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Ростовский Государственный Медицинский Университет

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Книга_1050_Библиотеки_им_академика_М_И_Перельмана

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■ Theendoscopeisthenadvancedbackintothestomachtoallowinspectionofthe antirefluxvalveandtoassessforanybleedingorinjuriestotheesophagus andstomach.Thefastenersarevisualizedinthedistalesophagus(FIG13).

■ ThefundoplicationcreatedbytheEsophyXdeviceshouldhaveasimilar endoscopicappearanceasonecreatedbyalaparoscopicNissen fundoplication.

RADIOFREQUENCYENERGYAPPLICATIONTOTHE LOWERESOPHAGEALSPHINCTER

■ ApprovedbytheFDAin2000,theStrettasystem(MederiTherapeuticsInc, Greenwich,CT)iscurrentlytheonlydeviceonthemarketthatuses radiofrequencyenergyforthetreatmentofGERD.

■ TheapplicationofradiofrequencyenergytotheGEjunctionresultsinthermal injuryandsubsequentscarring,whichreducesLEScompliance,decreasesthe

numberoftransientLESrelaxations,andtherebydecreasestheincidenceof refluxsymptoms.

■ TheStrettasystemiscomposedoftwomaincomponents:aradiofrequency generatorandacathetersystemthatconnectstothegenerator.Thecatheter systemiscomposedofanoutersheath,a30-Frbougietip,andfournickeltitanium22-gaugeneedleelectrodessurroundingaballoon.Thesystemalso includesachannelforsuctionandanotherforirrigation(FIG14).

PreoperativePlanning

■ ConscioussedationisusuallyadequateforuseoftheStrettasystem.Atour institution,Strettaisusuallyperformedintheendoscopysuiteasopposedto

theoperatingroom.

■ Onlyonephysicianistypicallyneededtoperformtheprocedure.

Positioning

■ Afteradministrationofconscioussedationmedications,thepatientisplacedinto theleftlateraldecubituspositionandabiteblockisplaced.

PlacementoftheStrettaDeviceintotheDistalEsophagus

■ AstandardendoscopeisadvanceddowntotheGEjunction.Thedistancefrom thepatient’slipstothesquamocolumnarjunctionismeasured.

■ Aguidewireisinsertedthroughtheworkingchanneloftheendoscopeandthe endoscopeisremoved.

■ Underfluoroscopicguidance,thecathetersystemisthenpassedoverthe guidewireintothestomach.Thecathetertipisthenpositioned1cmabovethe squamocolumnarjunctionbasedonmeasurementsobtainedfromthe endoscopicevaluation.

ApplicationofRadiofrequencyEnergy

■ Theballoonisinflatedtoapressureof2lb/in2.

■ Theelectrodesarethendeployedthroughthemucosaandintothemuscularis propria.Suctionandirrigationareinitiatedthroughtheirrespectiveworking channels.

■ Thegeneratorisactivatedandradiofrequencyenergyisappliedfor approximately90secondsperapplication.Duringthisprocess,themuscularis propriaisheatedtoatemperatureof85°C,whereastheesophagealmucosais maintainedbelow50°Cviacoldwaterthatisinstilledthroughthecatheter

system.Thiscreatesfourablationsitesthataredistributed90degreesapart fromeachother.

■ Afterthe90-secondintervaliscomplete,thecathetersystemisrotated45 degreesandanothercycleofradiofrequencyenergyisdeliveredfor90 seconds.Followingthiscycle,eightlesionsapproximately45degreesapart arecreatedinacircumferentialfashionatthatlevel.

■ Thecathetersystemisadvancedapproximately5mmandtheprocessisrepeated tocreateanother8sitesofablation.Intotal,thisprocessisperformedatsix levels(from1cmproximaltothesquamocolumnarjunctiontotheproximal gastriccardia),creating48ablationsites(FIG15).

■ TheStrettasystemisthenremoved.

InspectionoftheGastroesophagealJunction

■ TheendoscopeisadvancedbackdowntotheGEjunctiontoallowinspectionof theradiofrequencyenergyapplicationsite(FIG16).

LOWERESOPHAGEALSPHINCTER AUGMENTATIONSURGERY

■ TheonlycommerciallyavailablelaparoscopicLESaugmentationdeviceinthe UnitedStatesistheLINXRefluxManagementSystem(ToraxMedical,St. Paul,MN).TheLINXsystemisdesignedtodecreaserefluxofgastric contentsintothedistalesophagusviaplacementofaflexible,expandable deviceconsistingofmultipleinterlinkedtitaniumbeadswithamagneticcore (FIG17).

■ WhenplacedaroundtheGEjunction,itenhancestheabilityoftheLEStoresist openingandpreventrefluxintotheesophagus.

■ Withthedeviceinplace,onceapatientswallowsandesophagealperistalsis reachestheGEjunction,thepressureoftheperistalsisovercomesthe magneticfieldwithintheLINXdevicetherebyallowingthedevicetoopen andfoodtoenterintothestomach.Themagneticbeadscanalsoseparate whenintragastricpressureexceedsthemagneticstrengthofthebeads,which allowsthepatienttobelchorvomitif/whennecessary.

PreoperativePlanning

■ Generalanesthesiaisnecessary.

■ Preoperativeprophylacticantibioticsareadministeredpriortoincisiontoreduce

thechanceofinfection.

Positioning

■ Thepatientcanbeplacedintoeitherthesupineorsplit-legpositiononthe operatingroomtable.

PortPlacementandInitialDissection

■ OurtechniqueinvolvesinitialplacementofaVeressneedleintheleftupper quadrant.Fourportsaresubsequentlyplacedincludinga5-mm supraumbilicalport,8-mmleftupperquadrantport,5-mmleftupperouter quadrantport,and5-mmrightupperquadrantport.A5-mmportis temporarilyplacedinthesubxiphoidpositiontofacilitateplacementofaliver retractor(FIG18).

■ A5-mmcameraisinsertedthroughthesupraumbilicalport,whichisoperatedby anassistantsurgeonstandingonthepatient’sleft.Theoperatingsurgeon standsbetweenthepatient’slegsandusesthe5-mmrightupperquadrantport

andthe8-mmport.Theoperatingsurgeonusesabluntgrasper(lefthand)and anultrasonicdissector(righthand)toenterthelessersacviatheparsflaccida. Theleftupperouter5-mmportisusedbytheassistantsurgeontoretractthe stomachdownwardandlaterallytowardthespleentofacilitatedissectionof theGEjunction.

DissectionofGastroesophagealJunction

■ Themedialborderoftherightcrusofthediaphragmisidentifiedtofacilitatethe dissectionoftheretroesophagealspace(FIG19).Theposteriorvagaltrunkis identifiedandpreserved.Themedialborderoftheleftcrusisthenidentified fromthepatient’slefttofurtheropentheretroesophagealspace.

■ Thebluntgrasperinthesurgeon’slefthandisthenpassedthroughthe retroesophagealplanebetweentheposterioresophagealwallandtheposterior vagaltrunk,whichispreserved.Thetipofthegrasperexitsthe retroesophagealtunnelanteriortotheleftcrusofthediaphragmandis maintainedinthatlocation.

DeviceSelectionandPlacement

■ APenroseisplacedintotheupperabdomenandpulledthroughthe retroesophagealtunnel.Thisservesasatractforsmoothpassageofthesizer.

■

Thesizinginstrumentisplacedintotheabdomenthroughthe5-mmport (surgeon’slefthand)andadvancedthroughtheretroesophagealplanefrom thepatient’srighttoleft.

■ ThewhiteportionofthesizinginstrumentisthentightenedaroundtheGE junctioncephaladtothehepaticbranchesoftheanteriorvagaltrunk.Asthe circumferenceofthesizerapproachesthatoftheGEjunction,theappropriate LINXdevicesizewillbeindicatedonthesizingdevice(FIG20).

■ ThesizinginstrumentisremovedandtheLINXdeviceisinsertedthroughthe sameplanethatthesizerwasplacedthrough.TheLINXdeviceisthen wrappedaroundtheGEjunctionanteriorly.Thesuturesateachendofthe devicearethensecuredwithaTi-Knotdeviceorsecuringthemagneticclasp dependingontheversionofthedeviceemployed(FIG21).

■ Theabdomenisdesufflated,theportsareremoved,andtheskinincisionsare suturedclosed.

PEARLSANDPITFALLS

Pitfall Pearl

Transoralincisionlessfundoplication

■Cervicalesophagealinjuryduring

placementofthedevicegiventhe relativelylargesizeofthedevice

■Dilationoftheesophaguswitha

largebougie(i.e.,56Fr)and generousapplicationoflubricantto thedevicewillminimizethe likelihoodofesophagealinjury.

■Nasotrachealintubationwillhelp

cleartheoropharynxforEsophyX deviceinsertion.

■Postoperativebleedingduetohelix

retractorplacementorduring fastenerplacement,particularly alongthelessercurveofthe stomach

■Minimizethenumberoftimesthat

thehelixretractorisdeployed(once atthe12o’clockpositionandonce atthe6o’clockpositionshouldbe enough).

■Minimizefastenerplacementalong

thelessercurvature.

■PostproceduralEGDwillidentify

earlybleedingthatmayoccur duringthesesteps;ifidentified, endoclipscanbeplaced.

■Gastricoresophagealperforation

relatedtofastenerplacement

■Avoidplacementofthefasteners

throughthediaphragmaticcruraby ensuringthatthefastenersare deployedbelowthepointwherethe cruracrosstheesophagealwall.

■Administerantiemeticsaggressively

toavoidsignificantpostoperative retchingwhichmaypullonthe fasteners.

Radiofrequencyenergyapplication

■Impreciseradiofrequencyenergy

applicationduetopatient movementduringtheprocedure

■Adequateamountsofanxiolyticand

narcoticmedicationswillhelp minimizepatientmovement;if necessary,generalanesthesiacan beadministered.

■Overdistentionofthestomachfrom

excessirrigationfluid

■Monitorthesuctionreturncloselyto

preventthestomachfromfillingup withirrigant;thereshouldbe essentiallya1:1correlation betweenirrigationandsuction fluid.

■Unevenenergyapplicationviathe

four-needleelectrodesdueto asymmetryoftheGEjunction(i.e., ifasmallhiatalherniaispresent)

■Morethantwodevicerotationsper

levelmaybenecessarytoensure thattheradiofrequencyenergyis appliedatnumerouspoints throughoutthecircumferenceofthe esophagus.

Loweresophagealaugmentationsurgery

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