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Chapter • Epiphrenic Diverticula
Step-by-Step Procedure
Endoscopy and preparation of the diverticulum. An endoscope is inserted into the esophageal
lumen to the level of the diverticulum and by using insuation and transillumination the diverticular pouch is dened to allow safe dissection. e pouch is thoroughly dissected until the
neck of the diverticulum is completely clear of all adherent tissue, with care to avoid injury to the
pleural sacs (
. Fig. 17.2).
. Fig.17.2
Resection. An endoscopic stapling device is introduced through the operative trocar in the le
upper quadrant and is advanced to the level of the diverticular neck (.
are closed under simultaneous endoscopic control; the endoscope is advanced into the stomach
to prevent too much mucosa being excised, and it is then withdrawn. Once this is conrmed the
stapler is red and mucosal closure is veried. Additional stapler applications may be necessary
to completely incise and close the diverticular neck. e pouch is removed and the staple line is
inspected using the endoscope.
Fig. 17.3
). e stapler jaws
. Fig.17.3
Myotomy. A myotomy is performed on the opposite esophageal wall, with longitudinal and circu-
lar muscular bers divided and the submucosal plane carefully dissected using a combination of
blunt dissection and the harmonic scalpel. e myotomy is extended proximally above the upper
limit of the diverticulum and distally for almost 1.5 cm onto the cardia using a combination of
blunt dissection and either the harmonic scalpel or endoscissors (
. Fig. 17.4).
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6
Section II • Esophagus, Stomach, and Duodenum
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. Fig.17.4
Dor fundoplication. e hiatus is closed posteriorly with two or three interrupted sutures. e
anterior wrap is performed by suturing the gastric fundus to the muscular edges of the myotomy
(Dor type procedure) and the gastric fundus is also sutured to the superior part of the crura. e
fundus is sutured to the right crus and to both the right and the le sides of the esophagus.
Thoracic Approach
Access
A standard le posterolateral thoracotomy through the seventh intercostal space (ICS). e lung
and the pleural space are inspected thoroughly.
Exposure
e inferior pulmonary ligament is divided with diathermy to the level of the inferior pulmonary
vein and the lung is retracted upward. e mediastinal pleura overlying the esophagus is incised
longitudinally to expose the esophagus and diverticulum (
. Fig. 17.5).
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. Fig.17.5
Chapter • Epiphrenic Diverticula
Step-by-Step Procedure
1. e esophagus is mobilized from its bed suciently to allow dissection of the diverticulum,
which is most oen located posteriorly.
2. e diverticulum is isolated, grasped with a Babcock type forceps, and carefully dissected from
its attachments until the entire sac is free and attached to the esophagus only at the neck.
3. If the diverticulum has a wide neck a large bougie (60 F) is passed down the esophagus and the
diverticulum is then stapled longitudinally using a stapling device (TA) and excised (. Fig. 17.6).
4. e muscular layer is closed over the mucosal staple line with interrupted 3-0sutures.
5. A 2–3 cm incision is made in to the abdomen through the phrenoesophageal ligament at the
anterior margin of the hiatus along the midlateral border of the le crus. A tongue of gastric
fundus is pulled up into the chest. is exposes the gastroesophageal junction and its associated fat pad. e fat pad is excised.
6. A longitudinal myotomy is performed along the anterior wall of the esophagus (opposite side
to the diverticulum) from approximately 1 cm above the diverticulum extending down for
about 1–2 cm into the musculature of the stomach (. Fig. 17.7).
7. e cardia is reconstructed by suturing the tongue of the gastric fundus to the margins of the distal half of the myotomy for a distance of 4 cm using interrupted 3-0Prolene sutures (.
e fundus is then placed below the diaphragm and is sutured to the anterior lip of the crura.
8. A chest tube is le in situ and brought out through a separate intercostal stab wound in the
lower thorax, and its outer end is connected to an underwater drain. e lung is expanded
and the thoracotomy wound is closed in layers.
Fig. 17.8
).
. Fig.17.6
. Fig.17.7
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6
Section II • Esophagus, Stomach, and Duodenum
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. Fig.17.8
Video-Assisted Thoracoscopic Approach
Access
e patient is positioned in a right lateral position as for le posterolateral thoracotomy. e le
lung is deated using a double-lumen endotracheal tube. Ports are inserted as follows:
10 mm at the sixth ICS at the posterior axillary line for the camera,
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10 mm at the h ICS at the anterior border of the axillary line for retraction of the lung,
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10 mm at the third ICS for the working cannula,
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12 mm at the midaxillary line for the working cannula. e procedure is as for the open
-
procedure.
Intraoperative Complications and Management
Intraoperative hemorrhage is managed along standard lines.
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Perforation of mucosa at myotomy. is is tested for using insuation with the gastroscope
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under saline. is most commonly occurs at the gastroesophageal junction. It is repaired
using interrupted 4-0suture and covered with the fundus of the stomach.
e posterior vagus nerve is vulnerable when performing the diverticulectomy and should
-
be isolated and protected. e anterior vagus is vulnerable during myotomy and should also
be protected.
Tension pneumothorax during laparoscopic repair should be monitored intraoperatively
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and if detected the insuation pressure should be reduced and a chest drain inserted.
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Postoperative Care
Thoracic approach only
e chest drain is usually removed 48hours postoperatively if the lung is completely ex-
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panded and there is no evidence of leak or infection.
Chapter • Epiphrenic Diverticula
All Approaches
e nasogastric tube is le on free drainage and aspirated every 4hours for the rst day and
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removed on the second or third postoperative day.
Patients begin liquid oral intake following nasogastric tube removal, advancing to a full
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uid diet as tolerated. Analgesics and antiemetics minimize nausea and vomiting.
Once patients can tolerate a so/puréed diet, they are allowed to go home with instructions
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about resuming a normal diet from 2weeks postoperatively at home.
Standard Postoperative Examinations
A water-soluble non-ionic contrast swallow is performed on day5 postoperatively:
To exclude suture line leak
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To verify the position of the wrap
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To ensure that no signicant obstruction has developed
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To provide an impression of gastric emptying
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Carbonated beverages and very large meals must be avoided in the early postoperative period.
Postoperative Complications
Early (days to weeks)
Hemorrhage. is usually occurs within 48hours. is is managed along standard line with
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volume replacement and control of bleeding.
Suture line leak. Early obvious leak is managed by thoracotomy. If symptomatic then pro-
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ceed to thoracotomy and repair; if asymptomatic it is managed conservatively.
Pleural eusion. Aspirate and evacuate to treat hemothorax or empyema.
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Empyema. is is managed by aspiration and the esophagus checked for suture line leak by
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upper gastrointestinal studies.
Subphrenic abscess. is is managed by radiological guidance and suture line leak checked
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for by using upper gastrointestinal studies. ese complications are rare.
Late (months to years)
Recurrence of diverticulum. If symptomatic this is managed by open surgery.
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Gastroesophageal reux with stricture (treated by dilatation and antireux medication).
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Paraesophageal hernia (may require surgical therapy and repair of the hernia).
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Delayed gastric emptying or gastroparesis. is usually settles with prokinetic agents, but
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may require pyloroplasty.
Post-thoracotomy pain. is is managed symptomatically.
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Tricks of the Senior Surgeon
Verication of impermeability of the suture line is conrmed using insuation of air via the
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gastroscope in conjunction with insertion of saline via the laparoscope.
Non-ionic contrast media is preferred to Gastrogran for the postoperative swallow as it
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provides superior images and is less reactive if aspirated or inadvertently leaks into thorax or
abdomen.
Small diverticulae may be treated by plication and myotomy.
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Intraoperative upper gastrointestinal endoscopy facilitates transillumination of the diverticu-
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lum, safe staple placement as well as suture line evaluation with insuation.
Techniques of Local Esophagoplasty in Short Esophageal
Strictures
Asad Kutup, Emre F. Yekebas, Jakob R. Izbicki
Introduction
Local esophagoplasty is indicated for patients with short esophageal strictures when endoscopic
therapies including bougienage and balloon dilatation are not eective.
Indications and Contraindications
Indications
Contraindications
Short peptic stricture
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Short scarred stenosis
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Suspicion of malignancy
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Preoperative Investigations/Preparation for the Procedure
Esophagogastroscopy with multiple biopsies.
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Special preparation: no peculiarities compared to the previously mentioned operations.
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Anesthesia: endotracheal anesthesia; in case of intrathoracic stenosis, a double lumen tra-
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cheal tube with the possibility of separate ventilation should be used.
Procedure
z Positioning and Access
ese depend on the location of the stenosis.
Cervical stenosis: le cervical approach with lateral rotation of the neck.
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Intrathoracic stenosis: right anterolateral thoracotomy using the fourth to sixth intercostal
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spaces (ICS).
Stenosis of the abdominal part of the esophagus: “inverted T-incision” or median laparot-
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omy.
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_18, © Springer-Verlag Berlin Heidelberg 2016
Section II • Esophagus, Stomach, and Duodenum
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Step 1
Resection and technique of anastomosis
Aer resection of the stenotic segment, mobilization of the proximal and distal end of the esophagus restores the basis for reconstruction of the continuity with single layer end-to-end anastomosis
in an interrupted suture technique. e distance of each suture should be 5 mm. Each stitch should
be placed 5 mm distant to the anastomosis.
For stenoses less than 1 cm, stricturoplasty according to Heineke Mikulicz should be performed. erefore a longitudinal esophagotomy is performed using a single-layer transverse closure with mattress sutures (
. Fig. 18.1).
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Step 2
. Fig.18.1
In case of limited stenosis
In stenosis limited to mucosa and submucosa, a transverse transection of the esophageal musculature over the stenosis suces (. Fig. 18.2a). e anterior part of the stricture is resected
(. Fig. 18.2b). Reconstruction of the continuity of the mucosa and submucosa in the posterior
wall area (.
mattress sutures (. Fig. 18.2d).
Fig. 18.2c
) is done followed by transverse closure of the anterior wall with single-layer
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. Fig.18.2
Chapter • Techniques of Local Esophagoplasty in Short Esophageal Strictures
Step 3
In case of prestenotic dilatation
In case of a prestenotic dilation of the esophagus, side-to side esophagostomy of the pre- and
poststenotic esophageal segment should be performed.
In all local esophagoplasties an intraluminally placed tube (large gastric tube) and abundant
external drainage are obligatory (
. Fig.18.3
. Fig. 18.3).
Standard Postoperative Investigations
Daily check for anastomotic leak of the esophagoplasty
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If problems occur aer removal of the drain, a contrast study with water-soluble contrast is
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recommended
In case of early detected anastomotic leak, esophagoscopy with the feasibility of endolumi-
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nal stenting
Postoperative Complications
Leakage
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Mediastinitis
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Pleura empyema
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Peritonitis
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Re-stenosis
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Tricks of the Senior Surgeon
In case of caustic ingestions, organs adjacent to the esophagus (i. e., trachea) may be
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involved. In these instances, mobilization and repair of the esophagus has to be performed
carefully.
Operation for Achalasia
Luigi Bonavina, Alberto Peracchia
Introduction
In 1913 Heller reported the rst esophageal myotomy for achalasia through a le thoracotomy.
Over the years, the transabdominal approach has been extensively adopted, especially in Europe.
More recently, laparoscopic Heller myotomy has emerged as the initial intervention of choice in
several institutions throughout the world.
e operation consists of complete division of the two layers of esophageal muscle (longitudinal and circular bers) and of the oblique bers at the esophagogastric junction. A further step
of the transabdominal procedure is the construction of an antireux valve, most commonly an
anterior Dor fundoplication.
Indications and Contraindications
Indications
Contraindications
In patients with documented esophageal achalasia, regardless of the disease’s stage
Not deemed t for general anesthesia and in those with:
Signicant co-morbidity
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Short life expectancy in whom pneumatic dilatation or botulinum toxin injection represents
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a more reasonable therapeutic option
Extensive intra-abdominal adhesions from previous upper abdominal surgery can make the
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laparoscopic approach hazardous
Preoperative Investigation/Preparation for the Procedure
History and clinical evaluation: Duration of dysphagia, nutritional status
Chest x-ray: Atelectasis, brosis (s/p aspiration
pneumonia)
Barium swallow study: Degree of esophageal dilation and length-
ening
Esophageal manometry: Non-relaxing lower esophageal sphincter,
lack of peristalsis
Endoscopy: Rule out esophageal mucosal lesions,
Candida colonization, associated
gastroduodenal disease
CT scan and/or endoscopic ultrasound
(EUS) in selected patients:
Insert a double-lumen nasogastric tube 12hours before surgery to wash and clean the
esophageal lumen from food debris
Short-term antibiotic and antithrombotic prophylaxis
Rule out pseudoachalasia (malignancyinduced)
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_19, © Springer-Verlag Berlin Heidelberg 2016
1
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Section II • Esophagus, Stomach, and Duodenum
Laparoscopic Procedure
For details on access, see chapter “Laparoscopic Gastrectomy”.
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Step 1
Step 2
Instrumentation
One monitor
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ree 5-mmtrocars, two 10–12 mmtrocars
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30° laparoscope
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Standard laparoscopic instruments (Johannes forceps, needle holder, Endoclinch grasper,
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rod for liver retraction)
Unipolar coagulation
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Ultrasonic scissors
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Gastroscope (optional, mostly used in redo procedures)
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Exposure
Incision of the phrenoesophageal membrane. Dissection is limited to the anterior surface of the
esophagus and of the diaphragmatic crura to prevent postoperative reux by preserving the anatomical relationships of the cardia. e cardia is mobilized only in patients with a markedly dilated
sigmoid esophagus; in such circumstances, it is preferable to reduce the redundancy in the abdomen and to close the crura posteriorly.
Heller myotomy
e Heller myotomy is started on the distal esophagus using an L-shaped hook until identication
of the submucosal plane.
e myotomy is extended on the anterior surface of the proximal esophagus for about 6 cm
using insulated scissors, a harmonic scalpel, or Ligasure device.
e myotomy is extended onto the anterior surface of the gastric side including the oblique
bers for about 2 cm using the L-shaped hook (
. Fig. 19.1).
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Step 3
. Fig.19.1
Intraoperative endoscopy
Intraoperative endoscopy aids in evaluating the length of the myotomy, dividing residual muscle bers, and checking the patency of the esophagogastric junction and the absence of leaks.
is is most helpful in patients previously treated by pneumatic dilatation or botulinum toxin
injection.