Would You Perform an Esophagectomy at a Rural Hospital?
We're revisiting a conversation from The Rural American Surgeon archives with Dr. Gary Timmerman, exploring what it takes to perform complex surgery in a rural hospital, including the preparation, surgical judgment, and technical skills required to take on major operations.
In this How I Do It episode, host Dr. Randy Lehman and Dr. Timmerman take an in-depth look at esophagectomy, including transhiatal and Ivor Lewis approaches, open versus robotic surgery, reconstruction techniques, and why every surgeon needs a backup plan when things don't go as expected.
How do you know when you're prepared to perform a complex operation in a rural setting?
Dr. Timmerman shares how he developed an esophageal surgery practice in Watertown, South Dakota, and why he waited four years before performing his first esophagectomy. He discusses the extensive preparation involved, from continuing surgical education and mentorship to documenting outcomes and establishing relationships with larger medical centers, including Mayo Clinic and the University of Minnesota.
The conversation then moves into the surgical techniques themselves. Dr. Lehman and Dr. Timmerman compare transhiatal and Ivor Lewis esophagectomy, discuss open and robotic approaches, and examine the challenges of operating without the same resources and immediate specialist support available at major academic hospitals.
They cover stomach mobilization, gastric conduit creation, cervical anastomosis, lymph node dissection, and alternative reconstruction techniques, including colonic and small bowel interposition when the stomach isn't a suitable conduit.
Dr. Timmerman also shares his experience with early robotic esophagectomy in South Dakota and explains why he continued reviewing multiple operative approaches before every case, even after years of experience.
For rural general surgeons who may never perform an esophagectomy, the conversation also provides practical insights into esophageal cancer diagnosis, Barrett's esophagus surveillance, biopsy decisions during upper endoscopy (EGD), and laparoscopic jejunostomy (J-tube) placement.
Throughout the discussion, one message remains constant: practicing in a rural community is no excuse for compromising surgical standards. Whether performing a routine procedure or tackling a complex operation, surgeons must be prepared to make sound decisions, recognize their limitations, and provide the best care possible for their patients.
Key Takeaways
00:00 Rural Surgery Requires High Standards
00:29 Introducing the How I Do It Series
01:08 Taking on Esophagectomy in Rural Practice
02:53 Building Support From Larger Centers
03:34 The Responsibility of Complex Surgery
05:29 Learning Multiple Esophagectomy Approaches
06:19 Transhiatal vs Ivor Lewis Esophagectomy
08:21 Early Robotic Esophagectomy Experience
09:46 Always Have More Than One Surgical Option
11:25 Preparing Patients Before Esophagectomy
12:44 Transhiatal Esophagectomy Step by Step
16:12 Mobilizing the Esophagus and Neck
18:56 Creating the Cervical Anastomosis
21:47 When the Stomach Cannot Be Used
22:14 Colonic Interposition and Alternative Conduits
25:49 Hand-Sewn Anastomosis Technique
27:09 Biopsy and Barrett’s Surveillance
30:04 Holding Rural Surgery to the Same Standard
30:44 Feeding Access and J-Tubes
32:27 Laparoscopic Jejunostomy Technique
36:24 J-Tube Risks and Internal Hernias
37:25 Open Surgery vs Minimally Invasive Techniques
Resources Mentioned
American College of Surgeons:
https://www.facs.org/
ACS Clinical Congress:
https://www.facs.org/for-medical-professionals/conferences-and-meetings/clinical-congress-2026/
Mayo Clinic:
https://www.mayoclinic.org/
University of Minnesota:
https://www.umn.edu/
Da Vinci Surgical System:
https://www.intuitive.com/en-us/products-and-services/da-vinci
Episode Transcript
Dr. Randy Lehman (00:29):
All right. The next episode of our show is a how I do it. And so we go into extreme detail about how you do a particular operation. What are we going to do?
Dr. Gary Timmerman (00:38):
Well, you know, for my practice in Watertown, it is very much like it is believed to be. Most of it's endoscopy. a great deal of it was fundamental surgery like hernia repairs. A great deal of it is gallbladders. And then maybe a little bit more commonly was colon surgery and small bowel obstruction. So a lot of the fundamental things, I was very okay with that. But again, I was trained very much also in a very big city. And my favorite operation that I felt very good at when I left was esophagectomy. And then people are going to go,"Okay, what's he talking about, the esophagectomy?" And you may have heard me say about the idea of,
Dr. Gary Timmerman (01:24):
"If you're going to do something, you better do it well." and you better be able to defend it and you better be able to know that you offered the patient everything there was for it. And that actually is one of the biggest reasons I got heavily involved with the College of Surgeons and every clinical congress I went to. I absorbed every seminar on esophagectomy and esophageal management. I bought every journal and every text that I could that talked about esophageal surgery. And remember I said I was always doing lungs, I was doing vascular, and I really felt that if I had the right support with it, and I did have an intensive care, and by the way I was the intensivist,
Dr. Gary Timmerman (02:06):
and I had another contemporarily trained partner who also felt comfortable in the ICU. that given the opportunity we might consider doing something like that. It took me about four years to get the courage to do that but not only did I do it but I did on average probably anywhere from 7 to 12 a year. Now a lot of places would say that was way too few. Yet, you also need to know that every one of those patients I actually included in papers that I wrote, articles I wrote, presentations I made to our South Dakota, North Dakota chapter of College of Surgeons, and even to the point where I presented it elsewhere outside of South Dakota.
Dr. Gary Timmerman (02:47):
so that I could at least demonstrate to the individuals that were doing a lot of them that I was being conscientious. I also made allies with Mayo Clinic and University of Minnesota that I would be able to contact them. They felt comfortable with what I was doing out there. I never felt that I was doing something I shouldn't be doing. And so, yeah, I'm not encouraging your listeners to take on something like a Whipple, although ultimately that was my career at the end. But at the same time, I had to be able to say I'm not going to start doing Whipples again at age 45. I had to know how to keep that up.
Dr. Gary Timmerman (03:22):
And I always knew one day I'd probably be moving to a larger community. I did not suffer horrible complications. But believe me, I spent a lot of nights with folks to make sure they didn't suffer complications. Can you do it? Yeah, but it comes with a huge responsibility if you're going to take on big stuff.
Dr. Randy Lehman (03:40):
Yeah. So that's what I was hoping that you would say. And for the listener. Basically, we were thinking and we're going to talk about one quote that you have was that I've already heard is you have to have options when you don't have options. Am I saying that correctly? Yeah. So we were going to talk about inguinal hernia because there's several ways to do it and tissue repair and stuff like that. But then you kind of mentioned to me just before we started the show, you know, you had to practice with the stop objective. I'm like, I might not have. Most of my guests aren't going to be able to talk to me up and down about options for a
Dr. Randy Lehman (04:09):
subject. I'd love to talk about it. I'll tell you my background. I'm five years out of training. I can see how a person that's four or five years out of training now is different than a person that's one year out of training. I can see why you waited four years to do your first one. But I'll also say I trained at Mayo and the thoracic surgeons did. uh obviously lung surgery the esophagus surgery and the hiatal surgery at mayo and so i was i had two great rotations on thoracic surgery and i had a really great fellow and then some other good surgical mentors and we divided because he didn't really need any more hiatal work
Dr. Randy Lehman (04:42):
And I knew I wanted to have that as part of my practice, but I knew I wasn't going to do a esophagectomy. I'm not going to do lobectomies either. And so like I would do some of the minor chest cases and the hiatal work, and then he would go do the Ivor Lewis and... know, the lobectomies and it worked out really well, the division of labor. And so that's my perspective. I know I'm never going to do a esophagectomy because I took these tests when I was a medical student and it said, you like to do 30 to 90 minute operations that do well, and go home and you can go to sleep. And you like to do a lot of them.
Dr. Randy Lehman (05:11):
And I don't think I would sleep well enough. I don't know. We'll see. It's a long career. But I would love to pick your brain about the many options. And esophagectomy specifically is an operation where there are drastically different approaches. Right. So I'm going to let you just take that where you want. And then I'll fill in with some questions.
Dr. Gary Timmerman (05:29):
I was blessed in that I trained at Rush and we had several surgeons that did esophagectomy, one in particular. He's one of my giants of surgery, Alex Doolas, and he trained, he did him with Orringer. If you remember the blunt esophagectomy was a transhiatal. and he was phenomenal at it. And he showed me and then taught me how to do blunt esophagectomy. And then I had another surgeon down in the southern part as a community hospital that did Ivor Lewis's and retrosternal esophagectomies as far as replacements would do the stomach pull through retrosternal. So I was, I had a really large exposure and fund of knowledge for that.
Dr. Gary Timmerman (06:09):
and also knew about the complications, knew about what it took, but still my own paranoia kept me always at the cutting edge of what was going on. So you're right, trans-hiatal, blunt esophagectomy, it was back in the 80s when esophageal cancer. at a cure rate of less than probably 15%, maybe 12%. And so actually a blunt esophagectomy was moderately the least invasive operation because it got, you didn't have to open two cavities. You could get it down in the neck. If you get a leak in the neck, it's much better tolerated than a leak in the chest. And it kind of just got through the obstruction. And most of these folks still succumb to their metastatic cancer.
Dr. Gary Timmerman (06:51):
A lot of them were obstructed when they presented. And then... Over time, we finally got some decent chemotherapy and neoadjuvant, something new. And I helped bring that back to our community. We didn't even have radiation therapy yet in Watertown at the time. And my patients were going to Sioux Falls to get their neoadjuvant or Aberdeen, which is about both ways, about two hour drive to get five days a week of radiation. and then come back for me to do their definitive operation. And when I decided to do esophagectomies four, five years later, I remember visiting with Dr. Doulis and said, your safest bet is to do everything in front of you, do them open. You don't want a complication.
Dr. Gary Timmerman (07:33):
You can't afford a complication. Do an Ivor Lewis. So, an Ivor Lewis, of course, is a thoracoabdominal. There's three phases as well, but you still use the stomach as the conduit and you do the anastomosis in the neck and everything is with direct vision. Those went very well. And to be honest, I probably only had done a couple of blunts and I just liked the safety of open. in my circumstance. Again, having comfortable ability with my pneumonectomies and my lobectomies, I felt comfortable doing the chest and closing and it was a long operation. You're right, it's not a 30-minute operation. But at the end of the day, complication rates, our biggest complication was atrial arrhythmias,
Dr. Gary Timmerman (08:14):
SVT. I studied all of this. I had a leak rate of less than 2%. And thankfully, none in the chest. Most of those were in the neck when I was still doing some blunts. And then actually, well, I guess it was 1999, maybe 2000, I went to a clinical congress and there was a surgeon there sitting at a machine and the patient was like in France and he was doing a gallbladder and it was called the robot and back then it was called Zeus. And I got back and I, by this time, moved to Sioux Falls and I said, you know, we should get us one of these things.
Dr. Gary Timmerman (08:49):
This thing looks phenomenal. And we actually did. And we got the first da Vinci in the entire upper Midwest. And then I went off. You had to go to do training again. It wasn't hard for me. It was in my nature. And I went to San Jose where the company was and learned how to use the da Vinci to its maximum. with full intent to do trans-hiatal esophagectomies with it. And that, of course, you can do most anything you know with it. But I did the first 25 esophagectomies with the robot in South Dakota and then published that and presented that at numerous medical conferences across the United States. By this time, I was more involved in the college.
Dr. Gary Timmerman (09:28):
And again, because I have the ability to demonstrate my outcomes and people could question me about it. I don't think anybody threw anything at me. I don't think they probably do, but not openly. They didn't write articles about how horrible I was for doing it. They knew the due diligence that I was doing. And so. Talk about three ways to do it. Yeah, you can use the stomach. I've used the colon. I've used, I've put them in, in situ where the esophagus normally resides. I've done retrosternal. I brought it to the neck. I brought it in the chest. I've done three phase. All of those things, Randy, every time I do an esophagectomy, and there might be
Dr. Gary Timmerman (10:07):
even at the end of my career, 15 to 20 a year, I would read for darn near six hours, five hours, making sure I knew every way to do it in the event that maybe the stomach conduit didn't look viable. Maybe I needed something else and I couldn't use the stomach and the colon better be prepped. Maybe the colon didn't look well and I had to use a small bowel. So every one of those operations, I had an alternative. And that's what I just. drill into my medical students going into surgery. When you think of something, think of three ways to do it. When you think of a diagnosis, give me three diagnoses so that
Dr. Gary Timmerman (10:46):
you know how to hone in on something. That's probably been my best life lesson that I learned practicing where people were always going to be looking at me saying,"Are you sure you should be doing that? Can you be doing that?" And then having the wherewithal to show that, yes, you can do it, but you better prove to know you know how to do it.
Dr. Randy Lehman (11:04):
Yeah, I feel a lot of that same pressure. I very much understand it. For the how I do it, I often like to approach it as if, say, you're talking to an intern that never did an esophagectomy before, or even if you're writing an op note. Could you, one really quick question, did you prep everybody before all? Yeah.
Dr. Gary Timmerman (11:25):
Yeah, my first 10, 15 years, I sure did. But, you know, as technology got better and we could study the stomach better and we knew what the vasculature with CAT scans and, you know, CTs with IV contrast, I could actually see the vessels. Not as much. But I typically would give them. So. it is not uncommon to give GoLYTELY and I never felt bad about that. And especially after neoadjuvant where so many of the folks when they first came in, they were so debilitated and they had to go straight to surgery, just like Whipple's. As we got better and they got neoadjuvant, you could actually beef these people up.
Dr. Gary Timmerman (12:00):
And I had them all on impact. I had them on high protein diets, getting them ready for it so they could withstand a bowel prep. Because a lot of times they had one leg sadly in the grave. as we were able to do things neoadjuvantly, I can beef these folks up, get their back in positive nitrogen balance, get their protein levels back up. Bowel preps are really hard on people that are dehydrated and sick because they're obstructed and we didn't have neoadjuvant yet. Yeah, I was really nervous. Usually they don't use it anymore. Fleet Phospho-soda, that really worked well. It was a great bowel prep, but it just zapped the heck out of them.
Dr. Gary Timmerman (12:36):
Now with GoLYTELY, it was a lot better than what it was. But I mean, in the first 10 years, I sure did. And then as I got confidence with what I was doing, not as commonly.
Dr. Randy Lehman (12:45):
Yeah. So why don't we pick the transhiatal approach? And can you just talk to me from positioning? prepping oh yeah incision exactly in detail how you do each step of the operation all the way
Dr. Gary Timmerman (13:00):
through closure well okay so i'll be honest i'm gonna tell you how we did it because it's basically the same setup with the robot when i would do it because i would do transhiatal and And then now a lot of folks do the robot and then put the robot in the chest to do it an intrathoracic operation, like a minimally invasive Ivor Lewis, I would do it like a blunt. So of course, I lay the patient supine arms, anesthesia usually lives their arms out so they can put all kinds of access. They typically have a central line, but I prefer a subclavian because
Dr. Gary Timmerman (13:34):
I want the neck open. So, and then I would use the left neck. So we would prep the left neck. And then I, knowing that I was going to do a blunt, I would shave the chest, but I wouldn't prep the chest and then have them supine. much like doing a Nissen where the abdomen is exposed full torso. If I was doing this open, I'd make my upper midline incision, explore the whole abdomen first looking for mets. and then having found none, then I would mobilize the whole stomach, taking down usually the short gastric first around the spleen, leaving the right gastroepiploic so I have a decent blood supply to my proposed pouch. Then I go and encircle the esophagus.
Dr. Gary Timmerman (14:20):
Typically, if there's a cancer there, you can usually feel that. I would take a rim of hiatus with it if I could to make sure I got any kind of invasion. away from that even after they had neoadjuvant i would still do that just to for margins take that and then so that's a rim of the diaphragm a rim of the hiatus yeah just right around just the muscle right around it got it and then uh go along and i would skeletonize the left gastric um down all the way down to its root and then take the left gastric with the specimen um and then After I've got the whole proximal four stomach mobilized, then I would take staplers and I would
Dr. Gary Timmerman (15:00):
begin about the second vessel to the antrum. I would call it, you know, where your nerves of Latarjet come down onto the stomach and then that leaves you your antral branches. I usually would leave the first couple there and then staple into the lesser curve. and then make my pouch alongside so that, I don't know, it's more of a visual thing. I would give at least two, sometimes three centimeters along the greater curvature, which is going to be my interposition conduit and staple that up. It would take several staple loads. I'm an old-fashioned guy. I would always over-sew my staple line. I just didn't like leaks and I didn't like the risk of leak. And you did that.
Dr. Randy Lehman (15:39):
You're using an open stapler to do this.
Dr. Gary Timmerman (15:40):
Yeah, it was. um i don't know 60. the what stable height the thicker thicker staples the
Dr. Randy Lehman (15:47):
greens the green then you over sewed it with
Dr. Gary Timmerman (15:49):
silks or what you used to over so interrupt interrupted 3-0 silk pop-offs and then just go along up and so everything looks invaginated so it's and it also is smoother it slides easier and then Now, like I said, if I'm going to pull this out through the neck, I would not complete it. I would take the staple line close to the angle of His, but away from the angle of His toward the greater curvature. out toward the greater curvature and not complete it. Then put a silk suture on the anterior surface of that stomach pouch so I know what's anterior and what's posterior as I'm pulling that through. And then if I'm going to do the blunt at that point,
Dr. Gary Timmerman (16:24):
then I would take my hand inside and term it Roto-Rooter. And I would just literally, and that's why I never thought it was a good cancer operation because you're not really knowing what nodes you're going to take. But if I were to do it with the robot, I would have docked the robot at that point and then visually take the lymph nodes as I'm going all the way up. And I would typically with the first generation and second generation da Vinci systems, I could get to the level of the azygos vein. and make sure all the lymphatics were with that circumferentially. And then from that point, now I've got that all mobilized and the stomach is still attached to that angle of His,
Dr. Gary Timmerman (17:01):
so that it can still be a conduit to be pulled up as one unit. Then I'd make my incision in the neck, go up to the neck. make my incision there go down to the anterior border sternocleidomastoid or how are you doing that anterior border and pull it back reflect it take the thyroid and move it medially and then bluntly take my finger and find the esophagus and encircle the esophagus at that level lift that up. The recurrent laryngeal nerve typically is well anterior to that, but I always make sure it is. And then proceed to bluntly dissect it like a blunt esophagectomy down into
Dr. Gary Timmerman (17:37):
the chest with my fingers all the way down as low as I can. This was always the tricky part with the, if I did it with my hand, I could go all the way into the neck. and free it but if you do with the robot the technology back then when i was doing a lot of robotics with it was that i could only get to about the azygos so bluntly with my hand i would go from the neck down into the mediastinum and then free it off the back of the trachea and all the way down to the uh connection if you will where it's been freed up by the robot
Dr. Gary Timmerman (18:13):
At that point, you should be able to take the esophagus and the stomach and swing it back and forth in the chest cavity. Once you're able to do that. I always, again, paranoia, making sure there's no big bleeder. I always knew in the back of my mind that most bleeding in that area stops. And I always kind of laughed. There's some big structures that wouldn't stop. But, you know, blunt esophagectomy was never done with hemostasis. It was just done with your hand, and then it would stop on its own. So it effectively was a blunt esophagectomy, but done visually with the robot where the nodes are important,
Dr. Gary Timmerman (18:49):
which is usually the lower third of the esophagus to make sure you got all of those nodes. And then bring the whole specimen out through the neck. And then remember, I have my anterior stitch. to the edge of the wall of the stomach. I can see that coming out as I'm delivering the whole specimen in the neck and then complete the staple line there where I had brought it up and then bring the two ends, the esophagus and the stomach, so that... and if they were like this on hand i actually brought the back end like here put my anchor stitch opened both holes stapled it and triangulated the anastomosis so i would put
Dr. Gary Timmerman (19:26):
another just a this one wouldn't have to be this could be a blue load stapler firing down and then closing the in a triangulated fashion because then I pull it transversely and closed it so that that I typically would do even by hand two layer closure of the anterior one and then literally drop the whole thing back into the neck put a single drain a little uh blake drain into the neck and bring it out through a separate stab I would also then tack the posterior wall of that to the anterior fascia over the vertebral column that is there to keep the pressure off of that anastomosis
Dr. Gary Timmerman (20:02):
so that it was an anastomotic repair done with no pressure and all of the stitches were placed posteriorly to keep that pouch from slipping down and then close the belly. Now, when you do it with the robot again, I even would So I was faster laparoscopic with a lot of stuff than I was with the robot. And so a lot of that I would do just plain laparoscopically, mobilize the whole stomach, put the staple loads in and everything all through the laparoscope, and then dock the robot to do just the chest part of it so I could see the nodes.
Dr. Randy Lehman (20:37):
So you could get up there. I need a little more clarification on the anastomosis in the neck. Okay.
Dr. Gary Timmerman (20:42):
So take your two limbs, staple, staple, pull them up like this. So they're not together. I mean, it's like a side to side.
Dr. Randy Lehman (20:51):
Yes.
Dr. Gary Timmerman (20:51):
But I'm going to make it a functional end to end. So then I'll put my stitch where my... My palms are here for an anchor stitch. And then I open the two staple lines that are at my fingertips. Yeah. So I'm looking in. I'm dropping my stapler down through each hole, one the esophagus, the other the stomach. Fire my stapler. That brings those two together. Then pull transversely, like doing a pyloroplasty, and close the anterior. aspect of the esophagus to the anterior aspect of the stomach and the people that are the people
Dr. Randy Lehman (21:25):
that are listening on spotify and uh apple uh you might need to go to youtube for this one Because that was helpful. I guess what I was thinking is what keeps that crotch from splitting open, but I'm not thinking about my staples correctly. It's cutting all the way down, so it just plaits.
Dr. Gary Timmerman (21:39):
Remember I put a, and then old school, put a stitch down there. Yes. So, again, that anchors that angle of the stitch so it isn't an easy pull apart.
Dr. Randy Lehman (21:48):
Yeah. Okay. Got it. Oh, very good. And then you closed up. Obviously, we can skip that part. But I did want to talk about, you know, what's different for the other techniques of esophagectomy that you had in your back pocket. So one, I want to talk about when would you not use gastric conduit and how did you do the colonic conduit? And then also maybe some touch on Ivor Lewis.
Dr. Gary Timmerman (22:15):
Well, we could go into that extreme technical challenges there, but let's say a patient's had a gastric bypass and gets esophageal cancer. Stomach may not be an option at that point. And so that would be one that I would consider all options including, but most commonly is colon. So I might consider the left colon and bring it up on the middle colic vessel. Some use the right colon. I usually use the left because it was a little bit smaller, a little bit more functionally able to be done. And then I brought the distal colon up. So it actually was anti-peristaltic, and then would dock it to the stomach, what was left in the abdomen.
Dr. Gary Timmerman (23:01):
A lot of gastric bypasses, of course, have the remnant stomach that you could still use as a landing point. I saw it, but I never had to do it, where a kid once swallowed lye and had no esophagus. and had most of the stomach destroyed by the lye as well. And that was when we actually did with a retrosternal, because that whole bed was destroyed from the alkali, that we did a retrosternal colonic anastomosis and brought it up into the neck retrosternally. and that would take out the sternal head to make, you know, the maneuverable head here to make more room for that to come up to the neck. It's a bigger operation but certainly again remember I said
Dr. Gary Timmerman (23:47):
options. You have to have options to be able to think outside of the box to be able to get things together. And then another time, I don't know, the stomach just didn't look viable to go high enough to me after we did it. Maybe I did something to the left gastroepiploic. Maybe something got damaged. Who knows? But I just didn't like it, the whole stomach. And so I ended up using a small bowel interposition. not a free flap one, but brought small bowel with the Roux-en-Y and was able to bring it to the mid-esophagus to complete that anastomosis. So yeah, esophageal surgery, some folks think,
Dr. Gary Timmerman (24:25):
oh, that's easy. It's just one anastomosis. Oh my goodness. You got to think all the variables and all the reasons you're doing and all the anatomy that might be different. And to me, that was... an incredible challenge for me technically to be able to think of those things. And again, then being able to report on those, very exciting.
Dr. Randy Lehman (24:46):
If you brought up a colonic conduit, I can imagine your anastomosis in the neck being very similar.
Dr. Gary Timmerman (24:52):
Very similar.
Dr. Randy Lehman (24:53):
But how did you connect it in then to the stomach? And you put it like in the antrum, right?
Dr. Gary Timmerman (24:58):
Yeah, you have to. So you end it toward the antrum or the body, what might be left. But typically, like I said, if they took out and they made a 30 cc pouch and you've got the rest of that, some might say, well, can't you just use the rest of that stomach? Depends on what they were doing when they were doing the gastric bypass. What if they did a sleeve and they took all of the... gastroepiploic with it. And now you're based on the left gastric artery for the sleeve. You can't use the stomach at all for a conduit because you have to take the left gastric. That's required as
Dr. Gary Timmerman (25:26):
part of esophageal surgery. But you can use the antrum as a landing dock for the other end of
Dr. Randy Lehman (25:32):
the colon. That is correct. So then when you did the anastomosis there, was that a linear stapler usually hand sewn just hand sewed two layer hand sewn okay okay gotcha um actually you know why don't we stay with that tell me exactly how you did the the hand-sewn anastomosis if you don't
Dr. Gary Timmerman (25:50):
mind oh yeah sure so i'm a pds uh fan so i would do the inner layer just running and start at one inside if it was an N2 anterior, do it that way, running it with the 4-0 PDS, and then seromuscular 3-0 silks. So when you divided the proximal colon,
Dr. Randy Lehman (26:15):
say you're using a left colon conduit, you divided it with a stapler?
Dr. Gary Timmerman (26:19):
Yep.
Dr. Randy Lehman (26:20):
Did you cut the staple line off and then sew the end on?
Dr. Gary Timmerman (26:26):
Yeah. Okay.
Dr. Randy Lehman (26:26):
And so did you sew a back layer of silks before you put the PDS?
Dr. Gary Timmerman (26:31):
Oh, yeah. I mean, it's the easiest thing to do.
Dr. Randy Lehman (26:34):
So you just made a hole, sewed a back layer of silks, and then you ran the PDS around the inside at 4-0 PDS, and then you sewed your anterior layer.
Dr. Gary Timmerman (26:44):
Correct.
Dr. Randy Lehman (26:45):
Yeah. And so it just kind of like comes down and plops right into the antrum. Plops right into it. Yeah. Okay. A couple other things that I thought would be relevant for a rural surgeon, maybe who's not doing esophagectomy. So they are doing the scopes and they are diagnosing esophageal cancer. So things to do, tips and tricks on the EGD portion, maybe when the diagnosis is Do you have any of those?
Dr. Gary Timmerman (27:11):
If it looks at all funny, biopsy it. I've seen, you know, things that caught my eye and I said, geez, that probably is nothing. Let me biopsy. And then it's severe dysplasia. You know, esophageal cancer, if you catch it, it's curable. If you catch it early. you know, my biggest fear always was, well, what if I come back in five years and now there's a cancer there? And I knew there was something goofy. So anything that looked irregular, I would biopsy. Barrett's, yeah, I surveyed, I did surveillance on those depending on the amount of Barrett's, but certainly every one to three years, I would scope those folks. Remember again, a lot
Dr. Gary Timmerman (27:51):
of these farmers live a far way away. Getting them back yearly can be tough. But then I would tell them, you've still got a risk of cancer. We need to follow this. And then making sure the Barrett's doesn't progress. The beauty of the cameras today is that they're extremely great resolution versus 25 years ago where it was more hazy. And you can actually see progression of things as well with the cameras as you do with your own eye. and compare past photos that we weren't able to do as well back 40 years ago when we were doing this. I would say the other thing is, you know, there's the protocols for doing quadrant biopsies. Every sound I make, do it. Follow the protocols.
Dr. Gary Timmerman (28:32):
There's a reason for those protocols. And again, you'll pick up things that you're not likely to think. or anything and then all of a sudden they'll say, you know, there's a little bit of dysplasia here and you're like, whoa, I didn't expect that at all. And that's going to change your follow-up for that person as well. The biggest thing I would tell you about esophageal cancer, it's like pancreatic cancer. In the 1980s, People weren't really doing Whipple's as often anymore. And most of those folks came in, they were debilitated, jaundiced, ill. Their surgical outcomes were tough. Most of them were bypasses. Same with esophageal. That's why the blunt became so popular. It was basically just a bypass operation.
Dr. Gary Timmerman (29:10):
All of a sudden, we have neoadjuvant chemotherapy. And we have 40% survivals of these folks that I know that's not 90. But when I started, it was 12, 15%. And I have literally every month an esophageal patient that'll come up. And that's the neat thing about being in rural communities. They're still around. And they'll come up and say, hey, how are you doing? I actually did one of my high school classmates esophagectomies. And she comes and she sends me a happy Father's Day thing. She'll send me. And she's a high school classmate.
Dr. Randy Lehman (29:45):
Yeah.
Dr. Gary Timmerman (29:45):
And she's alive now eight years.
Dr. Randy Lehman (29:48):
And what's your graduating class size in high school?
Dr. Gary Timmerman (29:50):
Oh, we had a big one for Watertown. Remember, it was a city. So it was about 300, 310 kids.
Dr. Randy Lehman (29:57):
Okay.
Dr. Gary Timmerman (29:58):
Whereas my wife's was 12.
Dr. Randy Lehman (30:01):
Yeah. Somewhere in between is a vast majority of my audience.
Dr. Gary Timmerman (30:06):
That's why I say there is no forgiveness for being sloppy or saying no one will care when you're in rural. I believe every rural surgeon has to have the same standards and opinions of things as getting to the bottom of it as someone at Mayo or someone in Chicago or someone at Sloan Kettering. I just think we. cannot say,"Well, that's okay. We're just out here in rural." I think, if anything, we own more because I just really do believe we're blessed to be there with them and we should be providing them most outstanding care that we can give them. Yep, I totally agree. Another question,
Dr. Randy Lehman (30:43):
though, is feeding access for... Yeah, I love J-tubes. Absolutely.
Dr. Gary Timmerman (30:48):
And a lot of folks don't do that anymore. I guess they have a lot of confidence. I always did it. And oftentimes that was their biggest complaint was the feeding tube. And I'm always happy when it came out.
Dr. Randy Lehman (30:59):
Were you saying at the time of the esophagectomy doing a feeding tube?
Dr. Gary Timmerman (31:03):
No. Now with neoadjuvant, I oftentimes would put it in. But now also with radiation, the tumor shrinks and they can eat usually within a week. So a lot of times I might just put a Dobbhoff down them for about a week until they were swallowing again and take it out and let them eat.
Dr. Randy Lehman (31:19):
Okay.
Dr. Gary Timmerman (31:19):
While they're getting neoadjuvant. Yep.
Dr. Randy Lehman (31:21):
So let's say we didn't do that and we were asked by oncology because they're going to go for neoadjuvant to put a J-tube in.
Dr. Gary Timmerman (31:31):
That's a weekly occurrence for me. We have tumor conference every week and they always ask. you know, what do you think? Should we put a feeding tube in? And I said, let me look at them. Let me see what they look like. And then find out, judge how hard they're swallowing. And if they can't even hardly keep liquids down, even if it's only a week, I usually said, let's just put in a feeding tube. A lot of folks said. Don't put it in the stomach. Always use the jejunum. I'm just dead. But I know there are surgeons out there that did do G-tubes. And it really didn't affect my operation as much as I thought it would.
Dr. Gary Timmerman (32:03):
And so it's not absolutely taboo.
Dr. Randy Lehman (32:07):
But generally you want a J-tube. I did.
Dr. Gary Timmerman (32:09):
I sure did. Yep.
Dr. Randy Lehman (32:11):
And so how do you do your J-tubes? You do them laparoscopically or open?
Dr. Gary Timmerman (32:15):
No, I Witzel'd and I would do them laparoscopic when that became popular. But the only things I would open, put a red rubber tube in. But now they don't anymore. Now they have these nice, even the needle. uh jejunostomy tubes that you can put in much like a witzel yep yeah so at the end of your
Dr. Randy Lehman (32:31):
career how are you placing exactly how are you placing the J-tube yeah laparoscopic okay and so
Dr. Gary Timmerman (32:38):
where do you put your ports oh good lord that's so this has now been five six years since i did it No, no. I will put them, my periumbilical and then probably one in the upper abdomen on the right side and one in the lower abdomen on the right side. So, triangulating it from the left side to look to the right. Yeah. The feeding tubes would go on. I'm sorry. Start on the right to look to the left because I put my feeding tube on the left, right?
Dr. Randy Lehman (33:06):
You're gonna put it in the left upper quadrant And so let me talk through just for a second and then you correct me where I'm wrong Or where you would do something different. So say you put those ports exactly like you said and then you Elevate the omentum push it up over the stomach Identify the ligament of Treitz you chase down How many centimeters from ligament of Treitz?
Dr. Gary Timmerman (33:26):
20.
Dr. Randy Lehman (33:27):
20 centimeters or so from ligament of Treitz. Lift it up.
Dr. Gary Timmerman (33:29):
It easily reaches the anterior abdominal wall.
Dr. Randy Lehman (33:32):
Sure.
Dr. Gary Timmerman (33:33):
Then I'll hold it with the graspers. I got to even think I may even put three ends because I may have pulled you know grasper, grasper and then do something percutaneously depending on because they have the needle that can go percutaneously and then you can actually thread it into the jejunum and then you watch it you can actually watch it coil inside the jejunum as it goes down and then i would you know some of the kits you can actually just tack that point to the anterior abdominal wall i always worry about a leak there and it would cause a lot of inflammation so i preferentially would put a stitch
Dr. Gary Timmerman (34:11):
to semi-Witzel it, maybe only a centimeter or two, so that the tube is actually not going directly into mucosa when you bring that up to the anterior abdominal wall, and you're actually bringing serosa to the anterior abdominal wall and not the risk of mucosa to the anterior abdominal wall. Do you see the difference? I do, yeah. And that's why I like the Witzel better than just... Some people say you can just tack that up like a Stamm G-tube. And somehow those seal, but not always. But J-tubes, nah. And I had more probable troubles with the feeding tube because they could get infected while they're getting their chemotherapy. And that's why I really like the Witzel that reduced that likelihood.
Dr. Randy Lehman (34:51):
So let me tell you my trick, and you tell me what you think about this. Okay. For doing this, I will bring the tube in to the abdominal wall, and then I will... bring in my stitch i would use usually like a maybe a 2-0 Vicryl say and i would make my Witzel tunnel in this way bring the stitch in throw on either side of the tube my my stitch and then i would use a laparoscopic suture passer cut the needle off pull it out grab the one end and pull it out, grab the other end and pull it out, tag those outside the skin,
Dr. Randy Lehman (35:21):
and then do a row of those with the laparoscopic suture passer. And one usually proximal to where the Witzel tunnel starts to just kind of anchor. Because I had a problem, I was trying to do it where I was just like stitching it up there laparoscopically. And the weight of the bowel is so hard and I was dropping the pressures very hard. So then I started doing it that way. And then you can just get all of your stitches thrown with lots of laxity, pull up on all of them at once.
Dr. Gary Timmerman (35:46):
And then the weight is on the stitches through the anterior abdominal wall. Yeah.
Dr. Randy Lehman (35:50):
Did you ever do that or heard of that?
Dr. Gary Timmerman (35:51):
No, I wish I would have.
Dr. Randy Lehman (35:52):
I think I made that up, actually.
Dr. Gary Timmerman (35:54):
I think that's really smart. I wish I would have. That actually sounds a lot smarter than the way I was struggling with it.
Dr. Randy Lehman (36:00):
And I always use a balloon one now that's like the balloon is far away from the tip. and I get that balloon fed down before I pull up and then it'll kind of do it all at once. Last few that I've done have been pretty slick. Now I did talk to, um, last time I did it with a cancer, a thoracic surgeon, cancer surgeon. And he said to me that he thinks an open J-tube is better than a peg still. And I'm- No, no, no. You know, yes. I'm going to say that
Dr. Gary Timmerman (36:30):
When done correctly, absolutely. But the beauty of a peg is that you just take it out and it's done. Well, you can do the same with the feeding tube, I guess. But I don't know. What do you think about the risk of small bowel or internal hernias down the road with that?
Dr. Randy Lehman (36:46):
With your laparoscopic J-tube, you mean?
Dr. Gary Timmerman (36:49):
Yeah.
Dr. Randy Lehman (36:49):
Or, I mean, it... My practice isn't going to be the one that's going to speak about the risk. So maybe you're the one that sees more volume. You know, you have to have a catastrophic event, but it could be catastrophic.
Dr. Gary Timmerman (37:02):
I have seen bowel obstructions, internal hernias around my J-tubes. Yep.
Dr. Randy Lehman (37:08):
And you're not going to be taking that down, obviously. No, ever.
Dr. Gary Timmerman (37:12):
Ever. Ever.
Dr. Randy Lehman (37:15):
Okay. Well, I would say jury's out on a lot of this stuff. There's like a lot of things in surgery. There's not necessarily right or wrong. So you have several opinions.
Dr. Gary Timmerman (37:24):
I do really like the way you tacked it.
Dr. Randy Lehman (37:25):
All right. Well, thank you. Another thing you said to me about doing surgery open, you know, I do carpal tunnels. That's a good example of like the difference between me and you. Okay. I'm taking it easy. but i did do some operations with a plastic surgeon who's doing minimally invasive carpal tunnels right which basically is is like blind and it's a scissor and push mostly a feel and you know he said the same thing to me that sounds like someone told you uh just do them all open because you don't want to have a complicate what i'm doing is kind of gimmicky And at the end of the day, you know, once you start doing a good number of carpal tunnel releases
Dr. Randy Lehman (38:07):
and practice, you start to appreciate you change these people's lives and they just love you so much. And to hide a two inch or inch and a half incision in the, one of the skin creases in their palm. is not really a big part of the operation. Main thing is get a good proximal release, do it under direct visualization. So that's something that I could sort of relate.
Dr. Gary Timmerman (38:28):
Yeah, the whole key is make them functional. I agree.
Timecode:
00:29 How I Do It: Esophagectomy in Rural Practice
00:38 Dr. Timmerman on Taking On Complex Surgery
03:22 Big Operations Come With Big Responsibility
05:29 Training, Mentors, and Esophagectomy Approaches
06:09 Why Transhiatal Esophagectomy Mattered
06:51 Neoadjuvant Therapy Changes Esophageal Cancer Care
07:33 Choosing an Open Approach for Safety
08:49 Bringing Robotic Esophagectomy to South Dakota
10:07 Always Have a Backup Conduit
11:04 Bowel Prep and Preoperative Optimization
12:45 Step-by-Step Transhiatal Esophagectomy
14:20 Mobilizing the Stomach and Preserving Blood Supply
15:00 Creating the Gastric Conduit
16:24 Blunt Versus Robotic Mediastinal Dissection
17:01 Cervical Exposure and Esophageal Mobilization
18:49 Pulling the Specimen and Conduit Into the Neck
20:37 Cervical Anastomosis: The Technical Details
21:48 When the Stomach Is Not Available as a Conduit
23:01 Retrosternal Colon Interposition
23:47 Small-Bowel Interposition as a Backup Option
25:32 Hand-Sewn Colon-to-Stomach Anastomosis
26:45 EGD Pearls for the Rural Surgeon
27:51 Barrett's Surveillance and Biopsy Protocols
30:06 Standards of Care in Rural Surgery
30:43 Feeding Access During Esophageal Cancer Treatment
31:21 When to Place a J-Tube
32:11 Laparoscopic J-Tube Technique
33:06 Finding the Ligament of Treitz and Choosing the Site
34:51 Randy's Laparoscopic Witzel Technique
36:30 PEG Versus J-Tube and Internal Hernia Risk
37:25 Open Versus Minimally Invasive Carpal Tunnel Release
38:28 The Goal: Make the Patient Functional
