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ISBN 10:1451183739
ISBN 13:9781451183733
Author: Luketich James
It’s time to grab a copy of Master Techniques in Surgery: Esophageal Surgery. Fully illustrated and comprising the clearest, most procedural approaches to esophageal surgery in any textbook available today, this surgical atlas distills vast stores of knowledge from the field’s most renowned surgeons into one definitive book. Covering the full spectrum of surgical techniques, and enhanced by illustrations and tables, each chapter presents a deconstructed, sequential breakdown of every procedure, mimicking real-life experience in the operating room. Don’t leave anything to chance; ensure the utmost in accuracy by sinking your teeth into this authoritative text. Key Features: • Formatted chapters briefly assesses indications, contraindications, and preoperative planning before fully explaining and illustrating the procedure in step-by-step detail. Outcomes, complications, and follow-up are also discussed. • Topics include gastroesophageal reflux disease, paraesophageal hernia, swallowing disorders, esophageal cancer, and endoscopic ablative therapies and resection • Procedures are presented as both open and minimally invasive • Color illustrations visually describe each surgical technique and highlight key anatomic structures • End-of-chapter further reading facilitates comprehension and complete understanding Now with the print edition, enjoy the bundled interactive eBook edition, offering tablet, smartphone, or online access to: • Complete content with enhanced navigation • A powerful search that pulls results from content in the book, your notes, and even the web • Cross-linked pages, references, and more for easy navigation • Highlighting tool for easier reference of key content throughout the text • Ability to take and share notes with friends and colleagues • Quick reference tabbing to save your favorite content for future use
Esophageal surgery 1st Table of contents:
Part I: Surgical Treatment of Gastroesophageal Reflux and Paraesophageal Hernia
Chapter 1: Laparoscopic Nissen Fundoplication
Chapter 1 Introduction
Indications/Contraindications
Preoperative Planning
Surgery
Room Setup
Positioning
Peritoneal Access
Remaining Cannula and Liver Retractor
Procedure
Dissection of the Hiatus
Division of Short Gastric Vessels
Creating a Retroesophageal Window
Esophageal Mobilization
Assessing Esophageal Length
Crus Closure
Complete 360-degree Nissen Fundoplication
Figure 1.1: This shows the room set up.
Figure 1.2: Surgical field extends from above the xiphoid to the pubic symphysis and from the mid axillary line on each side.
Figure 1.3: Trocar placement sites.
Figure 1.4: The gastrohepatic ligament has been divided above the aberrant left hepatic artery, and the caudate lobe of the liver can be seen.
Figure 1.5: The right crus dissection is started by dividing the peritoneum and phrenoesophageal ligament near the arch.
Figure 1.6: Short gastric vessels are divided with an ultrasonic scalpel (Harmonic scalpel, Ethicon Endo-Surgery) starting from a distance of about 12 to 15 cm along the greater curvature.
Figure 1.7: A window has been made behind the esophagus and posterior vagus nerve.
Figure 1.8: The esophageal length is assessed without any downward traction on the GEJ or stomach.
Figure 1.9: Crus closure is done with nonabsorbable braided 0 sutures starting posterior to anterior.
Figure 1.10: The crus has been completely closed.
Figure 1.11: The proposed site of the posterior fundoplication limb is marked with a stitch 6 cm below the GEJ and 2 cm posterior to the greater curvature vessels.
Figure 1.12: A 360-degree fundoplication with a pledgeted U-stitch.
Figure 1.13: The completed fundoplication lays tension free below the closed hiatus and around the distal esophagus.
Figure 1.14: An intraoperative endoscopy is done and the fundoplication assessed.
Postoperative Management
Complications
Results
Conclusions
Recommended References and Readings
Chapter 2: Laparoscopic Partial Fundoplications
Introduction
Indications
Contraindications
Preoperative Planning
Figure 2.1: High-resolution manometry is useful to assess esophageal body motility and to screen for hiatal hernia.
Figure 2.2
Table 2.1: Preoperative Esophageal Tests Vary According to Presentation
Surgery
General Considerations
Positioning
Port Placement
Dissection
The Toupet Fundoplication
Operative Technique—The Repair
The Dor Repair
Operative Technique—The Repair
The Hill Repair
Operative Technique—The Repair
Figure 2.3: Typical OR positioning for a laparoscopic partial fundoplication.
Figure 2.4: Typical laparoscopic port placement for fundoplication.
Figure 2.5: Mediastinal dissection usually allows adequate mobilization of the gastroesophageal junction (2.5 to 4 cm).
Figure 2.6: The “shoeshine” maneuver checks for adequate esophageal length, optimal wrap fixation points, and floppiness of the fundoplication.
Figure 2.7: The final view of a well-constructed Toupet fundoplication.
Figure 2.8: Attaching the greater gastric curvature to the left crus accentuates the angle of His and the internal “flap valve.”
Figure 2.9: The finished 180-degree anterior (Dor) fundoplication.
Figure 2.10: The Hill esophagogastropexy.
Postoperative Management
Complications
Table 2.2: Postoperative Complications and Their Possible Causes
Results
Conclusions
Recommended References and Readings
Chapter 3: Fundoplication: Open Transabdominal Approach
Indications
GERD
Symptom Control
Mucosal Injury
Mechanical Obstruction
Contraindications
Obesity
Preoperative Planning
Investigations
Patient Preparation
Surgery
Positioning and Instrumentation
Technique
Restoration of Intra-abdominal Esophagus
Reconstruction of Extrinsic Sphincter
Reinforcement of Intrinsic Sphincter
Figure 3.1: The left lateral segment of the liver has been mobilized and the lesser omentum divided.
Figure 3.2: Mobilization of the esophagogastric fat pad is essential to both identify the EGJ and permit direct apposition of the peritoneal surface of the fundus to the bare surface of the distal esophagus.
Figure 3.3: A Collis gastroplasty is constructed if necessary to provide a sufficient intra-abdominal length of esophagus in patients with short esophagus.
Figure 3.4: The esophageal hiatus.
Figure 3.5: Standard reconstruction of the esophageal hiatus.
Figure 3.6: Complex reconstruction of the severely disrupted hiatus as necessary in paraesophageal (Type III and Type IV) hiatal hernias.
Figure 3.7: Nissen fundoplication.
Figure 3.8: Some fundoplication mistakes.
Postoperative Management
Complications
Results
Randomized Trials
Nonrandomized Trials
Conclusions
Recommended References and Readings
Chapter 4: Transthoracic Nissen Fundoplication
Introduction
Indications for Transthoracic Approach
Absolute Indications
Relative Indications
Preoperative Planning
Surgery
Surgical Access
Nissen Fundoplication
Figure 4.1: After fully mobilizing the esophagus, the phrenoesophageal membrane is identified beneath the hiatal muscle rim anteriorly and incised, providing access to the abdomen.
Figure 4.2: With the surgeon’s left index finger passed posterior to the esophagus in the abdomen, the remaining posterior attachments of the cardia to the hiatus are divided.
Figure 4.3: Gentle cephalad traction delivers the fundus through the hiatus.
Figure 4.4: This illustrates the left upper quadrant exposure after peripheral incision of the diaphragm.
Figure 4.5
Figure 4.6: A Collis type gastroplasty to functionally lengthen the esophagus in preparation for a Collis–Nissen procedure is depicted.
Postoperative Management
Complications
Results
Conclusions
Recommended References and Readings
Chapter 5: Belsey Mark IV Partial Fundoplication
Introduction
Indications/Contraindications
Preoperative Planning
Surgery
Initial Steps and Thoracotomy
Esophageal Mobilization
Mobilization of the Gastroesophageal Junction and Cardia
Construction of the Fundoplication
Belsey Fundoplication with Collis Gastroplasty
Final Steps
Figure 5.1: Mobilization of the esophagus and stomach through a left posterolateral thoracotomy.
Figure 5.2: A transthoracic exposure showing the fat pad removed and anterior retraction of the esophagus with placement of the crural sutures for closure of the posterior hiatus.
Figure 5.3: Construction of a Belsey 240-degree partial fundoplication showing placement of the first row of sutures 1.5 to 2 cm above the gastroesophageal junction.
Figure 5.4: Continued construction of the Belsey 240-degree partial fundoplication showing placement of the second row of sutures 2 cm above the row of previously tied sutures.
Figure 5.5: Continued construction of a Belsey 240-degree partial fundoplication showing the tails of the previously tied second row sutures are placed through the diaphragm, 0.5 cm apart and 1 to 1.5 cm from the edge of the hiatus.
Figure 5.6: A completed Belsey 240-degree partial fundoplication showing the right and left crura approximated after tying the previously placed crural sutures.
Figure 5.7: Position of the stomach for performing a Collis gastroplasty.
Figure 5.8: Before dividing the fundus of the stomach with a GIA stapler traction is exerted on the greater curvature side of the fundus before closing the jaws of the stapler.
Figure 5.9: The fundus of the stomach is stapled and cut to form a 5-cm gastric tube along the proximal portion of the lesser curvature.
Figure 5.10: The staple line is inverted by a running suture and a Belsey 240-degree partial fundoplication is constructed around the gastroplasty tube.
Figure 5.11: Continued construction of the Belsey 240-degree partial fundoplication over the gastroplasty tube by placing a second row of sutures 1.5 cm above the first row of sutures and a third row of sutures 1 to 1.5 cm above the previously tied sutures of the second row.
Figure 5.12: Continued construction of the Belsey 240-degree partial fundoplication showing placement of the tails of a third row of sutures through the diaphragm, 0.5 cm apart and 1 cm from the edge of the hiatus.
Postoperative Management
Complications
Results
Conclusions
Recommended References and Readings
Chapter 6: Laparoscopic Collis Gastroplasty
Introduction
Indications
Figure 6.1: Laparoscopic view of mediastinal esophageal mobilization.
Figure 6.2: Short esophagus.
Contraindications
Preoperative Planning
Surgery
Positioning
Technique
Figure 6.3
Figure 6.4: Collis wedge gastroplasty.
Figure 6.5: Initial set-up for Collis gastroplasty.
Figure 6.6: Stapler introduced through the left subcostal port.
Figure 6.7: First staple line.
Figure 6.8: Second staple line.
Figure 6.9: Final staple line.
Figure 6.10
Postoperative Management
Complications
Figure 6.11: Correct positioning of a Nissen fundoplication around the neoesophagus.
Results
Table 6.1: Results of Laparoscopic Repair of Large Hiatal Hernia with Collis Gastroplastya
Conclusions
Recommended References and Readings
Chapter 7: Open Collis Gastroplasty
Introduction
Figure 7.1: Original Collis illustrations from 1957.
Indications/Contraindications
Figure 7.2: Hiatal hernia with stricture and shortened esophagus.
Preoperative Planning
Surgery
Transabdominal Collis Gastroplasty
Transthoracic Collis Gastroplasty
Type of Fundoplication Performed with the Collis Gastroplasty
Figure 7.3: Wedge Gastroplasty
Figure 7.4: Transthoracic Collis Gastroplasty.
Figure 7.5: The combined Collis-Nissen as described by Orringer.
Postoperative Management
Complications
Results
Conclusions
Recommended References and Readings
Chapter 8: Reoperative Antireflux Surgery
Introduction
Indications/Contraindications
Preoperative Planning
Surgery
Positioning
Operative Technique for Redo Fundoplication
Operative Technique for Roux-en-Y Near Esophagojejunostomy
Figure 8.1: Collis gastroplasty performed with a transgastric EEA followed by a linear stapler.
Figure 8.2: Collis wedge gastroplasty.
Figure 8.3: Completed Nissen fundoplication.
Figure 8.4: A Roux-en-Y near esophagojejunostomy.
Postoperative Management
Complications
Results
Conclusions
Recommended References and Readings
Chapter 9: Gastric Bypass
Introduction
Indications/Contraindications
Preoperative Planning
Surgery
Patient Positioning
Technique
Figure 9.1: Trocar configuration for standard 5-port technique.
Figure 9.2: Construction of lesser curve-based gastric pouch.
Figure 9.3: Division of jejunum and its mesentery 30 cm distal to the ligament of Treitz.
Figure 9.4: Preparation for the jejunojejunostomy.
Figure 9.5: Completed construction of a stapled side-to-side jejunojejunostomy with handsewn closure of the common enterotomy and mesenteric defect.
Figure 9.6: Laparoscopic construction of the gastrojejunostomy using a linear 45-mm stapler.
Figure 9.7: Completed laparoscopic Roux-en-Y gastric bypass with antecolic Roux limb.
Postoperative Management
Complications
Table 9.1: Early (30 days) Complications After Laparoscopic Gastric Bypass
Results
Conclusions
Recommended References and Readings
Chapter 10: Endoscopic Antireflux Repair—EsophyX
Introduction
Indications/Contraindications
Indications
Contraindications
Preoperative Planning
Figure 10.1: Retroflexion view of the gastroesophageal junction used to assess transverse hiatal diameter.
Surgery
Device
Pertinent Anatomy
Technical Evolution
Patient Positioning and Preparation
Technique
Placement of Anterior Plication Sets
Placement of Posterior Plication Sets
Greater Curve Longitudinal Plication
Device Removal
Completion Endoscopy
Figure 10.2: EsophyX device consisting of the handle, shaft, and articulating tissue mold.
Figure 10.3: EsophyX device handle.
Figure 10.4: Partially closed tissue mold with deployed helical retractor.
Figure 10.5: Fully closed tissue mold with deployed stylet and polypropylene H fastener.
Figure 10.6: Schematic representation of tissue apposition and fastener deployment during TIF.
Figure 10.7: Preprocedure endoscopy shows a clear retroflexed view of the gastroesophageal junction demonstrating no evidence of hiatal hernia.
Figure 10.8
Figure 10.9: Retroflexed view of the device with the articulating arm flexed and in position to begin the TIF procedure.
Figure 10.10: The helical retractor engaging the mucosa at the gastroesophageal junction along the lesser curvature (12-o’clock position).
Figure 10.11: Anterior rotation of the device toward the 1-o’clock position to appose tissue for the anterior corner plication.
Figure 10.12: Engaged stylet for deployment of tissue fastener in the anterior corner.
Figure 10.13: Posterior rotation of the device toward the 11-o’clock position to appose tissue for the posterior corner plication.
Figure 10.14: Engaged helical retractor at the 6-o’clock position applies traction during longitudinal plication at the greater curve positions.
Figure 10.15: The tissue mold is closed at the 5-o’clock position to create a longitudinal gastroesophageal plication above the GEJ.
Figure 10.16: Postprocedure endoscopy demonstrating the retroflexed view of a completed TIF valve that resembles the classic omega-shaped appearance associated with Nissen fundoplication.
Postoperative Management
Complications
Results
Conclusions
Recommended References and Readings
Chapter 11: Laparoscopic Paraesophageal Hernia Repair
Introduction
Figure 11.1: Types of hiatal hernia.
Indications/Contraindications
Preoperative Planning
Surgery
Reducing the Hernia Sac
Re-establishing Adequate Intra-abdominal Esophageal Length
Re-establishing the Antireflux Barrier
Repairing the Hiatus
Figure 11.2: Surgeon and port position.
Figure 11.3: Reduction of the hernia sac without retraction on the stomach.
Figure 11.4: Establishment of an intraperitoneal stomach after complete reduction of the hernia sac.
Figure 11.5: Mobilization of the esophageal fat pad and identification of the GEJ.
Figure 11.6: Fully mobilized fat pad provides clear localization of the GEJ and facilitates assessment of esophageal length.
Figure 11.7: Laparoscopic wedge Collis gastroplasty.
Figure 11.8: Creation of “floppy, two-stitch” Collis–Nissen fundoplication.
Figure 11.9: Tension-free hiatal closure.
Postoperative Management
Complications
Table 11.1: Clinical Prediction Rules for In-hospital or 30-day Mortality (Mortality Model) and Major Morbidity (Morbidity Model): Variables Included in Predictive Models after Forward Stepwise Logistic Regression Analysis and Points Assigned for Each Risk Factor Present
Postoperative Follow-up
Results
Conclusions
Recommended References and Readings
Chapter 12: Open Paraesophageal Hernia: Transthoracic Approach
Indications/Contraindications
Preoperative Planning
Surgery
Anesthetic Considerations
Positioning
Incision
Technique
Belsey Fundoplication
Figure 12.1: After mobilizing the esophagus above the hernia, the esophagus is encircled with a Penrose drain including both vagus nerves within the Penrose.
Figure 12.2: The gastroesophageal fat pad is then dissected and removed, beginning just in front of the right vagus nerve.
Figure 12.3: If a Collis gastroplasty is required, a Maloney bougie is inserted and advanced into the stomach.
Figure 12.4: The gastroplasty staple line is then oversewn with a running absorbable 3-0 suture, taking care to reinforce the apex of the staple line.
Figure 12.5: The second tier of sutures is placed in similar fashion, 1.5 cm above the first.
Figure 12.6: The needles are left attached to the final tier of sutures.
Figure 12.7: Once the fundoplication is complete, the crural sutures are tied in sequence beginning with the most posterior suture.
Postoperative Management
Complications
Results
Conclusions
Recommended References and Readings
Chapter 13: Open Paraesophageal Hernia and Hill Repair: Open Abdominal Approach
Indications/Contraindications
Paraesophageal Hernia Repair Indications
Figure 13.1: Incidental finding on CXR: Chest x-ray showing incidental giant paraesophageal hernia identified by air–fluid level in the posterior mediastinum (the arrow shows the air–fluid level of gastric contents).
Preoperative Planning
Preoperative Assessment
Figure 13.2: UGI and EGD Passage:
Surgery
Keys to the Operation
Positioning
Technique
Figure 13.3
Figure 13.4: The hernia sac is freed from mediastinal attachments and reduced into the abdomen.
Figure 13.5: Dissection of the right (A) and left (B) crura.
Figure 13.6: The posterior vagus nerve (highlighted by the forcep) with the dissected right and left crura immediately posterior.
Figure 13.7
Figure 13.8: The posterior phrenoesophageal bundle or fat pad is just posterior to the posterior vagus.
Figure 13.9: The anchoring sutures are placed through the crural repair.
Figure 13.10: The anchoring sutures in place; the anterior Babcock clamp has been removed.
Figure 13.11: A, B: All sutures are placed from the anterior to the posterior paraesophageal bundle and then through the crural repair.
Figure 13.12: The first two repair sutures are tied with a single knot and held in place with clamps.
Figure 13.13: With the first two repair sutures clamped, manometric pressures are obtained to ensure the repair is not too tight.
Figure 13.14: A, B: The completed repair.
Figure 13.15: Pexying the stomach to the diaphragm at the hiatus.
Postoperative Management
Complications
Results
Conclusions
Recommended References and Readings
Part Ii: Surgical Treatment of Esophageal Motility Disorders—Achalasia and Esophageal Diverticula
Chapter 14: Laparoscopic Heller Myotomy and Fundoplication for Achalasia
Chapter 14 Introduction
Indications/Contraindications
Sigmoid Esophagus
Diagnosis and Preoperative Planning
Figure 14.1: Subclassification of achalasia based on high-resolution manometry.
Surgery
Positioning
Port Placement
Dissection
Myotomy
Fundoplication
Sigmoid Esophagus
Closure
Figure 14.2
Figure 14.3: Dissection of the gastroesophageal fat pad and anterior vagus nerve to identify the true gastroesophageal junction prior to myotomy.
Figure 14.4: Myotomy.
Figure 14.5: Dor fundoplication.
Figure 14.6: Toupet fundoplication.
Postoperative Management
Complications
Results
Surgical Approach
Sigmoid Esophagus
Need for Fundoplication
Dor versus Toupet Fundoplication
Dor Versus Nissen Fundoplication
Extension of Myotomy
Conclusions
Recommended References and Readings
Chapter 15: Transthoracic Approach for Achalasia
Introduction
Indications/Contraindications
Preoperative Planning
Surgery
Transthoracic Esophagomyotomy
Modified Heller Esophagomyotomy
Extended Myotomy For Vigorous Achalasia
Reoperative Transthoracic Esophagomyotomy
Esophageal Resection and Replacement
Figure 15.1: Operative exposure.
Figure 15.2: Esophagomyotomy is performed with scissor dissection exposing the underlying mucosal surface.
Figure 15.3: Two methods of myotomy are shown.
Figure 15.4: A two-stitch fundoplication is illustrated.
Figure 15.5: The completed modified Heller myotomy.
Figure 15.6: A long myotomy extends from the stomach to the aortic arch.
Figure 15.7: An achalasia patient with a distended, sigmoid esophagus.
Figure 15.8: Preservation of the azygos vein arch and upper mediastinal pleura separates the upper gastric tube and anastomosis from the right chest.
Figure 15.9: The completed gastric pull-up is shown.
Postoperative Management
Myotomy
Esophagectomy
Complications and Outcomes
Conclusions
Recommended References and Readings
Chapter 16: Open Esophageal Myotomy and Resection of Epiphrenic Diverticula
Introduction
Indications/Contraindications
Preoperative Planning
Figure 16.1: Barium esophagram of an epiphrenic diverticulum.
Surgery
Figure 16.2: Thoracotomy above the eighth rib with the patient in the right lateral decubitus position.
Figure 16.3: Penrose drains placed around the esophagus.
Figure 16.4: Visualization of the diverticulum after dissection from the fascia and vascular tissues of the mediastinum.
Figure 16.5: Duval clamp grasping the diverticulum, which has been freed from surrounding fibromuscular tissue.
Figure 16.6: Typical orientation of an epiphrenic diverticulum.
Figure 16.7
Figure 16.8
Figure 16.9: Stapled closure of the esophagomyotomy.
Figure 16.10: (A–C) Posterolateral, long esophageal myotomy.
Postoperative Management
Complications
Results
Conclusions
Recommended References and Readings
Chapter 17: Minimally Invasive Approach to Resection of Thoracic and Epiphrenic Diverticula
Introduction
Indications/Contraindications
Indications for Diverticulectomy
Considerations for Observation
Preoperative Planning
Figure 17.1
Surgery
VATS Approach
Laparoscopic Approach
General Considerations for Laparoscopy
Figure 17.2: Port placement for thoracoscopic repair.
Figure 17.3: Exposed base of an epiphrenic diverticulum.
Figure 17.4
Figure 17.5: A myotomy is made with ultrasonic shears or hook cautery.
Figure 17.6: Port placement for laparoscopic repair.
Figure 17.7: A partial anterior fundoplication (Dor) is done after completion of the long esophagogastric myotomy.
Postoperative Management
VATS or Laparoscopy
VATS
Figure 17.8: Barium esophagram of the esophagus after repair of the large epiphrenic diverticulum shown in Figure 17.1.
Complications
Results
Conclusions
Recommended References and Readings
Chapter 18: Open Cricopharyngeal Myotomy and Correction of Zenker’s Diverticulum
Introduction
Figure 18.1: Radiographic image of a Zenker’s diverticulum.
Indications/Contraindications
Etiology
Preoperative Planning
Surgery
General Principles
Surgical Technique
Figure 18.2: Incision following the anterior border of the left sternomastoid muscle and extending from the sternal notch to a few centimetres from the ear lobe.
Figure 18.3: Anatomic structures in the access plane.
Figure 18.4: Exposed sternomastoid, omohyoid, and prethyroid muscles after division of the subcutaneous tissues and platysma.
Figure 18.5: Deep cervical fascia is divided along the line of the incision.
Figure 18.6: Freeing the plane between the buccopharyngeal fascia and the prevertebral fascia.
Figure 18.7: The freed pharyngoesophageal diverticulum is lifted and a 36-French bougie is passed into the esophagus through the mouth.
Figure 18.8: Tip of the diverticula is fixed to the transected muscle of the pharyngeal wall using four or five stitches.
Figure 18.9: Resection of a large diverticulum via transverse application of a linear stapler.
Figure 18.10: Fixing the transected collar of the diverticulum to the hypopharyngeal musculature.
Figure 18.11: Verifying the integrity of the mucosa at the resection and myectomy sites by injecting air through a nasogastric tube while the pharyngoesophageal junction is submerged.
Postoperative Management
Complications
Table 18.1: Complications in Patients with Zenker’s Diverticulum
Results
Conclusions
Recommended References and Readings
Chapter 19: Transoral Repair of Zenker’s Diverticula
Introduction
Indications/Contraindications
Preoperative Planning
Surgery
Positioning
Technique
Figure 19.1: Stapler with anvil.
Figure 19.2: Weerda laryngoscope.
Figure 19.3: Placement of the Weerda laryngoscope.
Figure 19.4: Placement of traction suture in the common wall between the esophagus and the diverticulum.
Figure 19.5: Stapling of diverticulum.
Postoperative Management
Complications
Results
Conclusions
Recommended References and Readings
Part Iii: Techniques and Approaches for Esophageal Resection
Chapter 20: Transhiatal Esophagectomy
Introduction
History
Principles and Justification
Indications/Contraindications
Preoperative Planning
Surgery
Anesthetic Management
Positioning
Abdominal Phase
Cervical Phase
Transhiatal Phase
Cervical Esophagogastric Anastomosis
Closure
Figure 20.1: Patient positioned supine with head toward the right and a gel pad between the shoulders.
Figure 20.2: Upper midline incision is depicted.
Figure 20.3: A self-retaining tablemounted upper abdominal retractor (upper hand retractor, J. Hugh Knight Instrument Co., Slidell, Louisiana) is used to facilitate exposure of the upper abdomen and hiatus.
Figure 20.4: The hiatus is opened with cautery, and arterial blood supply to the conduit is reviewed.
Figure 20.5: Tumor is palpated to ensure resectability.
Figure 20.6: Short gastric arteries divided by the Ligasure Impact device (Valley Lab, Covidien, Mansfield, Massachusetts).
Figure 20.7: Celiac lymph nodes are excised with the Ligasure Impact device (Valley Lab, Covidien, Mansfield, Massachusetts).
Figure 20.8: Division of the periesophageal attachments are divided with the Ligasure Impact device (Valley Lab, Covidien, Mansfield, Massachusetts).
Figure 20.9: A Kocher maneuver is depicted.
Figure 20.10: A neck incision is made anterior to the sternocleidomastoid muscle.
Figure 20.11: The cervical anatomy is depicted including the relationship of the recurrent laryngeal nerve to the surrounding structures.
Figure 20.12: The proximal esophagus is transected preserving as much cervical esophagus as possible.
Figure 20.13: The surgeon’s hand is inserted through the hiatus, posterior to the esophagus, dissecting periesophageal tissue.
Figure 20.14: Proximal stomach is transected leaving a conduit (∼6 cm wide) preserving collateral circulation to the fundus.
Figure 20.15: A 28-French chest tube has been passed down from the cervical incision through the hiatus and is sutured to the fundus with a heavy silk suture.
Figure 20.16: Two stay sutures are placed on the esophagus marking the lateral edges and keeping proper orientation.
Figure 20.17: The back wall of the anastomosis is completed first with interrupted full-thickness 2-0 vicryl sutures.
Figure 20.18: The anterior wall of the anastomosis is now completed using interrupted full-thickness 2-0 vicryl sutures.
Figure 20.19: Anatomy of the completed procedure depicted after the stomach has been pulled down from the hiatus straightening it.
Figure 20.20: A pyloromyotomy is performed using straight scissors.
Postoperative Management
Complications
Hemorrhage
Tracheal Tear
Recurrent Laryngeal Nerve Injury
Anastomotic Leak
Postoperative Chylothorax
Anastomotic Stricture
Results
Conclusions
Recommended References and Readings
Chapter 21: Ivor Lewis Esophagectomy
Introduction
Indications
Contraindications
Preoperative Planning
Radiologic Evaluation
Endoscopic Evaluation
Open Ivor Lewis Esophagectomy: Surgery
Abdominal Phase
Positioning
Technique
Thoracic Phase
Positioning
Technique
Anastomotic Technique
Figure 21.1: Standard incisions for an Ivor Lewis esophagectomy.
Figure 21.2: The omentum is separated from the transverse colon and care taken to preserve the gastroepiploic artery.
Figure 21.3: Surgical technique.
Complications
Anastomotic Leaks
Delayed Gastric Emptying
Mortality
Survival
Results
Late Functional Results
Conclusion
Minimally Invasive Esophageal Resection
Minimally Invasive Ivor Lewis Esophagectomy: Surgery
Abdominal Phase
Positioning
Technique
Thoracic Phase
Positioning
Technique
Figure 21.4: Five ports are placed in the abdomen for gastric mobilization.
Figure 21.5: Creation of the gastric tube.
Figure 21.6: Placement of feeding jejunostomy.
Figure 21.7: Placement of thoracoscopic ports.
Figure 21.8: Division of the esophagus with Endo Shears.
Figure 21.9: Creation of the anastomosis.
Results
Conclusion
Recommended References and Readings
Chapter 22: En Bloc Esophagectomy
Introduction
Indications/Contraindications
Preoperative Planning
Surgery
Positioning and Anesthetic Technique
Operating Technique: Abdominal Phase
Operating Technique: Thoracic Phase
Figure 22.1: Figure showing detachment of the gastrocolic omentum off the stomach.
Figure 22.2: Figure showing the celiac axis to be dissected.
Figure 22.3: Origin of coronary vein dissected and about to be ligated.
Figure 22.4: Ligation of left gastric artery at its origin; hepatic artery lymph node already taken off the anterior surface of hepatic artery.
Figure 22.5: Dissection and ligation of the right gastric artery is done at the angular incisura or at least beyond the third branch from the origin of the left gastric artery (where the incidence of nodal metastases became minimal).
Figure 22.6: The thoracic duct is ligated together with the loose connective tissue on the aortic surface.
Figure 22.7: The esophagus has been dissected away.
Figure 22.8: The stomach has been delivered up to the thorax via the diaphragmatic hiatus, the stomach has been partially transected with a linear stapler, the blue line marks the intended line of transection toward the lesser curvature of the stomach distally to complete making a narrow gastric tube.
Figure 22.9: The beginning of the anastomosis between the esophagus and the gastric conduit using a handsewn method at the apex of the thoracic cavity.
Figure 22.10: Completion of the anastomosis.
Postoperative Management
Complications
Results
Conclusions
Recommended References and Readings
Chapter 23: Left Thoracoabdominal Exposure for Esophagectomy and Complex Hiatus Pathology
Introduction
Indications/Contraindications
Figure 23.1: Operative plan for resection of adenocarcinoma of the distal esophagus/gastroesophageal junction with cervical anastomosis.
Preoperative Planning
Figure 23.2: Patient position for left thoracoabdominal and neck incisions.
Surgery
Thoracoabdominal Incision
Incision Closure
Figure 23.3: Lateral view of the completed thoracoabdominal incision.
Figure 23.4: Exposure of the celiac axis through the left thoracoabdominal incision.
Figure 23.5: En bloc mobilization of the thoracic esophagus can be performed through the thoracoabdominal approach.
Figure 23.6: Left neck exposure of the esophagus for cervical anastomosis if indicated.
Figure 23.7: Hybrid cervical anastomosis.
Figure 23.8: The anterior aspect of the anastomosis is performed with a continuous or interrupted suture technique.
Figure 23.9: The anastomosis is repositioned in the superior mediastinum, and the conduit is gently straightened.
Postoperative Management
Complications
Conclusions
Recommended References and Readings
Chapter 24: Minimally Invasive Ivor Lewis Esophagectomy
Introduction
Indications/Contraindications
Preoperative Planning
Surgery
Patient Positioning
Laparoscopic Phase
Port Placement/Staging
Mobilization of the Stomach
Creation of Gastric Conduit
Creation of Pyloroplasty
Placement of Feeding Jejunostomy
Final Abdominal Steps
Thoracoscopic Phase
Thoracoscopic Port Placement
Thoracoscopic Esophageal Mobilization
Creation of Esophagogastric Anastomosis
Final Thoracoscopic Steps
Figure 24.1: Laparoscopic port placement.
Figure 24.2: Laparoscopic staging, with opening of the gastrohepatic ligament and evaluation of left gastric/celiac lymph nodes.
Figure 24.3: Laparoscopic staging (continued).
Figure 24.4: Division of highest short gastric vessels and dissection along the greater curve of the stomach.
Figure 24.5: Creation of the gastric conduit.
Figure 24.6: Completed gastric conduit with an intact right gastroepiploic arcade and an intact right gastric artery.
Figure 24.7: Creation of a flap of omental pedicle.
Figure 24.8: Creation of pyloroplasty (A and B) and vertical closure (C and D) in a Heineke–Mikulicz fashion.
Figure 24.9: Placement of a 10-French needle jejunostomy catheter and an antitorsion stitch 3 to 4 cm distally along the antimesenteric border.
Figure 24.10: The gastric conduit is secured to the specimen along the lesser curve staple line for proper orientation during the thoracoscopic portion with a horizontal U stitch.
Figure 24.11: Thoracoscopic port placement.
Figure 24.12: Thoracoscopic esophageal mobilization.
Figure 24.13: Creation of the esophagogastric anastomosis.
Figure 24.14: The gastrotomy is closed with an Endo GIA stapler and this part of the stomach is sent as final gastric margin.
Figure 24.15: Completed reconstruction.
Postoperative Management
Complications
Table 24.1: Comparison of Postoperative Adverse Outcomes after Elective MIE with Either a Cervical (MIE-Neck) or Intrathoracic (MIE-Chest) Anastomosis
Results
Conclusions
Recommended References and Readings
Chapter 25: Esophagectomy with Substernal Pull-up
Introduction
Indications/Contraindications
Indications
Relative Contraindications
Preoperative Planning
Surgery
Anatomy
Position and Incision
Operative Technique
Figure 25.1: The gastric conduit can be created with a stapler as described in other chapters.
Figure 25.2: A gastric conduit 4 to 6 cm in diameter is recommended.
Figure 25.3: The cervical esophagus is identified and dissected, while the left recurrent laryngeal nerve should be distinguished and protected.
Figure 25.4: A to C: The substernal route is created under direct visualization by a combination of sharp and blunt dissection and should be as wide as possible.
Figure 25.5: A and B: By a combination of pushing and carefully pulling, the conduit can be positioned through the tunnel.
Figure 25.6: Both ends of the gastric tube should be fixed to the surrounding tissues.
Postoperative Management
Complications and Results
Conclusions
Acknowledgments
Recommended References and Readings
Chapter 26: Merendino Jejunal Interposition
Introduction
Indications
Preoperative Planning
Surgery
Surgical Considerations
Surgical Technique/Sequence of Operative Steps
Positioning
Exploration
Dissection of the Diaphragmatic Hiatus and the GEJ
Transection of the Distal Esophagus
En Bloc Dissection of the Distal Esophagus and Gastric Cardia with Mediastinal and Abdominal Lymphadenectomy
Transection of the Proximal Stomach
Preparation of the Isoperistaltic Jejunal Conduit
Reconstruction by Esophagojejunostomy and Jejunogastrostomy
Figure 26.1
Figure 26.2: Complete dissection of the distal esophagus and the diaphragmatic crura.
Figure 26.3: Placement of the purse-string clamp on the distal esophagus.
Figure 26.4: Placement of the anvil of the circular stapler into the esophageal lumen and tying the purse-string suture.
Figure 26.5: A, B: Transection of the proximal stomach with the linear stapler.
Figure 26.6: Reinforcement of the staple line with interrupted 3-0 absorbable sutures.
Figure 26.7: Preparation of the pedicled isoperistaltic jejunal segment.
Figure 26.8: Appearance of the pedicled jejunal segment (interponate/interposition graft) after completing the jejunojejunostomy.
Figure 26.9: Reconstruction using the EEA stapler.
Figure 26.10: Dilation of the pylorus with a large curved clamp.
Figure 26.11: Reconstruction of the angle of His with interrupted absorbable 3-0 sutures to secure the fundus to the diaphragm.
Figure 26.12: Completed reconstruction with the isoperistaltic pedicled jejunal segment.
Postoperative Management
Complications
Anastomotic Leakage
Results
Recommended References and Readings
Chapter 27: Long Segment Reconstruction with Jejunum
Introduction
Indications
Contraindications
Preoperative Planning
Posterior Mediastinal Route
Substernal Route
Anatomy
Positioning
Figure 27.1
Surgery
Dissection of the Jejunum
Preparing the Neck
Dissection of the Neck and Blood Supply/Partial manubriectomy and resection of the first rib (Fig. 27.2)
Creating the Tunnel for the Conduit
Creation of the Substernal Tunnel
Selection and Division of Jejunal Branches
Planning the Intra-abdominal Route for Jejunum
Plan A (Antecolic Tunneling of the Jejunal Segment) (Fig. 27.4A)
Plan B (Retrocolic Tunneling of the Jejunal Segment) (Fig. 27.4B)
Delivery of the Jejunum Through the Substernal Tunnel
Microvascular Anastomosis
Creation of the Indicator Flap
Esophagojejunal Anastomosis
Recreating Continuity in the Abdomen
Plan A: Creation of the Roux Anastomosis (Preferred)
Plan B: Jejunogastric Anastomosis
Feeding Jejunostomy
Intraoperative and Postoperative Management
Figure 27.2: Manubriectomy and dissection of donor vessels.
Figure 27.3
Figure 27.4
Figure 27.5: Indicator flap.
Figure 27.6: Functional end-to-end stapled anastomosis.
Complications
Other Potential Complications
Results
Conclusions
Recommended References and Readings
Chapter 28: Colon Interposition
Introduction
Indications/Contraindications
Preoperative Planning
Surgery
Choosing Short-segment or Long-segment Colon Interposition
Colon Conduit Preparation in Foregut Replacement
Left Colon Interposition
Right Colon Interposition
Vagal-sparing Esophagectomy
Figure 28.1: Vascular anatomy of the colon.
Figure 28.2: The colon is retracted cephalad to note the tether point of the ascending left colic vessels.
Figure 28.3: The previously measured length of umbilical tape is placed proximally along the colon from the first suture to a point typically at the mid-ascending colon, marking what will become the proximal end of the isoperistaltic colon interposition.
Postoperative Management
Figure 28.4: Computed tomography image of a substernal colon interposition.
Complications
Results
Figure 28.5: Redundant substernal colon interposition.
Conclusions
Recommended References and Readings
Part Iv: Resection of Benign Esophageal Tumors
Chapter 29: Open Resection of Esophageal Leiomyoma and GIST
Introduction
Esophageal Leiomyoma
Clinical Presentation and Diagnosis
Figure 29.1: Computed tomography of the chest demonstrating a mass in the esophageal wall demonstrated by the arrow.
Indications/Contraindications
Preoperative Planning
Surgery
Anesthesia
Positioning
Technique
Figure 29.2: This picture demonstrates proper positioning of the patient for a left thoracotomy.
Figure 29.3: Skin incision for a lateral thoracotomy.
Figure 29.4: Skin incision for a muscle-sparing thoracotomy.
Figure 29.5: The latissimus dorsi muscle is divided with electrocautery leaving the serratus anterior muscle intact.
Figure 29.6: The posterior border of the serratus anterior muscle is dissected and elevated.
Figure 29.7: Chest wall retractors are placed at right angles to separate the ribs and fully distract the soft tissues anteriorly and posteriorly.
Figure 29.8: View of the posterior mediastinum demonstrating a mass above the azygos vein.
Figure 29.9: The technique of enucleation is illustrated.
Figure 29.10: Once the leiomyoma is removed, mucosal integrity is tested by insufflation with the esophagoscope.
Figure 29.11: The ribs are reapproximated with heavy gauge reabsorbable sutures taking care not to create overapproximation or to entrap the neurovascular bundle under the rib below.
Figure 29.12: The chest wall musculature (latissimus and serratus) is reapproximated in layers with heavy reabsorbable suture taking full thickness bites.
Postoperative Management
Complications
Results
GISTs
Presentation and Diagnosis
Figure 29.13: Computed tomography of the chest demonstrating a large (8.5 cm) gastrointestinal stromal tumor of the lower esophagus.
Treatment
Results
Conclusions
Esophageal Leiomyoma
GISTs
Recommended References and Readings
Chapter 30: Resection of GIST and Leiomyoma: Thoracoscopic Approach
Introduction
Figure 30.1: Relative incidence of leiomyoma in the esophagus.
Figure 30.2: A computed tomography (CT) of a leiomyoma that presented as a proximal esophageal mass.
Figure 30.3: CT of a GIST that presented at the gastroesophageal junction.
Incidence and Presentation of Leiomyoma
Indications/Contraindications
Preoperative Planning
Indication for Biopsy
Surgery
General Principles
Right VATS Technique
Figure 30.4: Circumferential dissection of the esophagus taking care to avoid the vagus nerves.
Figure 30.5: Using graspers to perform the myotomy.
Figure 30.6: Dissecting tumor away from the submucosa.
Figure 30.7: Closure of myotomy.
Postoperative Management
Complications
Results
Management of Esophageal GISTs
Table 30.1: GIST Recurrence by Resection Method (Enucleation vs. Esophagectomy)
Conclusions
Recommended References and Readings
Part V: Endoscopic Ablative Therapies and Resection
Chapter 31: Esophageal Radiofrequency Ablation for the Treatment of Barrett’s Esophagus with and without Dysplasia
Introduction
Indications/Contraindications
Indications
Contraindications
Preoperative Planning
Surgery
RFA Device
RFA Procedure
Figure 31.1: HALO 360 RFA catheter.
Figure 31.2
Figure 31.3: HALO 90 catheter affixed to an endoscope.
Figure 31.4: Circumferential ablation with balloon-based RFA system.
Figure 31.5: Esophagoscopy revealing the ablation zone.
Figure 31.6: Focal ablation with endoscope-mounted HALO 90 RFA system.
Postoperative Management
Complications
Results
Surveillance After RFA
Conclusions
Recommended References and Readings
Chapter 32: Photodynamic Therapy, Lasers, and Cryotherapy for Esophageal Neoplasia
Introduction
Photodynamic Therapy
Laser Therapy
Cryotherapy
Indications/Contraindications
Photodynamic Therapy and Thermal Laser Therapy Indications
Cryotherapy Indications
Photodynamic Therapy Contraindications
Cryotherapy Contraindications
Preoperative Planning
Photodynamic Therapy
Thermal Laser Therapy (APC; Nd:YAG)
Cryotherapy
Surgery
Photodynamic Therapy Technique
Thermal Laser Therapy Technique
Cryotherapy Technique
Figure 32.1: Patient is in left lateral decubitus position, sedated and the endoscope is inserted transorally.
Figure 32.2: PDT laser eyewear is required for ocular safety.
Figure 32.3
Figure 32.4: Esophageal centering balloons.
Figure 32.5: Priming the cryospray from endoscope.
Chapter 33: Endoscopic Mucosal Resection
Indications/Contraindications
Figure 33.1: Subdivision of early cancers of the gastrointestinal tract based on the depth of invasion.
Table 33.1: Factors to Consider for Endoscopic Resection of High-grade Dysplasia (HGD) and Intramucosal Adenocarcinoma
Table 33.2: Indications for Endoscopic Resection of Esophageal Squamous Cell Carcinoma (SCC)
Preoperative Planning
Surgery
Endoscopic Mucosal Resection
Endoscopic Submucosal Dissection
Handling of Resected Specimens
Figure 33.2: Four types of endoscopic mucosal resection (EMR) techniques.
Figure 33.3: Several sizes and types of caps for endoscopic cap resection technique.
Figure 33.4: A multiband mucosectomy device (Duette, Cook Medical Inc.).
Figure 33.5: Schematic representation of endoscopic submucosal dissection.
Figure 33.6: Endoscopic submucosal dissection of early esophageal SCC.
Figure 33.7: Different types of needle knives for endoscopic submucosal dissection.
Postoperative Management
Complications
Results
Esophageal High-grade Dysplasia and Intramucosal Adenocarcinoma
Esophageal Squamous Cell Carcinoma
Table 33.3: Risk Factors Potentially Associated with Recurrence after Endoscopic Resection of Early Esophageal Cancer
Conclusions
Recommended References and Readings
Part Vi: Miscellaneous Esophageal Procedures
Chapter 34: Esophageal Stents
Introduction
Table 34.1: Available Modalities for the Palliation of Dysphagia from Esophageal Cancer
Figure 34.1: Esophageal stent insertion for malignant disease.
Indications
Special Considerations
Stent Design
Figure 34.2: Uncovered (A) and Covered (B) expanding metallic stent.
Figure 34.3: Partially covered self-expanding metallic stents.
Table 34.2: FDA-approved Self-expanding Stents Currently Available in the United States
Figure 34.4: Completely covered self-expanding stents.
Preoperative Planning
Technique
Figure 34.5: Deployment of esophageal stent.
Figure 34.6: Esophageal stent delivery system.
Figure 34.7: Endoscopic (A) and radiographic (B) appearance of esophageal stent after deployment.
Figure 34.8: Barium esophagram before (A) and after (B) esophageal stent placement for a malignant stricture.
Postoperative Management
Complications
Table 34.3: Complications of Esophageal Stent Placement
Figure 34.9: Extensive overgrowth of exuberant granulation tissue at the distal end of an Ultraflex stent 4 months after insertion.
Figure 34.10: Esophageal stent migration to stomach (A) and small bowel (B).
Results
Rigid Versus Expandable Stents
Esophageal Stents in the Management of Malignant Disease
Esophageal Stents in the Management of Benign Disease
Figure 34.11: Multimodality approach in the management of advanced esophageal cancer.
Figure 34.12
Conclusions
Recommended References and Readings
Chapter 35: Bougie and Balloon Dilation of Esophageal Strictures—Malignant and Benign
Introduction
Table 35.1: Types of Esophageal Dilators
Indications/Contraindications
Table 35.2: Most Common Indications for Esophageal Dilation
Preoperative Planning
Surgery
Principles
Positioning
Push Dilators
Balloon Dilators
Rendezvous Procedure
Figure 35.1: Savary-Gilliard dilator with guidewire in place.
Figure 35.2: Esophageal dilation technique using the Savary-Gilliard dilator.
Figure 35.3
Figure 35.4
Figure 35.5
Figure 35.6: Simultaneous endoscopy through the mouth and through a gastrostomy to assess and dilate short stricture with near-complete esophageal occlusion.
Postoperative Management
Complications
Results
Conclusions
Recommended References and Readings
Chapter 36: Esophageal Perforation
Introduction
Figure 36.1: Chest radiograph demonstrating extravasation of oral contrast into the mediastinum following a cervical esophageal perforation sustained during transesophageal echocardiography.
Presentation
Preoperative Planning
Figure 36.2: Contrast esophagogram demonstrating contained leakage of oral contrast due to perforation of a midesophageal stricture sustained during attempted esophageal dilation.
Figure 36.3: Computed tomography of the chest from the same patient shown in Figure 36.2, demonstrating the thickened midesophagus at the site of stricturing and pneumomediastinum resulting from the contained perforation.
Figure 36.4: A, B: Computed tomography of the chest demonstrating a large right hydropneumothorax, mediastinal air, right lower lobe lung consolidation, and small amount of extravasation of oral contrast into the right pleural space, diagnostic of esophageal perforation.
Treatment
Principles of Initial Management
Determining the Treatment Plan
Nonoperative Management
Endoscopic Management
Operative Management
Primary Surgical Repair
Esophagectomy
Esophageal Diversion
Special Considerations
Location of the Perforation
Pre-existing Esophageal Pathology
Table 36.1: Suggested Criteria for Nonoperative Management of an Esophageal Perforation
Figure 36.5: Contrast upper gastrointestinal radiograph demonstrating a fully covered stent placed to occlude a cervical esophagogastric anastomotic leak following esophagectomy.
Figure 36.6
Figure 36.7
Table 36.2: Factors That May Mandate Esophagectomy Over Primary Repair or Endoscopic Stenting
Complications and Results
Conclusions
Recommended References and Readings
Chapter 37: Congenital Diaphragmatic Hernia Repair: Open and Thoracoscopic
Indications/Contraindications
Figure 37.1: External view of a congenital diaphragmatic hernia in a newborn.
Figure 37.2: Chest x-ray of a congenital diaphragmatic hernia in a newborn.
Preoperative Planning
Surgery
Open Repair
Positioning
Technique
Minimally Invasive Repair
Positioning
Technique
Figure 37.3: Retraction of the anterior lip of the diaphragm and mobilization of the posterior lip during manipulation of the bowel back into the abdomen.
Figure 37.4: Primary repair using silk suture (pledgeted polyester can be used as well).
Figure 37.5
Figure 37.6: Classes of CDH defects.
Figure 37.7: Patient and surgeon positioning for minimally invasive CDH repair.
Figure 37.8: Port placement for minimally invasive CDH repair.
Figure 37.9: Inspection of the diaphragmatic defect after reduction of the herniated contents.
Figure 37.10: CDH repaired thoracoscopically with 3-0 silk sutures.
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