Anatomy of Important Structures for Esophageal Reconstruction

Esophageal reconstruction is a difficult operation. The difficulty arises from the fact that the operation concerns the neck, chest, and abdomen, and many organs, such as the thyroid gland, recurrent laryngeal nerves, thoracic duct, and pleura, are at particular risk. The parietal pleura is firmly attached to both sides of the vertebral column, thus forming a recessed protruding relationship with the esophagus. This configuration makes it difficult to dissect the esophagus in the thorax. Therefore, pleural rupture is dangerous during surgery. Another difficulty is that the organs used for esophageal reconstruction or replacement vary according to the tumor’s location. The stomach is used for esophageal reconstruction for tumors in the middle or lower third of the esophagus. In superior mediastinal segment tumors, the use of the stomach is not appropriate and a flap formed between the terminal ileum and right colon is used for esophageal reconstruction. Due to its vascular structure, the right colon is used more frequently. The suitability of abdominal structures for esophageal reconstruction or interposition primarily depends on their ability to be mobilized to the extent permitted by their self-supplying vessels. In addition, the lumen diameter and length of the organ to be interposed, whether there are intrinsic diseases, and its ability to maintain aboral peristalsis are also important factors. Therefore, it is necessary to know especially the vascular anatomy and other anatomical features of the stomach, the duodenum, the jejunum, and the colon used in reconstruction after esophagotomy. It is essential to know the anatomy of the neck, as extensive neck dissection is performed during esophagotomy. Although the cervical part of the esophagus is located behind the trachea, it usually protrudes toward the left lateral. Therefore, in esophageal surgery, neck dissection is performed on the left side. Thus, only the thoracic duct, the left thyroid lobe, and the left recurrent nerve located on the left side of the neck become meaningful. The thyroid gland needs excellent attention during neck surgery owing to its relations and its variational structure. Since esophagectomy is performed on the left side of the neck, anatomical abnormalities or variations of the left recurrent laryngeal nerve are also significant for esophagus surgery. Another vital structure for esophageal surgery is the thoracic duct. Any injury to the thoracic duct can cause chylothorax, which is sometimes fatal. In recent years, thoracoscopic esophagectomy applications in the prone position have become widespread due to the precise dissection around the thoracic canal.