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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_794_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter • Minimally Invasive Esophagectomy
Management of Common Complications
Early
Leak: ensure adequate drainage, operative repositioning of drains if necessary, nutritional
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support.
Conduit necrosis: reoperate to drain infection and revise anastomosis with resection of dead
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tissue; diversion may be indicated depending on the clinical picture.
Pleural space infection: early thoracoscopic drainage.
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Chylothorax: medical management if low-volume; thoracoscopic duct ligation and/or
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image-guided duct embolization if it fails to resolve conservatively.
Pneumonia: aggressive pulmonary toilet for prevention; bronchoscopy and bronchoalveolar
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lavage for culture-directed antimicrobial therapy.
Late
Stricture: serial endoscopic dilation
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Conduit dysfunction: careful evaluation for a correctable anatomical issue and consider-
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ation of operative conduit revision
Key Points
Minimally invasive esophagectomy has become an established approach for the treatment of
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esophageal carcinoma.
In our retrospective series of more than 1000patients who underwent MIE, overall morbid-
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ity, mortality, lymph node yield, and oncological outcomes were similar to or better than
most published series of open esophagectomy.
Our favored approach is a laparoscopic-thoracoscopic Ivor Lewis MIE whenever oncologi-
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cally appropriate.
e Ivor Lewis approach for MIE signicantly lowers the incidence of recurrent nerve
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injury compared with approaches requiring a cervical anastomosis.
In the rst randomized controlled trial of MIE versus open esophagectomy, MIE was associ-
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ated with a shorter hospital stay, fewer pulmonary infections, less vocal cord paralysis, and
better short-term quality of life compared with open esophagectomy. Oncological principles
of resection and lymph node retrieval were not compromised using the minimally invasive
approach.
Treatment of Zenker Diverticulum
Yogesh Vashist, Stefan Groth, Uwe Seitz
Endoscopic Approach
e Zenker diverticulum (pharyngoesophageal diverticulum) arises from the triangle of mucosa
located between the inferior pharyngeal constrictors and the cricopharyngeal muscle (Killian triangle). is type of diverticula is a false diverticulum and more common than true esophageal diverticula. e treatment options range from various endoscopic techniques to open surgical resection.
Treatment of Zenker diverticulum with a exible endoscope provides an alternative to surgery or
the intraluminal approach with a rigid endoscope (Weerda laryngoscope). e “septum” between the
diverticulum and the esophagus is transected, thereby creating a common cavity of esophageal lumen and diverticulum, allowing easier food passage. It is not always necessary to divide the complete
septum between the esophagus and the diverticulum because patients already have a good relief of
symptoms aer incision of one third to one half of the septum. at is why the aim of the endoscopic
treatment is the relief of symptoms and not necessarily the complete separation of the septum.
Indications and Contraindications
Feasible in any patient including those not appropriate for general anesthesia.
Preoperative Investigations and Preparation for the Procedure
Clinical examination
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Contrast swallow (water-soluble)
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Ultrasound
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A large gastric tube is carefully placed in the upper esophagus
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Procedure
Intubation of the esophagus is oen dicult in patients with a Zenker diverticulum. A pediatric
endoscope can be used to facilitate intubation. If the diverticulum is lled with food, cleaning by
using a large-channel endoscope should be rst performed to avoid aspiration.
Aer intubating the esophagus, a Savary-Guillard wire is placed in the antrum, the endoscope
is withdrawn, and a nasogastric tube is placed over the wire through the mouth.
e nasogastric tube indicates the entrance into the esophagus. is tube provides a better anatomical overview and simultaneously protects the esophageal wall during treatment (.
Alternatively a exible diverticuloscope (Cook Endoscopy, Winston Salem, NC) can be
introduced via the endoscope. It is designed as an overtube on the basis of the “Weerda” laryngoscope from otolaryngology. It has a double duckbill extremity, one to be placed in the
esophagus and one for the diverticulum leaving the septum in the middle of the two bills. is
device allows an excellent anatomical overview. Sometimes it can be quite challenging to get
the device in position.
Once the endoscope is in position, there are dierent options on how to transect the septum.
e most common ones are the treatment with argon-plasma coagulation and with a needle
knife.
Fig. 16.1
).
P.-A. Clavien, M. G. Sarr, Y. Fong, M. Miyazaki (Eds.), Atlas of Upper Gastrointestinal and Hepato-Pancreato-Biliary Surger y,
DOI 10.1007/978-3-662-46546-2_16, © Springer-Verlag Berlin Heidelberg 2016
1
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9
Section II • Esophagus, Stomach, and Duodenum
. Fig.16.1
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Argon-plasma coagulation of the septum
e septum is treated with argon-plasma coagulation. e advantage of this method over conventional diathermy is the spray-like application. Bleeding from smaller vessels is avoided. In
one session 1 cm of the septum is coagulated. e session is repeated aer 4weeks if required
(.
Fig. 16.2a
depth of 1 cm per session because the strong coagulation eect does not allow further treatment.
. Figure 16.2b shows the eect of argon-plasma coagulation at the end of the rst session.
). e limitation of this method is that you can treat only the septum about a
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23
. Fig.16.2
Chapter • Treatment of Zenker Diverticulum
Needle knife incision
e beginning and the end of a session of needle knife incision are shown (. Fig. 16.3). Fibers
of the cricopharyngeal muscle are visualized. In our experience the risk of bleeding is slightly
higher using the needle knife than using argon-plasma coagulation, particularly in the rst session.
erefore fewer treatment sessions (on average, one) are needed for a good relief of symptoms.
To avoid perforation on the distal end of the septum, one to two clips can be placed at the ground
(at the distal end of the area treated).
. Fig.16.3
Residual septum
Residual septum aer successful endoscopic treatment (. Fig. 16.4)
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. Fig.16.4
Standard Postoperative Investigations
No specic investigations are necessary.
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1
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3
Section II • Esophagus, Stomach, and Duodenum
Postoperative Complications
Bleeding
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Perforation
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Mediastinitis
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Sepsis
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Indications
Contraindications
Tricks of the Senior Surgeon
Control bleeding with hemoclips and injection of diluted epinephrine (1:20,000) or with a hot
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biopsy forceps.
Pay attention to keep the incision of the septum central to avoid bleeding.
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Use CO2insuation for the endoscope.
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Open Approach
Most Zenker diverticula are located le dorsolateral. is is due to the vertebra, which
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represents the posterior rigid plane; hence the Zenker diverticulum juts out to the le and
follows a vertical growth parallel to the esophagus.
Zenker diverticula are classied according to Brombart, Morton and Bartley and Lahey.
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Lahey classication dierentiates between three stages:
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StageI: no symptoms, local mild inammation
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StageII: dysphagia and regurgitation
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StageIII: esophageal obstruction, dysphagia, and regurgitation.
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Progress over time. Treatment is recommended for patients who have moderate to severe
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symptoms/complications (pneumonia or aspiration).
Severe physical constitution
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Preoperative investigations and preparation for the procedure
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Clinical examination
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Contrast swallow (water-soluble)
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Upper gastrointestinal endoscopy
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Ultrasound
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Manometry
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A large gastric tube is carefully placed in the upper esophagus
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Procedure
Access
e le arm should be adjacent to the patient’s body and the patient placed in a supine position
with the head rotated to the right.
Approach
e approach to the diverticulum for surgical therapy comes through a le cervical incision (most
Zenker diverticula present on this side) at the level of the cricoid cartilage on the anterior aspect
of the sternocleidomastoid muscle just above the clavicle. e anatomical overview of the access
to the cervical esophagus is given in
. Fig. 16.5.
Chapter • Treatment of Zenker Diverticulum
. Fig.16.5
Dissection
Dissection is performed between the medial aspect of the sternocleidomastoid muscle, which is
pulled laterally, and the strap muscles by retracting the carotid sheath laterally and preserving
the recurrent laryngeal nerve. e omohyoid muscle may be either retracted or transected. e
thyroid gland is mobilized and vessels are dissected (
. Fig. 16.6).
. Fig.16.6
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Section II • Esophagus, Stomach, and Duodenum
Mobilization of the esophagus and the diverticulum
e esophagus is mobilized from the prevertebral fascia, and the diverticulum is evident posterior
to the esophagus. Large diverticula may extend into the mediastinum, but gentle traction and blunt
dissection are sucient to mobilize even the largest diverticula. . Figure 16.7 shows the anatomy
of the cervical diverticulum.
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. Fig.16.7
Preparation of the diverticulum
e neck of the diverticulum is dissected. Gentle traction on the diverticulum exposes the bers
of the cricopharyngeus muscle. Oral insuation of air may help to nd the diverticulum.
Myotomy
e cricopharyngeus muscles are divided and bluntly dissected from the mucosa. Myotomy of the
pars transversa and of the upper esophagus is performed and is essential.
Aer myotomy the diverticulum can be addressed dierently, depending on the size of the
diverticulum. Small diverticula measuring up to 2 cm virtually disappear aer the myotomy is
completed and may be le alone or xed cranially with the apex. ey may be inverted and sutured to the prevertebral fascia, which prevents food retention without necessitating creation of a
staple line or suture line that is at risk for stula formation. Larger diverticula are resected with a
linear stapler parallel to the esophageal lumen, taking care not to compromise the diameter of the
esophagus. Alternatively open resection and two-layer closure is performed (. Figs. 16.8 and 16.9).
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. Fig.16.8
Chapter • Treatment of Zenker Diverticulum
. Fig.16.9
Closure
A so Penrose drain is placed at the resection line. e skin is closed aer placing only a few
subcutaneous sutures.
Standard postoperative investigations
Contrast study of the upper gastrointestinal tract (not routinely performed before starting
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oral intake).
Most patients may be started on a liquid intake within hours of the operation.
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e duration of hospitalization has been declining, and may be necessary for only 3 to
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5days.
e drain is le in situ until solid food intake is possible.
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A solid intake should be started aer the third postoperative day.
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Postoperative complications
Recurrent laryngeal nerve injury.
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Wound infection.
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Fistula formation/stump leakage – conservative treatment with drainage and opening of the
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wound is usually the appropriate treatment.
Retropharyngeal abscess may require surgical intervention.
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Recurrence rates aer resection of a cricopharyngeal diverticulum are low, if the cricopha-
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ryngeus muscle has been divided completely.
Tricks of the Senior Surgeon
Placement of a large gastric tube helps to identify the esophagus and the diverticulum.
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Tension-free resection helps to avoid leakage.
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Epiphrenic Diverticula
Dedicated to the memory of Professor Gerald C. O’Sullivan – surgeon, scientist, mentor, and friend
Chris G. Collins
Introduction
An epiphrenic diverticulum is a herniation of a pouch of esophageal mucosa thought the musculature of the thoracic esophagus within 10 cm of the esophagogastric junction. e pathological
process is thought to be the application of pulsion forces to the mucosa above a functionally
obstructing region of abnormal esophageal motility. Investigations include endoscopy, contrast
esophagogram and esophageal manometry. Operative interventions include laparoscopic, thoracic
and thoracoscopic approaches in order to excise the diverticulum with a myotomy to address the
underlying motility disorder.
Indications
Contraindications
Indications and Contraindications
Dysphagia
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Pulmonary complications (recurrent pneumonia, aspiration pneumonitis, and lung abscess)
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Ongoing pneumonia or lung abscess (temporary)
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Preoperative Investigation/Preparation for the Procedure
z Clinical
Full history and examination
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Esophagogastroduodenoscopy (EGD): it is necessary to enter the diverticulum to examine
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the mucosa and exclude associated carcinoma
Esophageal manometry: it may be necessary to position the manometry probe distal to the
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diverticulum in order to accurately dene the dysmotility. (High resolution manometry and
twenty-four-hour recordings provide a more accurate diagnosis.)
z Laboratory
Routine biochemical prole to out rule any abnormality related to prolonged vomiting or forced
fasting such as hypoalbuminia.
z Radiology
Plain chest radiograph
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Contrast esophagogram (may need rotation to see smaller diverticulae)
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Broad-spectrum antibiotics are given preoperatively (e. g., co-amoxiclav and metronidazole)
Treat complications of the diverticulum (aspiration pneumonia/lung abscess) prior to surgery.
Empty the diverticulum of retained secretions, food, or barium as completely as possible before
anesthesia is induced to reduce the risks of aspiration.
P.-A. Clavien, M. G. Sarr, Y. Fong, M. Miyazaki (Eds.), Atlas of Upper Gastrointestinal and Hepato-Pancreato-Biliary Surger y,
DOI 10.1007/978-3-662-46546-2_17, © Springer-Verlag Berlin Heidelberg 2016
1
2
3
4
Section II • Esophagus, Stomach, and Duodenum
What Not to Do
Small asymptomatic diverticulae can be le alone. Regular follow-up is advised to detect
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malignant change or signicant enlargement with regurgitation or aspiration.
Failure to perform myotomy is associated with higher rates of recurrence and leak from the
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suture line.
Candidates with an underlying motility disorder unt or unwilling for surgery may benet
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from endoscopic pneumatic dilatation.
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Procedure
e focus of the procedure is on both the underlying motor disorder and the epiphrenic pouch.
e main approaches are as follows:
Laparoscopic abdominal approach (most common approach today)
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oracic approach mostly for larger and higher (> 10 cm from diaphragm) thoracic pouches
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Video-assisted thoracic approach
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Laparoscopic Procedure
Access and Exposure
e patient is placed in the lithotomy position with 20–30° reverse Trendelenburg (“French
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position”) and the surgeon stands between the legs.
Pneumoperitoneum is established and four ports inserted as shown (. Fig. 17.1). e cam-
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era is inserted to the le of the midline 2–3 cm above the umbilicus (or higher depending
on the size of the patient) and three additional ports are inserted under direct vision. e
Nathonson retractor is inserted at the xiphisternum for liver retraction, le subcostal for
traction on the stomach, and two working ports on either side of the midline.
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. Fig.17.1
Exposure
e phrenoesophageal ligament is incised using endo-scissors or a harmonic scalpel.
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Dissection begins on the right crus and then moves to the le crus.
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e right crus is then dissected downward and the esophagus is encircled with a Penrose
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drain for traction, via the le subcostal port. e Penrose drain may be maintained in posi-
tion for traction by approximation with a 3-0endoloop.
Mediastinal dissection is then carried out using blunt instruments and harmonic scalpel,
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staying close to the esophagus until the diverticular pouch is reached.