What is the surgical procedure for esophageal cancer that involves sewing in a tube?

Esophagectomy with Gastric Conduit Reconstruction

The surgical procedure you're referring to is esophagectomy with gastric conduit (gastroplasty) reconstruction, where the stomach is mobilized, fashioned into a tube, and sewn to the remaining esophagus to restore continuity of the digestive tract. 1

The Gastric Conduit ("Tube") Procedure

The "tube" being sewn in is actually the patient's own stomach that has been surgically mobilized and tubularized to replace the resected esophagus:

• The stomach is the preferred conduit for esophageal reconstruction after cancer resection 1
• During the procedure, surgeons mobilize the stomach by dividing the left gastric artery while preserving the gastroepiploic and right gastric arteries to maintain blood supply 1
• The stomach is then pulled up through the chest and anastomosed (sewn) to the remaining esophagus 1
• Alternative conduits include colon or jejunum, but these are typically reserved for patients who have undergone previous gastric surgery or procedures that compromised the stomach 1

Standard Surgical Approaches

The specific technique used depends on tumor location and surgeon preference:

Ivor Lewis Esophagogastrectomy (Most Common)

• Uses laparotomy and right thoracotomy with intrathoracic anastomosis at or above the azygos vein 1, 2
• The most frequently used procedure for transthoracic esophagogastrectomy 1, 2
• Suitable for lesions at any thoracic location, though proximal margin may be inadequate for middle esophageal tumors 1, 2

McKeown Esophagogastrectomy

• Involves right thoracotomy, laparotomy, and cervical anastomosis 1
• Recommended specifically for midesophageal tumors 3
• Creates the anastomosis in the neck rather than the chest 1

Transhiatal Esophagogastrectomy

• Performed through abdominal and cervical incisions without thoracotomy 1, 4
• The gastric conduit is drawn through the posterior mediastinum and exteriorized in the cervical incision for anastomosis 1
• Associated with lower morbidity than transthoracic approaches but less extensive lymph node dissection 1, 2

Modern Minimally Invasive Techniques

Minimally invasive esophagectomy (MIE) is increasingly recommended over open approaches due to superior outcomes:

• MIE results in lower postoperative morbidity, reduced pulmonary complications, quicker functional recovery, and improved quality of life 3, 5
• Population-based studies show better long-term overall survival with MIE compared to open esophagectomy 3
• MIE is considered the surgical approach of choice in experienced centers 3
• Techniques include minimally invasive Ivor Lewis (laparoscopy + limited thoracotomy) and minimally invasive McKeown (thoracoscopy + laparoscopy + cervical incision) 1

Anastomotic Techniques

The actual "sewing" of the gastric tube to the esophagus can be performed using:

• Hand-sewn anastomosis: Two-layer technique with creation of an esophageal mucosal tube for precise mucosal approximation, associated with leak rates as low as 2% 6
• Stapled anastomosis: Circular stapled or triangulating stapling techniques, though these may have higher rates of anastomotic complications including leakage and stenosis 6, 7

Critical Considerations

This surgery should only be performed in high-volume esophageal centers by experienced surgeons 1, 3:

• At least 15 lymph nodes should be removed during esophagectomy for adequate staging 1, 8
• Patients unable to swallow during induction therapy should receive feeding jejunostomy rather than gastrostomy, which would compromise the gastric conduit 1
• Open surgery remains the standard for patients with previous abdominal surgery, large/bulky tumors, or when lymph node dissection may be difficult 8