent manipulations, the mobilized organ is secured with rubber vessel loops.
Resection and management of the stumps
After isolation of the organ, its transection is performed. Work is carried out on the two ends (stumps) of the esophagus:
- Abdominal (lower) stump. The esophagus is ligated directly above the diaphragm. For this, either a transfixion ligature or a mechanical stapling device (e.g., UO-40) is used. After transection, the stump is inverted using a purse-string suture, over which 2–3 interrupted silk sutures are placed for reliability.
- Cervical (upper) stump. The organ is transfixed and transected at the level of the cupula of the pleura. A special rubber cap is placed over the resulting upper stump.
The resected segment of the thoracic esophagus along with the tumor is removed from the operative field. The thoracic stage concludes with closure of the chest cavity, while mandatory placement of two drains is required: one directed toward the cupula of the pleura, and the second toward the diaphragm.
Cervical stage and creation of the esophagostomy
To perform the cervical stage, the patient is placed in the supine position with a roll placed under the shoulder blades. The patient's head must be hyperextended and turned to the side opposite to where the stoma will be brought out.
- Access: a small incision 3–4 cm long is made along the medial border of the lower third of the sternocleidomastoid muscle.
- Isolation: combining blunt and sharp dissection techniques, the surgeons locate the cervical esophagus and bring the upper stump out into the wound.
- Creation of the fistula: the edges of the brought-out esophagus are sutured to the skin with interrupted silk sutures, incorporating all layers of the organ wall.
After the skin wound on the neck is closed, the final stage is performed—gastrostomy, which is necessary for feeding the patient during the period when the continuous digestive tract is absent.
Delayed reconstruction
Dobromyslov-Torek extirpation leaves the patient with an esophagostomy brought out to the neck and a gastrostomy. Restoring the natural passage of food is a separate, complex task.
Reconstructive surgery (esophageal replacement) is performed 3–6 months after the first stage, but only under the condition of confirmed absence of metastases.
Briefly: answers to topical questions
Which arteries supply blood to the thoracic esophagus and are ligated during its mobilization?
The thoracic esophagus is supplied primarily by branches of the thoracic aorta.
Confirmed sources of blood supply include:
- Esophageal branches of the thoracic aorta (rr. esophagei aortae / aa. esophageales) arise from the thoracic aorta; according to sources, there are 3–6 of them.
- Along the walls of the esophagus, arteries branching from the thoracic aorta run and anastomose.
- For the lower thoracic segment, sources indicate the left gastric artery (a. gastrica sinistra).
During esophageal mobilization, blood vessels are ligated and transected. At the level of the tracheal bifurcation within the peri-esophageal fatty tissue, short and large arteries arise from the aorta; during esophageal dissection, there is a risk of damaging them and causing severe hemorrhage.
Which nerves can be damaged during the isolation of the cervical esophagus?
During the isolation of the cervical esophagus, the recurrent laryngeal nerves may be affected, as they are closely related to the trachea and esophagus.
Topography:
- Right recurrent laryngeal nerve (n. laryngeus recurrens dexter) lies in the groove between the trachea and esophagus and ascends toward the larynx.
- Left recurrent laryngeal nerve (n. laryngeus recurrens sinister) runs posterior to the trachea along the anterior wall of the esophagus; in the superior mediastinum, it runs on the left side in the groove between the esophagus and trachea.
Sources also indicate that the innervation of the cervical esophagus is provided by branches of the recurrent laryngeal nerves and the sympathetic trunk.
Which groups of regional lymph nodes are removed along with the thoracic esophagus in cancer?
During extirpation of the thoracic esophagus for cancer, the esophagus is resected en bloc with the tumor, surrounding adipose tissue, and lymph nodes.
According to sources, lymphatic drainage from the esophagus is associated with the following groups of lymph nodes:
- Mediastinal lymph nodes are indicated for the middle thoracic esophagus.
- Tracheobronchial lymph nodes are listed among the lymph nodes of the esophagus.
- Gastric / left gastric lymph nodes are indicated for the lower thoracic and abdominal segments of the esophagus.
- Cervical lymph nodes are indicated for the cervical esophagus.
Sources explicitly state the removal of the esophagus with surrounding tissue and lymph nodes, but without a detailed list of the specific groups that must be removed precisely during thoracic esophagus extirpation.
Class and exam questions
What access is used during the thoracic stage of the Dobromyslov-Torek operation?
A right-sided lateral thoracotomy is used. An incision in the 5th or 6th intercostal space is considered optimal access.
What is done with the azygos vein during esophageal mobilization?
If the tumor is located in the upper or middle thoracic segment, the arch of the azygos vein must be transected between previously placed ligatures.
How is the lower esophageal stump treated before invagination?
The esophagus above the diaphragm is ligated with a transfixion ligature or stapled using a UO-40 device, transected, inverted into a purse-string suture, and additionally reinforced with 2–3 interrupted silk sutures.
When can esophageal plasty be performed after extirpation?
Reconstruction is performed 3–6 months after the primary surgery, provided that the patient has no detectable metastases.
What else to study on this topic
- Topographic anatomy of the azygos and hemiazygos veins
- Surgical anatomy of the mediastinal pleura
- Types of gastrostomy and their creation technique
- Options for esophageal replacement: gastric tube, small and large bowel interposition
- Topography of cervical fasciae and fascial spaces (for esophageal access)
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