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Ростовский Государственный Медицинский Университет

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Книга_1050_Библиотеки_им_академика_М_И_Перельмана

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fluoroscopy,regardlessoftheultimateoutcomeofourintraoperativeleaktest. IftheradiologicexamisnegativeonthemorningofPOD1,thepatient’sdiet isadvancedperearliermentionedprotocolwithdischargeanticipatedfor POD2andtheearliermentionedmedicationroutine.Althoughitis acceptabletodischargeahealthy,goodcandidateonPOD1,themajorityof ourpatientsleaveonPOD2andsoforth,dependingonmedical comorbidities.

OUTCOMES

■ Resultsdependonthenatureofthediseaseprocessforwhichanoperationis indicatedandthenumberofcomponentsoftheoperationused.

■ PEHrepair:Morietal.6refertoeightstudiesthathadameanormedianfollow- upof6to40monthswitharangeof2%to43%recurrence.Andujaretal.

describelaparoscopicPEHrepairsbeingassociatedwithalowincidenceof recurrenceandreoperationinaseriesof166patients.Improvementwasseen inheartburn,regurgitation,dysphagia,andchestpainwithanoverall6% reoperationrateforsymptomaticPEH(1.2%),reflux(2.4%),anddysphagia (2.4%).Withtheexceptionoffundoplicationwrapfailureinwhichall requiredreoperation,one-thirdofrecurrencesrequiredsurgery,whereasonetenthofslidinghiatalherniasrequiredsurgery;sooverall,thereoperationrate isquitelow.

■ Redoantirefluxprocedures:Inaseriesof124patients,fourmajorfailure mechanismswerenoticedbyOhnmachtetal.15:recurrenthiatalhernia(65%), disruptedfundoplication(32%),perigastricfundoplication(14.5%),andtight fundoplicationandhiatalclosure(10%).

■ Useofmesh:AsentinelseriesbyOelschlageretal.ofpatientsundergoingcrural repairwithsmallintestinesubmucosa(Surgisis,CookMedical,Bloomington, IN)meshinitiallyshowedpromisingdatafordecreasedPEHrecurrencerate at6months(9%Surgisis,24%primaryrepair),10butthesamegroup

demonstratedthatlong-termfollow-upatamedianof58monthsshowedno statisticaldifference(54%Surgisis,59%primaryrepair).11Notwithstanding shapeandmaterial(bioprostheticvs.synthetic)ofmeshused,thesestudies maybeupdatedinyearstocomewiththeuseofbioabsorbablemesh, acellulardermalmatrix,andvarioustypesofsyntheticmesh.Ringleyetal.

reportedtheuseofacellulardermalmatrix(AlloDerm,LifeCellCorporation, Bridgewater,NJ)withaninitial6-monthfollow-upwithoutrecurrenceversus primaryclosureinvolving9%recurrence.Wedonotadvocate,therefore, prohibitingtheuseofmeshinPEHrepairatthistime.

■ Choiceofantirefluxoperation:Aprospective,randomizedtrialbyKochetal.

of50patientsineacharmofNissenversusToupetfundoplication demonstratedthatNissenproceduresfavoredimprovementinhoarsenessand showedsignificantimprovementinoutcomesmanometricallyandvia multichannelimpedanceimaging,whereastheToupetfundoplicationwas favoredbylowerdysphagia,inabilitytobelch,andbowelsymptoms. Nonetheless,bothproceduresimprovedgastrointestinalqualityoflifeindices, GERDsymptoms,reconstructedLESpressures,coughandasthmasymptoms.

COMPLICATIONS

■ PEHrecurrence

■ Mesherosion

■ Dysphagia

■ Esophagealstricture

■ Gasbloatsyndrome

■ RecurrentGERD

■

Slippedantirefluxprocedure

REFERENCES

1.AllisonPR.Refluxesophagitis,slidinghiatalhernia,andtheanatomyofrepair.SurgGynecol

Obstet.1951;92(4):419–431.

2.StylopoulosN,RattnerD.Thehistoryofhiatalherniasurgery:fromBowditchtolaparoscopy.

AnnSurg.2005;241(1):185–193.

3.AhadS,OelschlagerBK.Laparoscopicrepairofparaesophagealhernias.In:SoperNJ, SwanstromLL,EubanksWS,etal,eds.MasteryofEndoscopicandLaparoscopicSurgery.3rded. Philadelphia,PA:LippincottWilliams&Wilkins;2009:122–129.

4.NissenR.Asimpleoperationforcontrolofrefluxesophagitis[inGerman].SchweizMed Wochenschr.1956;86(suppl20):590–592.

5.MinjarezRC,JobeBA.Surgicaltherapyforgastroesophagealrefluxdisease.GIMotilityOnline.

2006.doi:10.1038/gimo56.

6.MoriT,NagaoG,SugiyamaM.Paraesophagealherniarepair.AnnThoracCardiovascSurg. 2012;18(4):297–305.

7.NguyenNT,ChristieC,MasoomiH,etal.Utilizationandoutcomesoflaparoscopicversusopen paraesophagealherniarepair.AmSurg.2011;77(10):1353–1357.

8.ZaninottoG,CostantiniM,RizzettoC,etal.Fourhundredlaparoscopicmyotomiesfor esophagealachalasia:asinglecentreexperience.AnnSurg.2008;248(6):986–993.

9.DeMeesterTR,BonavinaL,AlbertucciM.Nissenfundoplicationforgastroesophagealreflux disease.Evaluationofprimaryrepairin100consecutivepatients.AnnSurg.1986;204(1):9–20.

10.OelschlagerBK,PellegriniCA,HunterJG,etal.Biologicprosthesistopreventrecurrenceafter laparoscopicparaesophagealherniarepair:long-termfollow-upfromamulticenter,prospective, randomizedtrial.JAmCollSurg.2011;213(4):461–468.

11.OelschlagerBK,PellegriniCA,HunterJ,etal.Biologicprosthesisreducesrecurrenceafter laparoscopicparaesophagealherniarepair:amulticenter,prospective,randomizedtrial.AnnSurg. 2006;244(4):481–490.

12.RingleyCD,BochkarevV,AhmedSI,etal.Laparoscopichiatalherniarepairwithhuman acellulardermalmatrixpatch:ourinitialexperience.AmJSurg.2006;192(6):767–772.

13.SoricelliE,BassoN,GencoA,etal.Long-termresultssofhiatalherniameshrepairand antirefluxlaparoscopicsurgery.SurgEndosc.2009;23(11):2499–2504.doi:10.1007/s00464-009-0425-

14.AndujarJJ,PapasavasPK,BirdasT,etal.Laparoscopicrepairoflargeparaesophagealherniais associatedwithalowincidenceofrecurrenceandreoperation.SurgEndosc.2004;18(3):444–447.

15.OhnmachtGA,DeschampsC,CassiviSD,etal.Failedantirefluxsurgery:resultsafter reoperation.AnnThoracSurg.2006;81(6):2050–2053;discussion2053–2054.

16.KochOO,KaindlstorferA,AntoniouSA,etal.LaparoscopicNissenversusToupet fundoplication:objectiveandsubjectiveresultsofaprospectiverandomizedtrial.SurgEndosc. 2012;26(2):413–422.

Chapter2

CollisGastroplasty



JohnG.HunterMarkJ.Eichler

DEFINITION

■ Encounteringaforeshortenedesophagusduringsurgeryatthehiatus,a lengtheningprocedureisnecessaryforadequatedistalabdominalesophageal lengthforanantirefluxprocedure.FirstdescribedinThoraxbyJohnLeigh Collisin1957forpatientswithashortesophagusandhiatalhernia,withor withoutreflux,agastroplastyisperformedviaathoracotomyontheleft aspectoftheherniatedproximalstomach.1Thistechniquehassubsequently evolvedthroughthoracoscopicandlaparoscopicmeansforhiatalhernia repairsaswellasrefluxdiseaseinordertolengthentheabdominalportionof theesophagusforanadequateaxialdistancearoundwhichtoperformgastric fundoplication.TheCollisgastroplastycommonlyinvolvesalaparoscopic staplingtechniqueaboutthegastroesophagealjunction(GEJ)byremovinga wedgeofstomachattheangleofHis,therebylengtheningtheeffectivedistal esophagealdimensionintraabdominally,aboutwhichafundoplicationcanbe wrapped.

PATIENTHISTORYANDPHYSICALFINDINGS

■ Secondarytochronicacidinflammationandsubsequentfibroticremodelingof thedistalesophagus,approximately10%to25%ofpatientswithrefluxhave

ashortenedesophagus.

3,4

Themajorityofthesepatients,however,donot needanesophageallengtheningprocedureforatension-freefundoplicationif adequatemediastinaldissectiongainsreturnofabdominalesophageallength.

SufficientintraabdominallengthcanbeevidencedbytheGEJlying intraabdominallywithadistancebetweenthediaphragmatichiatusandthe GEJofatleast2.5cm.Itisatthisthresholdof2.5cm(approximatelythe lengthofafullyopenedatraumaticlaparoscopicgrasper)afteradequate mediastinalandcruraldissectionshouldthedecisiontoperformaCollis gastroplastytakeplace,3withanoverallincidenceofimplementationof3%to 4%ofrefluxoperations.

IMAGINGANDOTHERDIAGNOSTICSTUDIES

■ Thepreoperativeworkupforrefluxdiseasespansendoscopy (esophagogastroduodenoscopy[EGD]),esophagography(upper gastrointestinalcontrastswalloworesophagram),manometry,andpHprobe testing.However,thereisnogold-standardradiologicimagingstudyfor preoperativepreparationinrefluxdisease,asthesurgicaldecisionmakingto performaCollisgastroplastyisdoneultimatelyintraoperatively.Yet, esophagographyandendoscopymaybetheoptimalstudiestodemonstratea foreshortenedesophagusbythefollowingsigns6:

■

Hiatalherniaof5cmormore

■

GianttypeIIIparaesophagealhernia(FIG1)

■

Esophagitis,Barrett’schanges,and/orstricture

SURGICALMANAGEMENT

PreoperativePlanning

■ BecausetheCollisgastroplastyisanadjunctiveprocedureduringgastric fundoplication,theprinciplesofaproperantirefluxprocedure(wrap)or gastropexyapply,includingleftandrightcruralexposure,adequate mediastinaldissection,atraumaticesophagealretraction,anddivisionofthe shortgastricvessels.PleaserefertoChapters1and5forfurtherdetails.

■ Allstudies,includingesophagram,EGD,manometry,andpHtestingshouldbe readilyavailableandreviewedpriortoandatthetimeofsurgery.The esophagramshouldbedisplayedonaspareordedicatedmonitorinthe operatingtheaterandEGDimagesbeloadedaswellforintraoperative reference.

■ Attentiontofinedetailofthemanometricreportmayavoidanunnecessaryand detrimental360-degreefundoplication,asacompletewrapmayworsen symptomsinthelightofthefollowingfindings7:

■

Severeesophagealdysmotility

■

Verylowresidualpostrelaxationloweresophagealsphincter(LES)pressures lessthan30mmHgduringwetswallow

Positioning

■ Althoughtherearemanyportplacementtechniques,thestapledCollis gastroplastynecessitatesaleftupperquadrant,endoscopic,angulatingstapler bythesurgeon’srighthandthrougha12-mmtrocar.Steepreverse Trendelenburgisthepositionofchoice(FIG2).

■ Assumeextensivemediastinaldissectionwillbewarranted,andtherefore,riskof pleuralcompromise(FIG3).Thesterileskinpreparationmustbewide enoughoneitherflankincasetubethoracostomiesarenecessaryfrom resultantpneumothorax.However,aredrubbercatheterbetween10and14Fr

maybeplacedinawitnessedpleuraldefectintraabdominallyspanningthe diaphragmtothehemithoraxinquestion.Thisreducestheresultant pneumothoraxandpeakventilatorypressureswiththeaidoflowering insufflationpressuresaswellasanesthesia-assistedventilatoryValsalva.

TECHNIQUES

MEASUREMENTOFGASTROPLASTY

■ Asmentionedinthe“Positioning”section,thisisanadjunctivemaneuver,and thus,aspreviouslydescribed,adequatemediastinal,hiatal,andperigastric dissectionshouldhavealreadytakenplace.

■ DissectthefatpadfromtheGEJtoexposethetrajectoriesofstaplerfiring(FIG

4).

■ Removeanyorogastric,nasogastric,orbougiefirsttorecreatethenascent relaxedanatomyoftheGEJ.Fromaposteriorgastricapproach,pulltheleft crustotheright,approximatingitwiththerightcrus.Thisdemonstratesthe relaxedpositionofthecrurauponclosureofthehiatus.

■ Withanopen,premeasuredgrasper,theintraabdominallengthforthe gastroplastyisthenestimated(FIG5).Adistancefromtheanteriorhiatusto theGEJoflessthan2.5to3cmwarrantstheCollisgastroplasty.Measure fromtherelaxedhiatus3cmdistallyalongatrajectorypasttheGEJ,ifa bougiewereinsertedendoluminally,and1cmlaterally.Here,markwith electrocauterytheplacementofthefirstperpendicularstaplefiring.

INTRAABDOMINALRETRACTIONANDBOUGIE PLACEMENT

■ A48-Frdilatorisplacedtransorallyupto55cmfromtheincisors(FIG6).This servesasthestentaboutwhichtheCollisgastroplastyisperformed.The surgeon’slefthandretractsthecardiatowardthepatient’sleftshoulderwhile theassistantretractsthegreatercurvelaterallytotheleftflank.

FIRSTSTAPLETRAJECTORY

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