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474 Thoracoscopic cardiomyotomy for achalasia
https://t.me/med1917
Positioning
The patient is placed in the right lateral decubitus posi-
1
tion, slightly prone. The left lateral interspaces are distracted to facilitate port placement by placing a large sand bag
under the right lower lateral chest wall.
2
1
Port placement
A left pneumothorax is created by blunt dissection in the
2
seventh interspace in the anterior axillary line. Insertion
of an 11 mm port allows the insertion of a 30 degree thoracoscope. The remaining ports are inserted under direct vision.
Choosing the best site for port insertion is assisted by preliminary palpation of the interspace, while at the same time viewing the interspaces internally with the thoracoscope.
An 11 mm port is placed as caudally as possible in the
midaxillary line in the ninth interspace just above the lateral
insertion of the diaphragm. This port is used for distal retraction of the left crus with the claws of a laparoscopic Babcock
forceps as well as distal displacement of the dome of the left
hemidiaphragm with the shaft of the instrument.
An 11mm port is placed in the tenth interspace, just lateral
to the lateral border of the erector spinae muscles. A 5 mm
port is also placed in the tenth interspace 3–4 cm anterior to
the 11 mm port.After insertion of these ports, the thoracoscope is switched to the 11 mm port in the tenth interspace.
Finally a 5 mm port is inserted in the eighth interspace in
the posterior axillary line. This port is used for periesophageal dissection and the cardiomyotomy.
Positioning of staff and monitors
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The surgeon stands on the left-hand side of the operating
table. The assistant stands just caudad to the surgeon. The
scrub nurse stands on the right-hand side of the operating
table. Two monitors are placed cephalad to these three persons, one on either side of the operating table. (see Figure 1)
Mobilization of the left lung
The patient is tilted head down to assist cephalad dis-
3
placement of the left lung. A blunt retractor is placed
between the diaphragm and the diaphragmatic surface of the
left lung to push the lung cephalad and expose the left inferior
pulmonary ligament. This ligament is divided in a cephalad
direction with scissors inserted through the tenth interspace
5 mm port. The cephalad limit of this dissection is the left
inferior pulmonary vein. After this dissection the lower portion of the left lung falls away cephalad.
Operation 475
3
Exposure of the esophagus
The structures of the mediastinum are identified for
4
orientation. To be defined in a posterior to anterior axis
just above the diaphragm are the vertebral bodies, the
descending aorta, the triangular space overlying the distal
esophagus, and the pericardium. If the position of the esophagus is uncertain at this point, it can be defined by having a
flexible endoscope passed into the distal esophagus and prodding its lateral wall with the instrument lighted.
4
476 Thoracoscopic cardiomyotomy for achalasia
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The mediastinal pleura overlying the esophagus is picked
5
up and divided in a caudad direction. The incision starts
just caudad to the left inferior pulmonary vein and extends to
the reflection of mediastinal pleura onto the diaphragm. The
scissors are inserted through the eighth interspace 5mm port.
Laparoscopic Debakey forceps inserted in the ninth space
11 mm port and the tenth space 5 mm ports distract the
pleura anteriorly and posteriorly respectively. The scrub
nurse holds the anterior grasper. The assistant holds the posterior grasper in his left hand and the telescope in his right.
This exposes the fibro-fatty tissue overlying the left lateral
side of the esophagus, which needs to be divided in a longitudinal direction to expose the longitudinal fibers of the distal
esophagus. One or two interconnecting branches between the
anterior and posterior vagal trunks may be encountered
which need to be divided. There may also be one or two small
esophageal branches to the aorta, which need to be coagulated. Once the peri-esophageal plane has been identified it
should be opened up both anteriorly and posteriorly by blunt
dissection to expose the left lateral wall of the esophagus. The
two DeBakey forceps are used to retract peri-esophageal
adventitia laterally during this exposure.
5
6
Once the fleshy fibers of the left crus are encountered,
6
division of the pleura proceeds anteriorly and posteriorly
along the line of reflection of mediastinal pleura onto the
diaphragm for 1–2 cm in either direction. This allows the
muscular left crus where it overlies the esophagus to be firmly
grasped with the laparoscopic Babcock forceps. At this point
the anterior and posterior vagal trunks should be clearly visible at the anterior and posterior limits of the subcrural dissection. Subcrural dissection is essential to access and divide
the circular fibers of the distal esophagus and the uppermost
sling fibers of the stomach. The phrenoesophageal ligament is
not recognizable as a distinct structure. It amounts to little
more than peri-esophageal adventitia slightly more resilient
than the adventitia above.
The myotomy
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The longitudinal myotomy is begun at the level of dilated
7
esophagus as determined endoscopically at the time. In
order to find the submucosal plane the muscle is grasped
anterior and posterior to the point of commencement of the
myotomy and distracted. The plane is soon encountered after
several small trial longitudinal cuts. The graspers need to be
slightly repositioned at this time to pick up and gently distract
the edges of the myotomy.
The submucosal plane is developed caudad by opening the
blunt-nosed scissors. The myotomy is extended caudally
through mobilized muscularis propria. With each cut of the
myotomy the graspers are repositioned further caudad. The
mucosa is separated from the muscularis propria over a quarter of the esophageal circumference by blunt lateral dissection
through the loose relatively avascular submucosal plane. This
allows the disturbingly thin mucosa to bulge laterally with
minimal luminal insufflation
The endoscopist determines the end point of the myotomy
functionally. It is the point at which the myotomy enables the
gastroesophageal junction to pout open with air insufflation
alone. The endoscope needs to manipulated very gently as the
esophageal mucosa deep to the myotomy might potentially
be torn. If necessary the myotomy will need to be extended to
achieve this end point. The other guide to the end point is the
submucosa itself. In the esophagus it is loose and avascular.
At the gastroesophageal junction it becomes less loose and
more vascular.
Once the myotomy is complete, it is leak tested by gentle
luminal insufflation with the myotomy submerged in irrigation fluid.
Outcome 477
7
PROBLEMS
Bleeding points on the cut muscle can be carefully coagulated, taking great care not to coagulate the mucosa.
The most likely point for perforation is the distal end of the
myotomy where the submucosal tissue is less loose. A tiny
perforation can be closed by careful mucosa-to-mucosa
suture and decompressed with a nasoesophageal tube placed
proximal to the myotomy
Closure
A small caliber intercostal catheter is inserted to drain the
base of the left pleural cavity. The left lung is then re-inflated.
Skin wounds are closed with subcuticular absorbable sutures.
POSTOPERATIVE CARE
The intercostal catheter is usually removed on the first
postoperative day. Clear fluids are commenced on the first
postoperative day after the integrity of the esophagus is
assured by contrast radiology. A pureed diet is usually commenced on the second postoperative day and continued for
a week.
OUTCOME
The primary expectation of the patient will be a relief of
dysphagia and an ability to eat normally. Whilst a very significant improvement in swallowing is to be expected, the
ability to swallow normally never really returns completely.
Nevertheless, the usual improvement is so great that
patients don’t seem to mind that normality has not been
quite achieved. Weight gain postoperatively can be very
impressive. Regurgitation is likely to disappear and the
patient should be able to lie flat without fear of aspiration.
Enquiry should be made about heartburn as a possible complication.
478 Thoracoscopic cardiomyotomy for achalasia
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THORACOTOMY FOR CARDIOMYOTOMY
Only differences from the thoracoscopic approach are mentioned.
Good access to the lowermost esophagus is possible
through a left lateral seventh space thoracotomy. The assistant stands on the right-hand side of the table opposite the
surgeon. The wound is distracted with a Finochetti retractor.
The instruments used to mobilize the left lung, expose the
esophagus, and perform the myotomy will be different, obviously, but the sequence of the surgical steps will be the same.
FURTHER READING
Csendes A, Braghetto I, Henriquez A, Cortes C. Late results of a
prospective randomized study comparing forceful dilatation and
esophagomyotomy in patients with achalasia. Gut 1989; 30:
299–304.
Patti MG, Pellegrini CA, Horgan S, et al. Thoracoscopic versus
laparoscopic modified myotomy for achalasia: efficacy and safety in
87 patients.
164–70.
Way LW. Minimally invasive surgery for achalasia. An 8 year experience
with 168 patients. Annals of Surgery 1999; 230: 587–94.
Journal of the American College of Surgeons 1999; 189:
46
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Esophagogastrectomy for adenocarcinoma of the
esophagus and cardia
A. H. HÖLSCHER MD, FACS, FRCS
Professor of Surgery and Chairman, Department of Visceral and Vascular Surgery, University of Cologne, Cologne, Germany
RUDOLF BUMM MD
Associate Professor, Department of Surgery, Technical University of Munich, Munich, Germany
J. RÜDIGER SIEWERT MD
Professor, Director and Chairman, Department of Surgery, Technical University of Munich, Munich, Germany
CLASSIFICATION
In this institution the term adenocarcinoma of the
1
gastroesophageal junction is used to describe all tumors
that have their center within an area 5 cm orad or 5 cm
aborad to the lower esophageal sphincter (LOS). Esophageal
adenocarcinomas and subcardial gastric carcinomas are
included in this category if they infiltrate the cardia, meaning
the terminal esophageal musculature. This therefore leads to
the following classification for different types of adenocarcinomas at the gastroesophageal junction:
1 Type I: adenocarcinoma in Barrett’s esophagus (center of
tumor 1–5 cm oral to the LOS)
2 Type II: carcinoma arising from the cardia proper (center
of tumor between 1 cm above and 2 cm below the LOS)
3 Type III: subcardial or fundal carcinoma of the stomach
that infiltrates the lower esophagus mostly within the submucosa (center of tumor 2–5 cm below the LOS)
Type I
Type II
Type III
1
480 Esophagogastrectomy for adenocarcinoma of the esophagus and cardia
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PRINCIPLES AND JUSTIFICATION
Five different procedures are available for the
2a–d
For type I carcinomas transthoracic en bloc esophagectomy or transmediastinal (transhiatal) esophagectomy and
partial upper gastrectomy can be applied (Figure 2a).
For type II and III carcinomas extended total gastrectomy
with distal esophageal resection via a transhiatal approach is
appropriate (Figure 2b, d). Splenectomy en bloc with gastrectomy is only performed in case of tumor infiltration of the
splenic hilus or overt lymph node metastasis in this area.
Total esophagogastrectomy is a procedure for very
advanced type II carcinomas (Figure 2c). This is only applied
if tumor free resection margins cannot be achieved by distal
esophageal resection in combination with total gastrectomy.
Distal esophageal resection with proximal partial gastrectomy and jejunum interposition represents the so-called
Merendino operation.
In this chapter the surgical technique for transmediastinal
subtotal esophageal resection and partial upper gastrectomy
as well as total esophagogastrectomy is described (Figures 2a,
c). Transthoracic en bloc esophagectomy is shown in Chapter
36.
surgical treatment of these types of carcinoma:
2a
2b
Indications
From the authors point of view transthoracic en bloc
esophagectomy and upper partial gastrectomy with gastric
pull-up and high intrathoracic anastomosis represents
the procedure of choice for type I adenocarcinoma. The
justification is the more extended mediastinal lymphadenectomy compared to transmediastinal esophagectomy. This
principal is supported by the results of the prospective randomized trial by Hulscher.
Transmediastinal esophagectomy as described in the
following can be justified in patients with a disturbed lung
function to avoid thoracotomy. For patients with type I or
type II mucosal carcinomas which usually have no lymphnode metastasis, a Merendino operation could be appropriate.
2c
2d
PREOPERATIVE ASSESSMENT AND PLANNING
A careful preoperative diagnostic examination is necessary
for surgery of adenocarcinoma of the gastroesophageal
junction. The tumor is staged by endoscopy, endoscopic
ultrasonography, barium swallow, and computed tomographic scan. These investigations give quite exact informa-
Operations 481
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tion for TNM staging. If an advanced tumor of the gastroesophageal junction is present, neoadjuvant chemotherapy or
radiochemotherapy may be appropriate. It is also important
in preoperative assessment to consider the risk factors that
are present. This includes an assessment of pulmonary, cardiac, renal, and hepatic function. In most cases a reconstruction is performed by stomach interposition, but the
colon should be prepared before operation by orthotopic
bowel lavage and ideally, a colonoscopy, so that an alterna-
OPERATIONS
Transmediastinal esophagectomy and proximal
gastrectomy (open technique)
tive is available should technical difficulties occur, as
described in Chapter 35.
Anesthesia
The operation is performed under routine general anesthesia.
In contrast to a transthoracic esophagectomy, a doublelumen endotracheal tube is not necessary. A peridural
catheter is recommended.
Transmediastinal esophagectomy with proximal gastrec-
3
tomy involves the subtotal removal of the esophagus and
proximal stomach by a transmediastinal route (without a
thoracotomy) and is performed through an abdominal and
cervical approach.
POSITION OF PATIENT
Transmediastinal esophagectomy is performed with the
4
patient lying supine. A bolster is used to bring the cardia
region forward to lessen the depth of dissection.
3
4
482 Esophagogastrectomy for adenocarcinoma of the esophagus and cardia
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The neck is positioned as for thyroid gland surgery with
5
the head turned to the right to expose the left part of the
neck. Sterile draping is placed in such a way that two surgical
teams (cervical and abdominal) can work simultaneously.
The esophagus is intubated with a large tube to facilitate palpation.
If the cervical dissection is performed endoscopically, the
position of the video monitor on the right side of the neck of
the patient must be taken into account. In addition, enough
space should be available for the movement of the mediastinoscope on the left side of the neck where the surgeon for
the cervical approach is positioned.
A suprapancreatic lymphadenectomy is an important part
of the operation for adenocarcinoma of the cardia. Therefore,
a wide abdominal approach is necessary. The authors perform the operation via a transverse upper abdominal incision
with enlargement by an upper midline incision in the direction of the xiphoid process. This approach provides an excellent view of the whole upper abdominal cavity.
6
5
PREPARATION OF THE DISTAL ESOPHAGUS
The first step in the operation is to divide the left tri-
6
angular ligament of the liver and to hold the left lobe to
the right side using a retractor. The esophageal hiatus is next
enlarged. It is crucial to enlarge the hiatus enough. This
enlargement is performed in a ventral and slightly left lateral
direction and should avoid opening the adjacent pericardium. This dissection of the anterior commissure of the
diaphragm is nearly always sufficient. Very rarely an additional division of the left or right diaphragmatic crus is
undertaken to improve exposure further. After dissection of
the visceral peritoneum, the terminal esophagus is bluntly
dissected and a tape is passed around it. The lower mediastinum can now be palpated to decide the resectability of the
tumor. If it is removable, attention is turned to the stomach.
The preparation of the stomach as an esophageal substitute is
described in Chapter 35 on pp. 353–366.
PREPARATION OF THE MEDIASTINAL ESOPHAGUS
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After the stomach has been mobilized, transmediastinal
7
blunt dissection of the esophagus is performed. Two or
three fingers are moved close to the esophageal wall and used
to free the esophagus with spreading and circular movements. A 42-Fr bougie is placed within the esophagus to facilitate palpation. All pliable tissue can be dissected bluntly
without danger provided the dissection is kept close to the
esophageal wall. Direct aortic branches are very rare in the
lower part of the mediastinum. The only structures that cannot be bluntly divided by the fingers are the vagal trunks.
These are divided with scissors.
Operations 483
7
The esophageal hiatus can be opened up using two very
8
long hook retractors. This allows the whole posterior
mediastinum nearly up to the tracheal bifurcation to be
inspected without difficulty. If bleeding occurs in this area, it
can be controlled under direct vision. If bleeding is severe, it
is not necessary to reposition the patient immediately and
perform a thoracotomy because most of the bleeding points
can be exposed and stopped through the abdominal
approach.
The exposure afforded by this approach allows lymphadenectomy of the lower posterior mediastinum to be performed under direct vision. The ideal plane of dissection is
the anterior wall of the aorta. The periesophageal lymphatic
tissue between the pericardium and the aorta, as well as
between both diaphragmatic bundles, should be removed en
bloc with the esophagus. If the tumor is infiltrating the
diaphragmatic bundles or the pericardium, these should be
included in the resection. Attention has to be paid to the thoracic duct in order to avoid chylus fistula.
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