Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_639_Библиотеки_им_академика_М_И_Перельмана.pdf
422 Part III Esophagus
Mobilized
at hiatus
Attaching
gastric tube
to specimen
FIGURE 19-10 Completion of laparoscopic phase of minimally invasive Ivor Lewis esophagectomy.
facilitate bringing it through the hiatus without trauma to
the omentum or the supplying vasculature.
10. If the hiatus appears wide, we add one or two 0 Surgidac sutures (Covidien, Manseld, MA) to approximate
the right and left crus to minimize the likelihood of a
delayed herniation of the conduit into the chest. e
pyloroplasty site is covered with an omental patch as
described previously. e initial Hasson trocar site is
closed with the Carter-ompson suture passer with 0
Vicryl suture, the abdomen is desuated, and the skin
incisions are closed accordingly.
axillary line at the fourth intercostal space, through which
a fan-shaped retractor aids in retracting the lung to expose
the esophagus. A 5-mm port is placed just inferior to the
tip of the scapula, and this is used by the surgeon’s left hand
for countertraction. A nal port is placed at the sixth rib, at
the anterior axillary line for suction, and is especially useful
while fashioning the anastomosis.
3. An important initial step to aid in exposure is placement
of a traction suture (0-Silk) through the central tendon
of the diaphragm (Fig. 19-12), which is brought out
through a 2-mm stab incision in the antero-lateral chest
wall near the costophrenic angle using an Endo Close
THORACOSCOPIC PHASE
1. e patient is placed in the left lateral decubitus
position. e operating surgeon stands on the right side
of the table (facing the patient’s back) and the assistant
on the left side of the table.
2. Five thoracoscopic ports are used (see Fig. 19-2; Fig. 19-11).
A 10-mm camera port is placed in the seventh or eighth
intercostal space, just anterior to the midaxillary line. e
surgeon’s working port is a 10-mm port that is placed at the
eighth or ninth intercostal space, posterior to the posterior
axillary line. Ultimately, this eighth posterior interspace port
will be enlarged to 5 cm to enable passage of the end-to-end
stapler (EEA, US Surgical, Norwalk, CT) and removal of
the specimen. Another 10-mm port is placed in the anterior
FIGURE 19-11 oracoscopic (right VATS) port placement.
Chapter 19 Video-Assisted oracic Surgery of the Esophagus 423
Esophagus
Stitch for retraction
of diaphragm
FIGURE 19-12 oracoscopic mobilization of esophagus.
device (Covidien, Manseld, MA). is suture retracts
the diaphragm inferiorly and allows excellent visualization of the lower one-third of the esophagus.
4. oracic esophageal mobilization (see Fig. 19-12).
Mobilization of the esophagus is begun by dividing the
inferior pulmonary ligament to the level of the inferior pulmonary vein and retracting the lung anterior.
is facilitates incision of the mediastinal pleura over
the esophagus. Dissection moves in a cranial direction
from this point along the line of the mediastinal pleura.
It should be noted that the dissection should be carried down to the pericardium as it is actually the medial
boundary of the line of dissection. e deep boundary
is the contralateral pleura. e esophagus and accompanying periesophageal tissue and level 7 lymph nodes
are mobilized circumferentially en bloc toward the right
mainstem bronchus and carina. Care is taken not to
injure the posterior membranous wall of the right mainstem bronchus in this area. We use the ultrasonic shears
for much of the dissection, as the sharp blade of this
instrument is ideal for a precise dissection plane. Endoscopic clips are utilized for hemostasis on larger vessels.
Because of the extensive lymphatics in this area and
fragile vessels attached to the subcarinal nodes, careful
use of endoclips also aids in minimizing oozing of chyle
and blood. Lateral dissection is facilitated by opening
the mediastinal pleura in the groove posterior to the
esophagus. is should be done in a supercial dissection plane so as to avoid injury to the aorta and the thoracic duct. e azygous vein is mobilized and divided
as it overlies the esophagus posteriorly with a vascular
staple load. e vagus nerve is transected above the
level of the divided azygous vein to prevent any traction
injuries to the recurrent nerve during the mobilization
of the esophagus. e esophagus is then mobilized circumferentially from the hiatus to near the thoracic inlet,
the ultimate cephalad extent depending on the proximal
extent of the tumor and/or Barrett’s esophagus and the
length and condition of the gastric conduit. Above the
azygous vein, the plane of dissection should stay directly
on the esophagus so as to prevent injury to the posterior
membranous trachea and recurrent laryngeal nerve. We
do not perform an aggressive lymph node dissection at
level 2 or level 4 unless preoperative PET, CT, or EUS
conrmed presence of malignant nodes at this level.
5. e distal esophagus and previously constructed gastric
conduit are then brought up through the hiatus into the
chest (Fig. 19-13). Maintaining proper orientation of the
gastric conduit is critical to avoid spiraling or twisting of
the conduit. e staple line should face the camera so as
to avoid spiraling of the conduit. e stitch is cut between
the specimen and the conduit, and the specimen are
retracted anteriorly and superiorly. We carefully estimate
the amount of conduit that will lie in the chest. It is a
common mistake to bring an excess amount of stomach
into the chest in an eort to minimize tension on the anastomosis. is excess conduit will often assume a sigmoid
conformation above the diaphragm and may lead to signicant problems with gastric emptying.
6. e proximal esophagus is then transected above the azygous vein with Endo Shears (Covidien, Manseld, MA).
Again, the precise location of this division and ultimate
location of the anastomosis tends to be high, near the thoracic inlet. However, cutting the esophagus too proximal
424 Part III Esophagus
FIGURE 19-13 Specimen and gastric tube are carefully pulled to
intrathoracic position.
may make the anastomosis technically dicult and should
be avoided. In the case of concern over tumor margin, we
may rescope at this point to precisely determine where to
transect the esophagus.
7. e eighth interspace port site is enlarged, and an Alexis
wound protector (Applied Medical, Rancho Santa Margarita, CA) is placed for specimen removal after cutting
the previously placed sutures that secured the conduit
to the specimen. e specimen is then sent for frozensection analysis of the esophageal and gastric margins.
8. Creation of intrathoracic esophagogastric anastomosis
(Figs. 19-14 and 19-15). e anvil of a 28-mm EEA stapler is placed in the proximal esophagus, and a 2-0 Endo
Stitch purse-string suture is placed and tied (intracorporeal
technique) to secure the anvil in position. It is technically
challenging to make this rst stitch perfect as the anvil has
a tendency to migrate out of the open end of the proximal
esophagus. For this reason, a second purse-string suture is
placed to further secure the anvil and pull in any mucosal
defects, thereby ensuring complete rings following EEA ring. Ultrasonic shears are used to open up the tip of the
gastric conduit along the staple line. e EEA stapler is then
introduced through the eighth interspace incision into the
tip of the gastric conduit via the gastrotomy at the apex of
the conduit. is is technically challenging for most trainees, and care must be taken to angle the gastric tube facing straight up to accept the tip of the EEA device aimed
FIGURE 19-14 Creation of intrathoracic esophagogastric anastomosis.
Esophagus
Gastric tube
Excess
stomach
trimmed and
closed
FIGURE 19-15 Resection of redundant gastric tube tip.
Chapter 19 Video-Assisted oracic Surgery of the Esophagus 425
straight down, much the same way one angles the tip of
your foot as you pull on your sock. e anvil is then docked
into the stapler. A circular anastomosis is then created in an
end- (proximal esophagus) to-side (gastric conduit) fashion
above the level of the azygous vein. A reticulating Endo GIA
stapler is used to close the gastrotomy closure and excise
the redundant portion of the gastric conduit tip. Routine
endoscopy is not performed.
9. As previously mentioned, we have recently starting selectively wrapping a tongue of omentum mobilized from
the greater curve of the stomach around the anastomosis, securing in place with 2-0 Surgidac Endo Stitch at
several points (Fig. 19-16). It is important to ensure that
the conduit is not twisted in the process of wrapping the
FIGURE 19-16 Completed anastomosis with omental pedicle wrap.
omentum around the anastomosis.
10. Under direct vision, a nasogastric tube is advanced beyond
the anastomosis to just above the hiatus. e chest is
drained with a 28F chest tube placed posteriorly but not
on the anastomosis, and a number 10 Jackson Pratt drain
placed directly posterior to the anastomosis, behind the
gastric conduit, down to the diaphragmatic hiatus, across
the dome of the diaphragm, and out through a small stab
incision near the costophrenic angle. To prevent herniation, the conduit is tacked to the right crus with one or two
interrupted 2-0 Endo Stitches.
pericardium during VATS was the mechanism for the develop-
43
ment of postoperative tamponade in the third patient.
is
very low mortality rate compares favorably with the largest
series of open esophagectomy (Table 19-1).
e rate of anastomotic leak in this series was 11.7%. In
our experience, this complication was frequently related to
the diameter of the gastric tube. e leak rate associated with
a 3-cm-diameter tube was 26% in 56 consecutive patients.
In the latter half of the series, those patients who underwent
creation of a larger diameter conduit had the leak rate of only
6%. us, there is invariably an operator learning curve.
Outcomes and Complications
Following MIE
Injury to the recurrent laryngeal nerve is a complication
associated with signicant morbidity. Mechanisms related
to this complication include excessive traction on the nerve
In 2003, we published our series of 222 consecutive
patients who had undergone McKeown or “three-hole”
(laparoscopic-thoracoscopic with cervical anastomosis) MIE
11
at the University of Pittsburgh.
To this date, the approximately half of our MIEs (>500 cases) was performed with this
three-eld technique. Indeed, the procedure was the mainstay of our initial experience in the rst 10 years with reduced
perioperative morbidity and mortality compared with many
other open series. Although early in the series we selectively
performed MIE on patients with smaller tumors and no previous therapy, 35% of the patients in the overall series had
been treated with chemotherapy and 16% with radiation. In
addition, 25% of patients had undergone prior open abdominal surgery.
MIE was completed as planned in 206 patients (93%).
ere were no emergent conversions to an open procedure.
Of the 16 cases who required nonemergent conversion,
11 required a minithoracotomy for adhesions and, in one
case, oversewing of an intercostal vessel that could not be
controlled by VATS.
ere were three deaths in the series (mortality 1.4%). ese
deaths were from postoperative pneumonia and multisystem
organ failure in one patient, a myocardial infarction on postoperative day 5 in another, and pericardial tamponade that
developed 3 days after MIE in the third patient. None of these
deaths were in patients who developed an anastomotic leak
or gastric tube necrosis. Presumably, traction injury to the
during the neck dissection or injury during dissection of the
upper one-third of the esophagus. In our series, vocal cord
palsy occurred in 3.6% of patients. is is lower than our
open experience and is in part due to enhanced visualization
of the upper thoracic esophagus during VATS. We believe
early division of the vagus nerve and limiting lymph node dissection above the azygous vein are important technical details
that contribute to lower rates of injury to the nerve in this
area. However, as previously mentioned, in addition to recurrent nerve injury, a signicant number of patients experience
pharyngoesophageal swallowing dysfunction after cervical
anastomosis. ese are among the concerns that prompted
our recent switch to a totally minimally invasive Ivor Lewis
approach in the last several years.
Other complications seen after MIE, as well as open
esophagectomy, include chylothorax, delayed gastric emptying, and airway injuries. All of these complications are
potentially related to surgical technique. Inadequate control of small ductules that branch o of the thoracic duct
or a gross tear of the main duct is typically the cause of a
chylothorax. Seven patients (3%) developed this complication early in our series. Following this early experience, we
have liberally applied clips to even small branches emanating from the thoracic duct along the right esophageal border during VATS, and this complication has fallen to less
than 1%. Delayed gastric emptying is reported to occur
in up to 10% of patients following esophagectomy. is
426 Part III Esophagus
TABLE 19-1: MORTALITY AND MORBIDITY FOLLOWING MIE COMPARED
TO OPEN ESOPHAGECTOMY
Mortality 1.4 4 9.8 4 5.8
Anastomotic leak 11.7 13 NR 21 14
Pneumonia 7.7 2 21.4 21 16
Vocal cord palsy 3.6 7 NR 4 NR
Gastric tube necrosis 3.2 0.83 NR 1 NR
Chylothorax 3.2 1.7 0.02 2.4 NR
Myocardial infarct 1.8 NR 1.2 NR NR
Delayed gastric
emptying
Tracheal tear 0.9 0.4 NR NR NR
Renal failure 0.9 NR 2.1 NR NR
Splenectomy 0 3.1 NR NR NR
Delayed (>30 days)
diaphragmatic hernia
NR, not reported.
Reprinted from Schuchert MJ, Luketich JD, Fernando HC. Complications of minimally invasive esophagectomy. Semin orac
Cardiovasc Surg . 2004;16:133–141. Copyright 2004, with permission from Elsevier.
Pittsburgh
n = 222 (%)
1.8 NR NR NR NR
1.8 NR NR 1.2 NR
Michigan
n = 1085 (%)
may be due to a number of factors, including the vagotomy
itself, the creation of a full-size gastric conduit that may
empty poorly compared to a tubularized conduit, incomplete pyloromyotomy or pyloroplasty, spiraling of the gastric tube, excess stomach above the diaphragm leading to a
sigmoid loop e ect, and an inadequate crural opening. In
our series, only 2% of patients developed delayed gastric
emptying after MIE. e creation of a pyloroplasty rather
than a pyloromyotomy and attention to all of the details
listed previously have contributed to this low complication
rate.
Fortunately, signi cant airway injuries in our experience
have been exceedingly rare, occurring in only two patients.
One of these injuries occurred postoperatively during reintubation for respiratory distress and one was believed to result
from injury to the posterior membranous trachea from unintentional contact of the autosonic shears. In other series, tracheal injury has been associated with the resection of bulky,
midthoracic tumors. is is usually either due to traction or
cautery injury during esophageal mobilization. In these cases
of bulky tumors, we would therefore recommend a thoracotomy, particularly if the patient has received neoadjuvant
radiation.
With a median follow-up of 19 months, overall survival
was similar to that after open esophagectomy. Of importance
in assessing outcomes is not only overall survival but also the
quality of life following esophagectomy. We have documented
this by administering a validated quality-of-life instrument
(Short Form-36 [SF-36]) and a disease-speci c questionnaire
(the Gastroesophageal Re ux Disease Health-Related Quality
44
of Life [GERD-HR-QOL] index
) to patients before and after
MIE. e GERD-HR-QOL instrument noted that dysphagia
VA
n = 1777 (%)
Sloan-Kettering
n = 510 (%)
Duke
n = 379 (%)
and heartburn scores following esophagectomy were excellent,
and that only 4% of patients had severe, poorly controlled
re ux. In addition, the overall quality of life as measured by
the SF-36 was no di erent than that of age-matched controls.
In our experience, perhaps the most signi cant technical
concern with the minimally invasive McKeown approach is
the cervical dissection. Recurrent laryngeal nerve injuries, perturbations in pharyngeal transit, and swallowing dysfunction
even in the absence of recurrent nerve injury are not infrequent. Moreover, as described in open series using a cervical
anastomosis, anastomotic stricture and leak have been shown
45
to occur with increased frequency.
Out of these concerns
emerged our more recent experience with completely thoracoscopic-laparoscopic Ivor Lewis esophagectomy. However, we
did rst evolve through a transition phase whereby a minithoracotomy (hybrid approach) was performed for creation of the
intrathoracic anastomosis.
Outside of case reports, there are currently few series report-
ing experience with laparoscopic-thoracoscopic Ivor Lewis
46,
esophagectomy.
47 Kunisaki et al described a small series
of laparoscopic-thoracoscopic Ivor Lewis esophagectomies
(n = 15), but the anastomotic leak rate was somewhat high
48
(13.3%) and length of stay was prolonged (30 days).
We
recently reported the largest series of minimally invasive Ivor
49
Lewis esophagectomies (n = 50) published to date.
Of these,
the rst 35 included hybrid approach with a planned minithoracotomy. e last 15 patients in this series were performed
with a completely laparoscopic-thoracoscopic method without need for minithoracotomy. e median length of stay was
9 days for the entire group, with the completely minimally
invasive group having a signi cantly shorter hospitalization
(7vs 9 days). e median ICU stay was 1 day for both groups.
Chapter 19 Video-Assisted oracic Surgery of the Esophagus 427
e anastomotic leak rate was 6%. All pneumonias (10%)
occurred in the hybrid minithoracotomy group. Importantly,
there were no recurrent nerve injuries.
We believe that the experience with totally thoracoscopiclaparoscopic Ivor Lewis esophagectomy will ultimately
reproduce the low morbidity and mortality we have previously published with our established MIE technique. e
omission of a cervical dissection has reduced our recurrent
nerve injury rate to near zero. From a theoretical standpoint,
one would presume that pharyngeal transit problems and
oropharyngeal swallowing dysfunction should be reduced as
well with a chest anastomosis. It should be emphasized that
there is a steep operator learning curve associated with this
approach. Both blood and lung can obscure visualization
of the esophagus, which lies at the dependent aspect of the
operative eld. Prone positioning has been described as an
alternative approach that may facilitate operative exposure
and address such technical concerns.
50
BENIGN ESOPHAGEAL DISEASE
Resection of Esophageal Leiomyoma
Leiomyomas represent the most common benign tumor of
the esophagus, accounting for approximately two-thirds of all
51
ese tumors occur in the middle (33%) and lower
cases.
(56%) esophagus, a distribution that parallels the degree of
smooth muscle in the esophageal wall.
myoma are rarely found in the cervical esophagus, which is
composed predominantly of skeletal muscle. e majority of
these tumors arise from the muscularis propria and extend
into the lumen of the esophagus. On occasion, however, they
may arise from the muscularis mucosa, in which case they
tend to pedunculate because of peristalsis.
Over 85% of patients with small leiomyoma are asymptomatic. When present, symptoms are often nonspecic, such
as chest pain, regurgitation, and dysphagia. On rare occasion,
these tumors may ulcerate and present with gastrointestinal
bleeding. Interestingly, there does not appear to be a clear
correlation between the size of the tumor and either the
frequency or severity of symptoms.
e natural history of these uncommon tumors is not
well understood, and therefore the guidelines for resection
of asymptomatic tumors are unclear. Certainly, resection of
either symptomatic tumors or those in which a malignant
histology is suspected is appropriate. In most series, the criterion for resection of asymptomatic lesions has been a size
greater than 3–5 cm. However, it has been well-documented
that the size of these tumors can remain stable over several
55
Furthermore, unlike smooth muscle tumors of the
years.
stomach, the propensity of these tumors to degenerate into
leiomyosarcoma is extremely rare, and in fact only two cases
have ever been documented.
56,57
sion to recommend surgery will depend on the morbidity
associated with the procedure.
51
Consequently, leio-
52
53,54
What is clear is that the deci-
Technique of Resection
e approach to resection depends on the location of the
tumor. Including our own experience, in most published
series, benign esophageal tumors (ie, leiomyoma) of the thoracic esophagus are approached through a right VATS or right
thoracotomy, whereas a laparoscopic transhiatal approach
is employed for most distal tumors at or near the GE junc-
58–60
tion.
resection of GE junction leiomyoma with left-sided thoracoscopy,
although a distal intrathoracic, benign esophageal tumor could
be enucleated through a laparoscopic transhiatal approach,
we believe the best exposure is achieved through the right
chest. Our preference is to resect tumors through a minimally
invasive approach, reserving thoracotomy or laparotomy for
tumors larger than 7 cm. For the purposes of this chapter, we
focus on the right VATS approach.
1. e patient is intubated with a double-lumen endotra-
2. Esophagoscopy is performed prior to draping to con-
3. e patient is positioned in the left lateral decubitus
4. e thoracoscopic ports are essentially the same as those
5. Exposure of the tumor is obtained by placing the
6. A myotomy is performed on the esophageal wall over-
7. e tumor is then enucleated with the ultrasonic dissec-
Although there are published case series that report
61
we are not in favor of this approach. Similarly,
cheal tube for single-lung ventilation.
rm location of the tumor. e scope is frequently left
in place to assist the surgeon in determining where to
begin the myotomy. In some cases, a 54F bougie may be
left in place to facilitate dissection and accentuate tumor
location.
position. e surgeon stands at the patient’s back.
used for MIE as depicted in Fig. 19-2.
diaphragm stitch, as previously described, above for
tumors in the distal thoracic esophagus. Removal of
benign midesophageal lesions does not always require
this maneuver. Subsequently, the inferior pulmonary
ligament is divided with the ultrasonic shears. e
mediastinal pleura overlying the esophagus is opened
sharply. Care must be exercised at this point to preserve
the vagus nerve trunk and its branches. e esophagus
may need to be dissected circumferentially for exposure, particularly if the tumor appears to arise from
the left side of the esophagus. A Penrose drain can be
placed around the esophagus and manipulated to help
expose left-sided tumors (Fig. 19-17).
lying the tumor (Fig. 19-18). e longitudinal muscular layer is then opened sharply and the leiomyoma is
exposed. e vagal trunks should be identied and preserved during this maneuver. Because of the rm, rubbery nature of the tumor, it is often dicult to grasp and
we frequently place a stitch into the tumor for traction.
e plane between the tumor, muscularis propria, and
submucosa is developed.
tor, hook electrocautery, and the Endo Peanut (Covidien,
Manseld, MA).
428 Part III Esophagus
FIGURE 19-17 Resection of an esophageal leiomyoma is facilitated
by use of a Penrose drain.
8. e tumor is removed with an endoscopic specimen bag.
9. After the tumor is removed, the esophagus is submerged
under water and insuated with air from the esophagoscope to determine mucosal integrity.
10. e myotomy is then closed using interrupted 2-0 Surgidac
Endo Stitch (Fig. 19-19). Although not all surgeons feel
FIGURE 19-18 oracoscopic myotomy.
FIGURE 19-19 Closure of myotomy.
that this step is necessary,62 several studies have documented
the occurrence of postoperative dysphagia due to the formation of a mucosal pseudodiverticulum at the myotomy
site. In these cases, symptoms resolved after approximation
of the myotomy.
Outcomes of Minimally Invasive
Thoracoscopic Resection for Leiomyoma
Between 1990 and 2005, we resected 15 patients with esophageal leiomyoma.
esophageal in eight patients and distal third of the esophagus
in six patients. All the patients with a tumor less than 7 cm in
the thoracic esophagus were approached with a right VATS.
Four patients with midesophageal tumors went on to require
an additional antireux procedure for either new-onset or
worsening reux. Among all patients, there were no perioperative complications and the median hospital stay was 2.3
days. One patient was noted to have a mucosal injury at time
of surgery; this was repaired using an endo-GIA stapler over
a bougie without complication. e mean tumor size was
2.7 cm; however, we have safely resected tumors up to 8 cm
in size using minimally invasive techniques. Larger tumors
do pose a greater technical challenge. As such, we recommend reserving thoracoscopic resection for tumors less than
7 cm. On the basis of this limited data set, the size of the
tumor does not correlate with the development of postoperative reux. Patients require close follow-up because of the
potential for delayed postoperative reux.
63
In this series, the tumor location was mid-
Chapter 19 Video-Assisted oracic Surgery of the Esophagus 429
Treatment of Achalasia
e introduction of minimally invasive techniques has
revolutionized the treatment paradigm of patients with
achalasia. e long-term benets of surgery over medical management have been clearly documented for many years.
However, in the past, patients were often not referred for surgery because of the morbidity of the thoracotomy necessary
for an esophagomyotomy. e advent of minimally invasive
techniques has led to a resurgence in surgery as the primary
treatment modality for this disease.
4
Most surgeons experienced in the treatment of achalasia
have adopted laparoscopy as their preferred approach (refer
to Chap. 14). Indeed in our own series of minimally invasive
esophagomyotomy, 92% of patients underwent laparoscopy
66,67
as opposed to thoracoscopy.
Similarly, the initial group
to describe VATS myotomy has now come to favor laparos-
68
However, there are reasons to consider thoracoscopy
copy.
as an acceptable alternative. During thoracoscopy, the distal
esophagus and GE junction are visualized without the necessity of dividing the phrenoesophageal ligament. Proponents
of thoracoscopy claim, consequently, that the preservation of
this ligament will prevent postoperative reux and obviate the
need for an antireux procedure, which is usually added after
a laparoscopic esophagomyotomy.
69
However, there are some inherent disadvantages to thoracoscopic myotomy. First, anesthesia is complicated by the
need for single-lung ventilation. In addition, thoracoscopy is
more uncomfortable for the patient, particularly because a
70,71
“minithoracotomy” access incision
and a chest tube are
often required for the procedure. More important is the concern that the myotomy may be incomplete when performed
thoracoscopically. Critics of the operation cite the diculty
of working in a plane perpendicular to the esophagus and
extending the myotomy adequately onto the stomach when
72
working through the chest.
Additionally, the addition of a
partial fundoplication to myotomy for the treatment of achalasia has become standard practice and is readily performed
and with reproducible results using laparoscopy.
Overall, thoracoscopic myotomy has been shown to provide
symptomatic improvement in 76% of patients with achalasia.
ese results do not compare favorably to laparoscopy, in
which 94% of the nearly 500 patients reported in the literature
72
have had relief of their dysphagia.
In addition, a 35% rate of
postoperative reux is associated with thoracoscopy, compared
with a rate of only 9% following laparoscopic myotomy and
fundoplication.
73
Most recent reports of thoracoscopic myotomy describe
a “hybrid operation,” which utilizes a minithoracotomy
74,75
through which standard instruments are used.
Additional
port sites are placed to provide illumination and counterretraction. is approach likely reects the preferences of
thoracic surgeons who may not be as familiar with techniques
of laparoscopy. We favor laparoscopy, as do the vast majority of surgeons performing myotomy. In our opinion, only
the rare patient with a hostile abdomen from multiple prior
abdominal procedures would be a potential candidate for
64,65
VATS myotomy. Even in this setting, a laparoscopic approach
would still be considered preferable.
Other Indications
A variety of other thoracoscopic esophageal procedures have
been described, though their merit is dicult to determine
due to the rarity of the diseases and the small number of
patients studied. Aside from esophageal tumors (benign and
malignant) and achalasia, thoracoscopic management of
esophageal diverticulum has also been reported in the literature. Similar to the literature on leiomyoma, many authors
report utilizing a laparoscopic transhiatal approach for epiphrenic diverticula at or near the GE junction. Palanivelu
et al reported one of the larger more recent experiences with
76
a minimally invasive approach.
In their series, eight epiphrenic (dened as within 10 cm of the GE junction) and
four thoracic (“midesophageal”) diverticula were resected.
Laparoscopy (with or without myotomy and fundoplication)
was employed for the epiphrenic diverticula whereas prone
position right-sided thoracoscopy was used for the thoracic
diverticula. Myotomy was included only when an underlying motility disorder was present. e only anastomotic leak
occurred with a midthoracic diverticulum resected by VATS.
In a few, very small series (fewer than ve patients), results
77,78
were described as “excellent.”
However, in a larger series of
11 patients from France, three developed an esophageal stula
79
and two required reoperation.
e authors of that study concluded, “Minimally invasive surgery does not confer signicant benet compared with open surgery in the treatment of
diverticula of the thoracic esophagus.” We have reviewed our
80
experience with this disease.
Of 20 patients who underwent
minimally invasive surgery for esophageal diverticula (either
laparoscopy or VATS) at UPMC, four patients developed an
esophageal leak and one death occurred as a result. Overall,
the results from these small case series of thoracoscopic resection of midesophageal diverticula suggest the potential for
considerable morbidity with a 20–30% leak rate. Management of epiphrenic diverticula with a minimally invasive laparoscopic approach (resection with or without myotomy and
fundoplication depending on underlying pathology) seems to
yield better results with low morbidity.
oracoscopic treatment of Boerhaave’s syndrome
and repair of an anastomotic leak following esophagectomy
have also been described in case reports. A minimally invasive
approach certainly merits consideration in these cases only if
the surgeon feels he/she can make safe and expeditious progress in these semiurgent cases. In general, we approach the
majority of these cases through an open approach.
REFERENCES
1. Dallemagne B, Weerts JM, Jehaes C, Markiewicz S, Lombard R. Laparo-
scopic Nissen fundoplication: preliminary report. Surg Laparosc Endosc.
1991 Sep;1(3):138–143.
81,82
83
430 Part III Esophagus
2. Ackroyd R, Watson DI, Majeed AW, Troy G, Treacy PJ, Stoddard CJ.
Randomized clinical trial of laparoscopic versus open fundoplication for
gastro-oesophageal reux disease. Br J Surg. 2004;91(8):975–982.
3. Douard R, Gaudric M, Chaussade S, Couturier D, Houssin D,
Dousset B. Functional results after laparoscopic Heller myotomy for
achalasia: a comparative study to open surgery. Surgery. 2004 Jul;
136(1):16–24.
4. Patti MG, Fisichella PM, Perretta S, et al. Impact of minimally invasive
surgery on the treatment of esophageal achalasia: a decade of change. J Am
Coll Surg. 2003;196(5):698–703; discussion 703–705.
5. Little AG. Gastroesophageal reux disease: a historical review of surgical
therapy. J Surg Res. 2004 Mar;117(1):30–33.
6. Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and
surgical mortality in the United States. New Engl J Med. 2002 Apr
11;346(15):1128–1137.
7. Millikan KW, Silverstein J, Hart V, et al. A 15-year review of esophagectomy for carcinoma of the esophagus and cardia. Arch Surg. 1995;130(6):
617–624.
8. McAnena OJ, Rogers J, Williams NS. Right thoracoscopically assisted
oesophagectomy for cancer. Br J Surg. 1994;81(2):236–238.
9. Collard JM, Lengele B, Otte JB, Kestens PJ. En bloc and standard esophagectomies by thoracoscopy. Ann orac Surg. 1993 Sep;56(3):675–679.
10. Peracchia A, Rosati R, Fumagalli U, Bona S, Chella B. oracoscopic
esophagectomy: are there benets? Semin Surg Oncol. 1997 Jul–Aug; 13(4):
259–262.
11. Luketich JD, Alvelo-Rivera M, Buenaventura PO, et al. Minimally
invasive esophagectomy: outcomes in 222 patients. Ann Surg. 2003
Oct;238(4):486–494; discussion 94–95.
12. Luketich JD, Schauer P, Landreneau R, et al. Minimally invasive surgical staging is superior to endoscopic ultrasound in detecting lymph
node metastases in esophageal cancer. J orac Cardiovasc Surg. 1997
Nov;114(5):817–821; discussion 21–23.
13. al-Sarraf M, Martz K, Herskovic A, et al. Progress report of combined
chemoradiotherapy versus radiotherapy alone in patients with esophageal
cancer: an intergroup study. J Clin Oncol. 1997;15(1):277–284.
14. Hulscher JB, van Sandick JW, de Boer AG, et al. Extended transthoracic
resection compared with limited transhiatal resection for adenocarcinoma
of the esophagus. New Engl J Med. 2002 Nov 21;347(21):1662–1669.
15. Bedenne L, Michel P, Bouche O, et al. Chemoradiation followed by surgery compared with chemoradiation alone in squamous cancer of the
esophagus: FFCD 9102. J Clin Oncol. 2007 Apr 1;25(10):1160–1168.
16. Stahl M, Stuschke M, Lehmann N, et al. Chemoradiation with and without surgery in patients with locally advanced squamous cell carcinoma of
the esophagus. J Clin Oncol. 2005 Apr 1;23(10):2310–2307.
17. Ajani J, D’Amico TA, Hayman JA, Meropol NJ, Minsky B. Esophageal
cancer. Clinical practice guidelines in oncology. J Natl Compr Canc Netw.
2003;1(1):14–27.
18. Chang L, Stefanidis D, Richardson WS, Earle DB, Fanelli RD. e role of
staging laparoscopy for intraabdominal cancers: an evidence-based review.
Surg Endosc. 2009;23(2):231–241.
19. Luketich JD, Meehan M, Nguyen NT, et al. Minimally invasive surgical
staging for esophageal cancer. Surg Endosc. 2000;14(8):700–702.
20. Flanagan FL, Dehdashti F, Siegel BA, et al. Staging of esophageal cancer
with 18F-uorodeoxyglucose positron emission tomography. AJR Am J
Roentgenol. 1997;168(2):417–424.
21. Kole AC, Plukker JT, Nieweg OE, Vaalburg W. Positron emission
tomography for staging of oesophageal and gastroesophageal malignancy.
Br J Cancer. 1998 Aug;78(4):521–527.
22. Dwamena BA, Sonnad SS, Angobaldo JO, Wahl RL. Metastases from
non-small cell lung cancer: mediastinal staging in the 1990s—meta- analytic
comparison of PET and CT. Radiology. 1999 Nov;213(2):530–536.
23. Hellwig D, Ukena D, Paulsen F, Bamberg M, Kirsch CM. [Meta- analysis
of the ecacy of positron emission tomography with F-18-uorodeoxyglucose in lung tumors. Basis for discussion of the German Consensus Conference on PET in Oncology 2000]. Pneumologie (Stuttgart,
Germany). 2001;55(8):367–377.
24. Luketich JD, Schauer PR, Meltzer CC, et al. Role of positron emission tomography in staging esophageal cancer. Ann orac Surg. 1997 Sep;64(3):
765–769.
25. Luketich JD, Friedman DM, Weigel TL, et al. Evaluation of distant
metastases in esophageal cancer: 100 consecutive positron emission tomography scans. Ann orac Surg. 1999 Oct;68(4):1133–1136; discussion 6–7.
26. Tytgat GN, Tio TL. Esophageal ultrasonography. Gastroenterol Clin North
Am. 1991 Dec;20(4):659–671.
27. Saunders HS, Wolfman NT, Ott DJ. Esophageal cancer. Radiologic
staging. Radiol Clin North Am. 1997 Mar;35(2):281–294.
28. Vickers J. Role of endoscopic ultrasound in the preoperative assessment of patients with oesophageal cancer. Ann R Coll Surg Engl. 1998
Jul;80(4):233–239.
29. Krasna MJ, Reed CE, Nedzwiecki D, et al. CALGB 9380: a prospective
trial of the feasibility of thoracoscopy/laparoscopy in staging esophageal
cancer. Ann orac Surg. 2001;71(4):1073–1079.
30. Walsh TN, Noonan N, Hollywood D, Kelly A, Keeling N, Hennessy TP.
A comparison of multimodal therapy and surgery for esophageal adenocarcinoma. New Engl J Med. 1996 Aug 15;335(7):462–467.
31. Steup WH, De Leyn P, Denee G, Van Raemdonck D, Coosemans W,
Lerut T. Tumors of the esophagogastric junction. Long-term survival in
relation to the pattern of lymph node metastasis and a critical analysis of
the accuracy or inaccuracy of pTNM classication. J orac Cardiovasc
Surg. 1996;111(1):85–94; discussion 94–95.
32. Kassis ES, Nguyen N, Shriver SP, Siegfried JM, Schauer PR, Luketich JD.
Detection of occult lymph node metastases in esophageal cancer by minimally invasive staging combined with molecular diagnostic techniques.
JSLS. 1998 Oct–Dec;2(4):331–336.
33. Godfrey TE, Raja S, Finkelstein SD, Gooding WE, Kelly LA, Luketich
JD. Prognostic value of quantitative reverse transcription-polymerase chain
reaction in lymph node-negative esophageal cancer patients. Clin Cancer Res.
2001;7(12):4041–4048.
34. Akaishi T, Kaneda I, Higuchi N, et al. oracoscopic en bloc total esophagectomy with radical mediastinal lymphadenectomy. J orac Cardiovasc
Surg. 1996 Dec;112(6):1533–1540; discussion 40–41.
35. Robertson GS, Lloyd DM, Wicks AC, Veitch PS. No obvious advantages for
thoracoscopic two-stage oesophagectomy. Br J Surg. 1996;83(5):675–678.
36. Law S, Wong J. Use of minimally invasive oesophagectomy for cancer of
the oesophagus. Lancet Oncol. 2002;3(4):215–222.
37. DePaula AL, Hashiba K, Ferreira EA, de Paula RA, Grecco E. Laparoscopic
transhiatal esophagectomy with esophagogastroplasty. Surg Laparosc
Endosc. 1995 Feb;5(1):1–5.
38. Swanstrom LL, Hansen P. Laparoscopic total esophagectomy. Arch Surg.
1997;132(9):943–947; discussion 7–9.
39. Atkins BZ, Shah AS, Hutcheson KA, et al. Reducing hospital morbidity
and mortality following esophagectomy. Ann orac Surg. 2004 Oct;78(4):
1170–1176; discussion 1170–1176.
40. Martin RE, Letsos P, Taves DH, Inculet RI, Johnston H, Preiksaitis HG.
Oropharyngeal dysphagia in esophageal cancer before and after transhiatal
esophagectomy. Dysphagia. 2001 Winter;16(1):23–31.
41. Easterling CS, Bousamra M, 2nd, Lang IM, et al. Pharyngeal dysphagia
in postesophagectomy patients: correlation with deglutitive biomechanics.
Ann orac Surg. 2000;69(4):989–992.
42. Bhat MA, Dar MA, Lone GN, Dar AM. Use of pedicled omentum in
esophagogastric anastomosis for prevention of anastomotic leak. Ann orac
Surg. 2006 Nov;82(5):1857–1862.
43. Cherian V, Divatia JV, Kulkarni A, Dasgupta D. Cardiomediastinal
tamponade and shock following three-stage transthoracic oesophagectomy.
J Postgrad Med. 2001 Jul–Sep;47(3):185–187.
44. Velanovich V, Vallance SR, Gusz JR, Tapia FV, Harkabus MA. Quality
of life scale for gastroesophageal reux disease. J Am Coll Surg. 1996
Sep;183(3):217–224.
45. Rizk NP, Bach PB, Schrag D, et al. e impact of complications on
outcomes after resection for esophageal and gastroesophageal junction
carcinoma. J Am Coll Surg. 2004;198(1):42–50.
46. Watson DI, Davies N, Jamieson GG. Totally endoscopic Ivor Lewis
esophagectomy. Surg Endosc. 1999;13(3):293–297.
47. Nguyen NT, Follette DM, Lemoine PH, Roberts PF, Goodnight JE, Jr.
Minimally invasive Ivor Lewis esophagectomy. Ann orac Surg. 2001
Aug;72(2):593–596.
48. Kunisaki C, Hatori S, Imada T, et al. Video-assisted thoracoscopic esophagectomy with a voice-controlled robot: the AESOP system. Surg Laparosc
Endosc Percutan Tech. 2004 Dec;14(6):323–327.
49. Bizekis C, Kent MS, Luketich JD, et al. Initial experience with minimally
invasive Ivor Lewis esophagectomy. Ann orac Surg. 2006 Aug;82(2):
402–406; discussion 6–7.
50. Palanivelu C, Prakash A, Senthilkumar R, et al. Minimally invasive esophagectomy: thoracoscopic mobilization of the esophagus and mediastinal
Chapter 19 Video-Assisted oracic Surgery of the Esophagus 431
lymphadenectomy in prone position—experience of 130 patients. J Am
Coll Surg. 2006l;203(1):7–16.
51. Seremetis MG, Lyons WS, deGuzman VC, Peabody JW, Jr. Leiomyo-
mata of the esophagus. An analysis of 838 cases. Cancer. 1976 Nov;38(5):
2166–2177.
52. Lee LS, Singhal S, Brinster CJ, et al. Current management of esophageal
leiomyoma. J Am Coll Surg. 2004;198(1):136–146.
53. Hatch GF, 3rd, Wertheimer-Hatch L, Hatch KF, et al. Tumors of the
esophagus. World J Surg. 2000;24(4):401–411.
54. Fountain SW. Leiomyoma of the esophagus. orac Cardiovasc Surg. 1986
Jun;34(3):194–195.
55. Glanz I, Grunebaum M. e radiological approach to leiomyoma
of the oesophagus with a long-term follow-up. Clin Radiol. 1977
Mar;28(2):197–200.
56. Biasini A. Su di un caso di broleiomyoma dell’esofago ipobronchiale in
transformazione maligna asportazione per via transpleurodiaframmatica
ed esofago-gastrostomia guarigione. Pathologica. 1949;41:260–267.
57. Calmenson M, Claggett O. Surgical removal of leiomyomas of the
esophagus. Am J Surg. 1946;72:745–747.
58. Bonavina L, Segalin A, Rosati R, Pavanello M, Peracchia A. Surgical therapy of esophageal leiomyoma. J Am Coll Surg. 1995 Sep;181(3):257–262.
59. Roviaro GC, Maciocco M, Varoli F, Rebuat C, Vergani C, Scarduelli
A. Videothoracoscopic treatment of oesophageal leiomyoma. orax.
1998;53(3):190–192.
60. Samphire J, Nafteux P, Luketich J. Minimally invasive techniques for
resection of benign esophageal tumors. Semin orac Cardiovasc Surg.
2003;15(1):35–43.
61. Li ZG, Chen HZ, Jin H, et al. Surgical treatment of esophageal leiomyoma located near or at the esophagogastric junction via a thoracoscopic
approach. Dis Esophagus. 2009;22(2):185–189.
62. Hennessy TPJ, Cuschieri A. Tumours of the esophagus. In: Hennessy TPJ,
Cuschieri A, eds. Surgery of the Oesophagus. 2nd ed. Oxford, UK; Boston,
MA: Butterworth Heinemann; 1992:275–327.
63. Kent M, d’Amato T, Nordman C, et al. Minimally invasive resection of
benign esophageal tumors. J orac Cardiovasc Surg. 2007 Jul;134(1):
176–181.
64. Ellis FH, Jr. Oesophagomyotomy for achalasia: a 22-year experience. Br J
Surg. 1993;80(7):882–885.
65. Ferguson MK, Reeder LB, Olak J. Results of myotomy and partial fundoplication after pneumatic dilation for achalasia. Ann orac Surg. 1996
Aug;62(2):327–330.
66. Luketich JD, Fernando HC, Christie NA, et al. Outcomes after minimally
invasive esophagomyotomy. Ann orac Surg. 2001 Dec;72(6):1909–
1912; discussion 12–13.
67. Schuchert MJ, Luketich JD, Landreneau RJ, et al. Minimally-invasive
esophagomyotomy in 200 consecutive patients: factors inuencing postoperative outcomes. Ann orac Surg. 2008;85(5):1729–1734.
68. Pellegrini C, Wetter LA, Patti M, et al. oracoscopic esophagomyotomy.
Initial experience with a new approach for the treatment of achalasia. Ann
Surg. 1992 Sep;216(3):291–296; discussion 6–9.
69. Codispoti M, Soon SY, Pugh G, Walker WS. Clinical results of thoraco-
scopic Heller’s myotomy in the treatment of achalasia. Eur J Cardiothorac
Surg. 2003 Oct;24(4):620–624.
70. Lee JM, Wang CH, Huang PM, et al. Enduring eects of thoracoscopic
Heller myotomy for treating achalasia. World J Surg. 2004;28(1):55–58.
71. Kesler KA, Tarvin SE, Brooks JA, Rieger KM, Lehman GA, Brown JW. oracoscopy-assisted Heller myotomy for the treatment of achalasia: results of
a minimally invasive technique. Ann orac Surg. 2004;77(2):385–391;
discussion 91–92.
72. Abir F, Modlin I, Kidd M, Bell R. Surgical treatment of achalasia: current
status and controversies. Dig Surg. 2004;21(3):165–176.
73. Richards WO, Torquati A, Holzman MD, et al. Heller myotomy versus
Heller myotomy with Dor fundoplication for achalasia: a prospective
randomized double-blind clinical trial. Ann Surg. 2004 Sep;240(3):
405–412; discussion 12–15.
74. Agrawal D, Meekison L, Walker WS. Long-term clinical results of
thoracoscopic Heller’s myotomy in the treatment of achalasia. Eur J
Cardiothorac Surg. 2008 Aug;34(2):423–426; discussion 6.
75. Ma N, Zhong H, Ye C, Shan G, Zhang F, Mei J. Minimally invasive
thoracoscope-assisted Heller myotomy for achalasia. Asian Cardiovasc
orac Ann. 2008 Dec;16(6):459–462.
76. Palanivelu C, Rangarajan M, Maheshkumaar GS, Senthilkumar R.
Minimally invasive surgery combined with peroperative endoscopy for
symptomatic middle and lower esophageal diverticula: a single institute’s
experience. Surg Laparosc Endosc Percutan Tech. 2008 Apr;18(2):133–138.
77. Beckerhinn P, Kriwanek S, Pramhas M, Armbruster C, Roka R.
Video-assisted resection of pulsative midesophagus diverticula. Surg Endosc.
2001;15(7):720–722.
78. Dado G, Bresadola V, Terrosu G, Bresadola F. Diverticulum of the
midthoracic esophagus: pathogenesis and surgical treatment. Surg Endosc.
2002;16(5):871.
79. Levard H, Carbonnel F, Perniceni T, et al. [Minimally invasive surgery for
diverticula of the thoracic esophagus. Results in 11 patients]. Gastroenterol
Clin Biol. 2001;25(10):885–890.
80. Fernando HC, Luketich JD, Samphire J, et al. Minimally invasive operation
for esophageal diverticula. Ann orac Surg. 2005 Dec;80(6):2076–2080.
81. Ikeda Y, Niimi M, Sasaki Y, Shatari T, Takami H, Kodaira S. oracoscopic
repair of a spontaneous perforation of the esophagus with the endoscopic
suturing device. J orac Cardiovasc Surg. 2001;121(1): 178–179.
82. Landen S, El Nakadi I. Minimally invasive approach to Boerhaave’s syndrome: a pilot study of three cases. Surg Endosc. 2002;16(9):1354–1357.
83. Nguyen NT, Follette DM, Roberts PF, Goodnight JE, Jr. oracoscopic
management of postoperative esophageal leak. J orac Cardiovasc Surg.
2001;121(2):391–392.