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434 Perforation of the esophagus
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The stomach is then divided using an
12a,b
lateral to the gastroesophageal junction in the greater
curvature and continuing to the midportion of the lesser curvature. This suture line is oversewn with interrupted 3/0 silk
suture.
A wide Penrose drain is sutured to the lower end of the
Endo GIA instrument, starting 2–3 cm
divided esophagus, and the esophagus and top of the stomach
are removed by pulling from the neck to leave the Penrose
drain in the posterior mediastinum. The inferior end of the
drain is then attached to the fundus of the stomach to serve as
a guide to direct the stomach to the neck, where a two-layer
anastomosis is performed to the cervical esophagus just above
the thoracic inlet.
12a
12b
Perforation diagnosed several days after
occurrence
Patients in whom the perforation is diagnosed several days
after occurrence are treated primarily by interventional radiological techniques, although some authors have used operative techniques. The strategy is to drain the cavity adjacent to
the perforation and the abscesses as adequately as possible.
This involves placing a transoral-transesophageal
13
addition, a percutaneous gastrostomy is performed, and
through it another tube is advanced in a retrograde direction
into the esophagus. This tube may also be used to decompress
the cavity. Finally, a thoracostomy tube may be placed to
drain the abscess directly, but this may lead to a temporary
esophagocutaneous fistula.
feeding jejunostomy catheter should be placed. This can be
done laparoscopically to obviate the need for laparotomy.
tube through the perforation to aspirate the cavity. In
Because the patient will not be able to eat for some time, a
13
Alternative approach
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In some patients it may not be possible to close the perforation because of a delay in diagnosis, because the patient is too
sick for the thoracotomy, or because sepsis persists after
interventional radiological management or dehiscence of a
previous closure.
The treatment of choice in these cases is to divide the
14
esophagostomy and closing the thoracic esophagus as low as
possible in the neck. A long length of cervical esophagus is
critical in this situation, as it makes subsequent reconstruction easier. The stoma can be tunneled onto the anterior chest
wall and matured at an appropriate location. The cardioesophageal junction is closed with a stapling device via laparotomy or laparoscopy. This effectively isolates the perforated
segment and stops mediastinal and pleural soiling.
to re-establish continuity of the gastrointestinal tract. This is
best accomplished 2–3 months later via a total esophagectomy by the transhiatal approach and a gastroesophageal
anastomosis at the neck. Not unexpectedly, this therapy is
associated with a high mortality and significant morbidity.
amenable to primary repair is the insertion of a T-tube. The T-
tube is inserted into the esophagus and an appropriate sized
cut chest drain, to ensure that the distal holes have been
removed, is inserted into the T-tube. A nasogastric tube is
passed through the T-tube into the stomach, securing it into
place. In this manner, the esophagus is drained and a controlled esophocutaneous fistula is created. Although this therapy has been used successfully by a number of surgeons, it is
not recommended as a routine measure and should only be
utilized when the esophagus cannot be reconstructed or
closed in a poor risk patient.
esophagus at the neck, bringing out an end-
Unfortunately, this procedure requires a second operation
A similar therapy for esophageal perforation that is not
Operations 435
Chest tube
Gastrostomy tube
Feeding
jejunostomy
14
436 Perforation of the esophagus
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Cervical esophageal perforation
Surgical access to the cervical esophagus has been described
in a previous section. A similar approach to thoracic
esophageal injury is undertaken, including debridement of
muscular tissue to identify the mucosal rent and closure in
two layers. The repair may be buttressed with strap muscle,
but this aspect is less critical in the neck. In fact, many authors
advocate simple drainage of cervical esophageal perforations
because of the tendency of these injuries to heal without
direct suture repair. Adequate drainage can be provided with
either closed suction drains or Penrose drains. Debridement
of the mediastinal space through a right thoracotomy should
be considered if there is significant undrained abscess on CT
scan.
POSTOPERATIVE CARE
The patient is intubated for the first 12–24 hours. Good ventilation and full lung expansion are essential to prevent
atelectasis, pneumonia and to allow the decorticated lung to
expand. Also, if the endotracheal tube is removed at the end
of the operation, not uncommonly emergency reintubation is
necessary. Forceful mask ventilation before emergency reintubation increases esophageal pressure and may lead to
dehiscence of the suture lines. These patients need intensive
care during the first few days. The nasogastric tube must be
carefully cared for and routinely flushed, as draining the
stomach and esophagus is imperative. To decrease gastric
acid secretion H2-receptor antagonists are administered. The
apical chest tube is removed as soon as good lung expansion
is achieved and no evidence of air leaks is seen (usually 2 days
after surgery).
Antibiotics and antifungals are continued for 7–10 days,
depending on the degree of contamination: in patients with
positive results on preoperative blood cultures, antibiotics
should be continued for 14 days. Enteral feeds using the feeding jejunostomy are started 48 hrs after surgery. If no feeding
tube is inserted total parenteral nutrition is administered for
the first 8–10 days.
Eight or nine days after surgery, a barium swallow examination should be performed (water-soluble material should
be used if there is any suspicion of dehiscence). If this study
demonstrates no extravasation, the angled chest tube is
removed, and the patient is started immediately on a
mechanically soft diet. Patients are discharged home as soon
as they can eat and have no evidence of residual infection. If
dehiscence is noted and it is contained and asymptomatic,
they are kept on enteral or parenteral nutrition for an additional 10 days and the study is then repeated. If symptoms of
abscess are present, treatment should be the same as if a
delayed perforation is discovered.
Late-diagnosed perforation
Management of the tubes is very important to the success of
the procedure to treat late-diagnosed perforation. The tube
placement should be inspected periodically (every 2–3 days
or more frequently if there is evidence of infection) and
cavity size measured by fistulography. The tubes are
advanced back into the esophageal lumen as soon as the cavity becomes smaller to allow for more rapid closure of the
perforation.
FURTHER READING
Attar S, Hankins JR, Suter CM, Coughlin TR, Sequeira A, McLaughlin JS.
Esophageal perforation: a therapeutic challenge. Annals of Thoracic
Surgery 1990; 50: 45–51.
Backer CL, LoCicero J 3rd, Hartz RS, Donaldson JS, Shields T. Computed
tomography in patients with esophageal perforation. Chest 1990;
98: 1078–80.
Brinster CJ, Singhal S, Lee L, Marshall MB, Kaiser LR, Kucharczuk JC.
Evolving options in the management of Esophageal Perforation.
Annals of Thoracic Surgery 2004; 77: 1475-83.
Dolgin SR, Wykoff TW, Kumar NR, Maniglia AJ. Conservative medical
management of traumatic pharyngoesophageal perforations. Annals
of Otology, Rhinology and Laryngology 1992; 101: 209–15.
Engum SA, Grosfeld JL, West KW, Rescorla FJ, Scherer LR, Vaughan WG.
Improved survival in children with esophageal perforation. Archives
of Surgery. 1996; 131: 604-10
Flynn AE, Verrier ED, Way LW, Thomas AN, Pellegrini CA. Esophageal
perforation. Archives of Surgery 1989; 124: 1211–15.
Gayet B, Breil P, Fekete F. Mechanical sutures in perforation of the
thoracic esophagus as a safe procedure in patients seen late.
Surgery, Gynecology & Obstetrics 1991; 172: 125–8.
Jones WG 2nd, Ginsberg RJ. Esophageal perforation: a continuing
challenge. Annals of Thoracic Surgery 1992; 53: 534–43.
Maroney TP, Ring EJ, Gordon RL, Pellegrini CA. Role of interventional
radiology in the management of major esophageal leaks. Radiology
1989; 170: 1055–7.
Port JL, Kent MS, Korst RJ, Bacchetta M, Altorki NK. Thoracic esophageal
perforations: a decade of experience. Annals of Thoracic Surgery.
2000; 75: 1071-4
Sauer L, Pellegrini CA, Way LW. The treatment of achalasia. A current
perspective. Archives of Surgery 1989; 124: 929–32.
Skinner DB. Instrumental perforation and mediastinitis. Philadelphia: WB
Saunders, 1988; 783–98.
Tilanus HW, Bossuyt P, Schattenkerk ME, Obertop H. Treatment of
oesophageal perforation: a multivariate analysis. British Journal of
Surgery 1991; 78: 582–5.
Tomaselli F, Maier A, Pinter H, Smolle-Juttner F. Management of
iatrogenous esophagus perforation.Thoracic and Cardiovascular
Surgery. 2002; 50: 168-73.
White RK, Morris DM. Diagnosis and management of esophageal
perforations. American Surgeon 1992; 58: 112–19.
42
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Open antireflux operations through a left
thoracic approach
ANDRÉ DURANCEAU MD
Professor of Surgery, Chair, Division of Thoracic Surgery, Centre hospitalier de l’Université de Montréal, Montréal, Québec, Canada
HISTORY
Hiatal hernia and its symptoms became recognized during
the initial half of the twentieth century. The deranged
anatomy of the hiatus with protrusion of the stomach into the
chest influenced surgeons to treat this condition and its associated reflux by restoration of the normal anatomy of the gastro-esophageal junction by operative techniques as proposed
by Harrington, Sweet, Lertat, Jacob and Allison. Allison,
however, documented that in a 20-year assessment of the
patients he had treated, 49% showed an anatomical recurrence. Allison recognized that the reflux of gastric contents
into the esophagus was responsible for the symptoms and he
proposed the term reflux esophagitis. Woodward and Pope
documented that approximately 50% of patients with an
anatomical repair had pH documentation reflux after their
operation.
Development of more effective antireflux operations were
reported mainly during the 1960s and 1970s, and associated
with the parallel development of more objective methods to
document reflux disease and its complications. The Belsey
technique, the Nissen total fundoplication, and the Hill operation were assessed with their respective approach, their
respective morbidity and recovery. Collis proposed an
esophageal lengthening operation for reflux associated with a
shortened esophagus consequent to mucosal damage and
peri-esophagitis. This elongation procedure was subsequently coupled to a partial or a total fundoplication with
excellent long-term results.
Standard antireflux repairs and modified repairs lengthening the esophagus with an added partial or total fundoplication have now been described using minimally invasive
techniques. The long-term results and the durability of these
procedures in relation to the level of reflux and the inflammatory change encountered are awaited.
The aim of this chapter is to describe the detailed techniques of selected antireflux repairs when they are performed
through the chest.
PRINCIPLES AND JUSTIFICATION
The basic principles of surgical reconstruction of the esophagogastric junction to insure competency of the cardia against
gastroesophageal reflux have been well described and apply to
all types of antireflux repairs:
1 The operation should restore the deficient lower
esophageal sphincter to physiological levels (gradient of
15–20 mmHg above resting intragastric pressure).
2 Adequate length of the distal esophagus, including the
lower esophageal sphincter pressure zone, should be
reduced to an intra-abdominal position, to be exposed to
positive intra-abdominal pressure.
3 The reconstructed cardia should not create a resistance
that will exceed the propulsive force of the esophagus.
4 The operation should be made without tension, and
ensure that the repair will not migrate into the mediastinum.
5 If the esophagus is shortened, either by inflammation
within its wall from long-term reflux or by peri-esophagitis encountered at surgery, an elongation gastroplasty with
an added partial or total fundoplication should be constructed. A repair which has placed the oesophagogastric
junction without tension to the infra-diaphragmatic position, associated with a partial or total fundoplication, is
offered as the ideal treatment.
438 Open antireflux operations through a left thoracic approach
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PREOPERATIVE ASSESSMENT
Symptoms usually bring the patient for investigation. These
symptoms are not reliable indicators of the presence of reflux
disease, the degree of esophageal damage, or provide an
indication for surgery.
Radiological assessment aims to document the anatomy of
the esophagus and stomach and to classify a hiatus hernia
when present. Visual demonstration of reflux on radiology is
a poor indicator of endoscopically proven esophagitis.
Objectivity in documenting reflux disease in the esophagus
requires the use of investigative methods whereby reflux can
be quantified.
1 Endoscopy using the Los Angeles classification or the
MUSE classification gives credit to mucosal damage when
mucosal breaks are documented.
OPERATION
2 Esophageal biopsies will document unequivocal evidence
of reflux damage when acute epithelial or subepithelial
inflammation and/or ulceration are present. Fibrosis in
the submucosa, in the muscle or the presence of a columnar lined esophagus are signs of more advanced disease.
3 Manometry documents the physiological abnormalities
and is the scientific basis of gastroesophageal reflux disease.
An absent lower esophageal sphincter with esophageal contractions showing poor strength and deficient or incoordated propulsion is highly suggestive of the diagnosis.
4 Long-term recording of an acid refluxate (24-hour pH) or
of a biliary-pancreatic refluxate (Bilitec) are used to document abnormal levels of reflux exposure.
5 Radionuclide scintigrams are used mostly to assess the
emptying capacity of the esophagus before and after treating esophageal diseases.
A double-lumen tube is positioned in the trachea, and
1
the patient is placed in a right lateral decubitus position.
The left arm is supported by an arm rest, and the incision follows the upper border of the eighth rib. The posterior arc of
the rib is divided, and 1 cm of the rib is removed to avoid
postoperative end-to-end rib contact.
Pericardium
1
Adhesions between the lung and the chest wall are
2a
is divided using electrocautery. The collapsed left inferior
lobe is retracted anteriorly and kept in place by large intrathoracic pads. The mediastinum is opened as an inverted T, and
the vertical incision is made 1 cm anterior to the descending
aorta and along the pericardium. Both incisions meet behind
the inferior pulmonary vein.
freed if necessary. The inferior pulmonary ligament
Hernia
2a
Aorta
The horizontal part of the T is made along the left
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2b
where the pericardium is freed from the fibrous portion of
the diaphragm. The mediastinum is opened widely, and
vessels from the aorta to the esophagus are clamped and
divided.
crus of the diaphragm and extended anteriorly,
Operation 439
Penrose
drain
Aorta Esophagus
2c
Pericardium
2b
After being freed from the aorta and pericardium, the
2c
both the anterior and posterior vagi. Doing so exposes the
contralateral pleura. The esophagus is dissected completely
free between the hiatus and the area above the inferior pulmonary vein just under the aortic arch.
esophagus is encircled by blunt dissection, protecting
440 Open antireflux operations through a left thoracic approach
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Complete dissection of the hiatus is made easier
3a
matic hiatus is freed with easy identification of the left crus.
Anterior to the herniated stomach or the esophagus, the
incision follows the circular limits of the hiatus.
when the peritoneal cavity is opened. The diaphrag-
3a
The right crus is exposed posterior to the esophagus.
3b
cavity, the index finger is passed behind the esophagus and
across the hiatus. The proximal gastrohepatic ligament is
opened, exposing the caudate lobe of the liver. With the index
finger behind the right crus, all posterior cardial attachments
to the diaphragm are divided. Circumferential clearing of the
hiatus is completed. The pleura to the right chest is then
opened and divided so that the pleura over the right crus is
left intact. The entire esophageal diaphragmatic hiatus is well
identified with normal peritoneum covering the abdominal
surface and normal pleura over the thoracic side. Left and
right crura are ready to be reapproximated by wide, tension
free 1-0 silk sutures.
With the hiatus widely opened to the abdominal
3b
If a massive hernia is present (types II, III, or IV), the
https://t.me/med1917
4a
easily opened anteriorly. In this situation, the fundus and
greater curvature are easily identified, and the short gastric
vessels are dissected free and ligated. More than 50% of
patients with severe complications of idiopathic reflux disease
(i.e. esophageal stricture or Barrett’s esophagus) actually
reveal no evidence of a hiatal hernia. In such a situation, two
techniques allow access to dissection of the greater curvature.
The first technique opens the retrogastric cavity behind the
esophagogastric junction and left crus. Progressive freeing of
the stomach is then accomplished by ligation of the short gastric vessels. The second approach creates a lateral opening in
the diaphragm, approximately 2–3 cm from the muscular
insertion on the chest wall. A GIA stapler is used to create a 6to 8-cm-long diaphragmatic division. Thus exposed, the
short gastric vessels are ligated under direct vision, and the
entire greater curvature is freed. With two or three fingers
positioned through the abdominal hiatus, the phrenoesophageal ligament is put under tension and divided around
the limits of the hiatus. The anterior and posterior aspects of
the lesser curvature are easily identified and dissected using
this approach. When completely free, the esophagus and
proximal stomach are delivered into the chest through the
hiatus.
hiatus is usually very wide, and the peritoneum is
Operation 441
4a
4b
When a lengthening operation needs to be added, the
4b
curvature are dissected as for a highly selective vagotomy. The
fat pad of the esophagogastric junction is resected, the anterior and posterior vagi are dissected free from the stomach
wall and pushed away to allow the creation of the gastroplasty, and 6 to 7 cm of lesser curvature is denuded from the
surrounding tissue. Closure of the hiatus behind the esophagus is accomplished at this point. These sutures cannot be
easily placed once the esophagogastric junction repair is completed. The right crus is grasped with a small Duval clamp,
holding the crus with the peritoneum under and the pleura
above. This maneuver creates an eversion of the right crus
toward the chest, allowing an excellent visualization of the
inferior vena cava. The left crus is seized in the same way with
a second clamp. 1-0 silk sutures are initially passed posteriorly with bites taking all the tissue layers, including the transversalis fascia and the fibrous portion of the crus. A distance
of 0.5–1 cm is left between each suture, and when the last
suture is installed, easy passage should remain for the index
finger between the esophageal wall containing the number 50
bougie and the last suture reapproximating the crura.
anterior and posterior portions of the proximal lesser
442 Open antireflux operations through a left thoracic approach
g
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The Belsey mark IV repair
With the esophagus and gastric
5
fundus completely mobilized and the
phrenoesophageal ligament divided at
2 cm from its esophageal insertions, the
esophagogastric junction is brought into
the chest through the hiatus. The fat pad
covering the anterior portion of the junction is then removed, creating a raw surface that will favor healing of the plication
against the esophageal wall.
Anterior
vagus
Posterior
us
va
5
Operation 443
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The goal of the Belsey repair is
6a,b
plication covering two thirds (240 degrees)
of the circumference of the distal esophagus.
This is accomplished using two rows of
sutures. The first row of 2-0 silk material is
passed through the muscularis of the distal
esophagus and then through the seromuscular layers of the proximal gastric fundus.
Three stitches are placed to appose the raw
surfaces between the anterior vagus and the
posterior vagus.
the creation of a partial fundo-
6a
6b
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