ADVANCED LAPAROSCOPIC FOREGUT SURGERY
B. Salky, Dept. of Surgery, Mount Sinai Medical Center, New York, USA
Surg Treatmt of achalasia
Heller myotomy is the procedure of choice for the surgical management of
achalasia. While balloon dilatation has a role in the management of this disease,
most physicians interested in esophageal diseases feel that it should be limited
to elderly patients who are at high risk to general anesthesia. Bo-tox has very
little role in the treatment of achalasia, and its use may make other definitive
treatments more risky. Although it still has a role in the elderly patient in whom
general anesthesia is dangerous. Surgical myotomy should be performed before
the esophagus becomes S shaped. There is a lot of interest in determining if an
anti-reflux procedure should be performed at the same time, and if performed,
what type should be constructed. A recent randomized-controlled study
documented less reflux with the addition of a partial fundoplication (DOR).
However, the answer as to the correct fundoplication is unknown at present.
Technique
The patient is placed in modified lithotomy position with the monitor placed in
the midline over the head of the patient. The surgeon stands between the legs
with one or two assistants on either side. An oral-gastric tube is not placed
because of the potential for perforation. For that matter, neither is a temperature
probe. Five trocars (each 5 mms) are placed in the same position as hiatal
hernia repair. The left lobe of the liver is elevated with a palpation probe or a
Nathanson® retractor, and the dissection of the phreno-esophageal ligament is
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begun after division of the gastro-hepatic ligament. If a large replaced left
hepatic artery is present, it is preserved. The anterior 180 degrees of the
esophagus is freed from the esophageal hiatus for a distance of 7-8 centimeters.
The anterior vagus is identified and preserved. The posterior aspect of the
phrenoesopheal ligament is not disturbed. The posterior vagus is not dissected
or identified. The gastric fat pad is dissected from the G-E junction until the
anterior portion of the stomach wall is clearly identified, including the course of
the anterior vagus (which is preserved). I prefer the 5-mm curved, Harmonic
Scalpel, but other dissection instruments are usable. A 7-centimeter myotomy is
made with at least 5mm onto the gastric wall. This is confirmed with
intraoperative endoscopy. A partial fundoplication is performed by suturing the
cut end of the left side of the myotomy to the cardia of the stomach. It reestablishes the angle of HIS. Intracorporeal suturing is employed here.
Results
One hundred-thirty nine consecutive patients underwent a laparoscopic Heller
myotomy by the author at the Mount Sinai Hospital, New York from 1993 through
November 2004. There were no moralities. The mean age was 39 years (range
14-89 years) with 60% males. Forty-one patients had at least one pneumatic
dilatation and 21 patients had at least one Bo-Tox injection. The completion rate
was 100%. No patient needed transfusion. Ninety-five patients (95%) were very
satisfied with the operation, where as five (5%) patients were not. An incomplete
myotomy was identified in two patients early in the series. Each was before the
routine use of intra-operative endoscopy. They responded to postoperative
pneumatic balloon dilatation. Three patients, all with sigmoid esophagus, did not
respond well to myotomy in the long term. All three were offered laparoscopic
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esophagectomy. There have been three mucosal injuries, all recognized and
repaired at laparoscopy without adverse affect. All patients with mucosal injury
had multiple pneumatic dilatations and multiple Bo-tox® injections. The addition
of intraoperative endoscopy (1994) has been very helpful in the identification of
mucosal injury, and the gastroesophageal junction, and, thereby, proper
placement of the myotomy. Intra-operative manometry was not utilized. Barium
study is performed on the first post-operative morning to confirm egress of
barium from the esophagus into the stomach. Patients are begun on solid food
the first postoperative day. Discharge is on day one. There has been two
aspiration pneumonias postoperatively, both significantly prolonging discharge
from the hospital. There have been no other significant morbidity.
Conclusion
Laparoscopic Heller myotomy is safe and feasible treatment for achalasia.
Intra-operative endoscopy and partial fundoplication are important adjuncts in
this surgery. Advanced laparoscopic skills are required (two handed technique,
suturing and knot tying). A partial fundoplication is recommended in order to
decrease the incidence of acid exposure to the lower end of the esophagus.
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Suggested Readings
1. Perretta S, Fisichella PM, Galvani C, Gorodner MV, Way LW, Patti
MG. Achalasia and Chest Pain: Effect of Laproscopic Heller Myotomy. J
Gastrointest Surg. 2003 Apr-Jun;7(5):595-8.
2. Bloomston M, Durkin A, Boyce HW, Johnson M, Rosemurgy AS. Early
Results of Laparoscopic Heller Myotomy Do Not Necessarily Predict
Long Term Outcome. Am J Surg. 2004 Mar;187(3):403-7.
3. Zaninotto G, Annese V, Costantini M, Del Genio A, Costantino M,
Epifani M, Gatto G, D’onofrio V, Benini L, Contini S, Molena D, Battaglia
G, Tardio B, Andriulli A, Ancona E. Randomized Controlled Trial of
Botulinum Toxin Versus laparoscopic Heller Myotomy for Esophpageal
Achalasia. Ann Surg.2004 Mar;239(3)364-70.
4. Chapman JR, Joehl RJ, Murayama KM, Tatum RP, Shi G, Hirano I,
Jones MP, Pandolfino JE, Kahrilas PJ. Achalasia Treatment: Improved
Outcome of Laproscopic Myotomy with Operative Manometry. Arch Surg.
2004 May;139(5):508-13.
5. Richards WO, Torquantl A, Holzman MD et al. Heller Myotomy vs
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Heller Myotomy with Dor Fundolasty for Achalasia: A Prospective
randomized double-blind Clinical Trial. Ann Surg 2004 Sep;240(3):40512.
Paraesophageal
Large hiatal hernias are potentially life-threatening conditions, and surgical
repair is indicated unless medical contraindications exist. It is important to
classify the types of hernia in order to be able compare results. Type II are those
hernias in which the gastroesophageal junction is located below the diaphragm.
(True paraesophageal). Type III have components of both sliding and
paraesophageal hernias.The esophagogastric junction and more than half of the
stomach are located above the diaphragm. This translates to a hiatal opening of
7-8 centimeters. Type IV hernia is a Type III with another organ in the hernia
sac (colon, spleen, etc.). Recent advances in therapeutic laparoscopic surgery
now allow a minimally invasive approach to these technically difficult problems.
Advanced laparoscopic skills, including suturing and knot tying are required for
this surgery. The surgeon should be experienced in GERD surgery before
embarking on the repair of paraesophageal hernias. There is significant
literature detailing the difficulty and learning curve with this disease entity.
Patient Selection
The symptom complex in patients with paraesophageal hernia is different
when compared to those patients with GERD. The most common presentations
are chest pain, dysphagia, and aspiration. Heartburn is uncommon. The work-up
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includes endoscopy and barium swallow. I have found barium swallow to be
invaluable for helping with an anatomical roadmap preoperatively. If GER is
present, manometry and motility are performed; however, this has been required
on only one-third of the patients. There is a recent article bringing up the
question of what to do in patients who are totally asymptomatic or those with
minimal symptoms, detailing benefit in only 20% of all patients. In my
experience, only patients with symptoms tend to show up in the surgeons office.
Those patients clearly benefit from laparoscopic surgical repair.
Methods
The laparoscopic approach to large hiatal hernias was begun in 1992 at our
institution. A review of my prospective database revealed 209 patients who
underwent an attempt at laparoscopic repair from June 1992 through November
2004. Two hundred and four patients were completed laparoscopically. This
included 31 Type II, 152 Type III, and 26 Type IV hiatal hernias. The mean age
was 70(range 43-97 years). All patients had preoperative endoscopy and barium
contrast studies. Motility and/or 24 hour pH studies were performed in only those
patients with symptoms suggestive of GERD. Fundoplication was performed in
all patients with clinical GERD (n=83). Nissen fundoplication was constructed in
74 and Toupet fundoplication in 9 patients. Cardiopexy (without fundoplication)
was performed in the rest. Barium swallow was performed on the first
postoperative morning. We began to excise the entire hernia sac after the first
25 patients, when an unacceptable early recurrence rate (N=5)(20%) and high
conversion rate (20%) were noted.
Results
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Since total sac excision in 1993(last 184 patients), there have been no
conversions to open. The five patients converted to open (early in the series)
were excluded from this study. Fundoplication was performed in the 83 patients
with preoperative symptomatic reflux. Seventy-four patients had Nissen
fundoplication, and the remaining nine patients underwent partial fundoplication
(Toupet). The choice of fundoplication was based on preoperative motility studies
performing partial fundoplication on those patients with ineffective esophageal
motility. Patients with GERD were the minority of patients, as mechanical
symptoms predominated as the symptom complex. Chest pain and dysphagia
were the most common presenting symptom. Excision of the sac and
Cardiopexy were performed in the rest (N=166). Primary closure of the hiatus
with 0 Ethibond suture material loaded with felt pledgets was accomplished in all
patients except one using intracorporeal suturing and extracorporeal knotting
techniques. One patient early in the series had mesh closure that promptly
recurred (pt.#21). Early recurrence occurred in 9 patients, five before sac
excision and four after sac excision (Table 1). Three of the four recurrences
after sac excision were secondary to vomiting in the immediate postoperative
period. These were diagnosed on barium swallow and repair effected on the first
postoperative day by repeat laparoscopy. Long-term follow up by telephone
survey of 184 patients (15 patients lost to follow up and 10 deaths), revealed
95% of patients remain asymptomatic relative to their preoperative complaints at
a mean of 65 months (range 2-122 months). However, documentation with
barium swallow has not been possible in all patients. It is common to see a 2-3
centimeter hiatal hernia after one to two years. These patients do not have the
same mechanical symptoms they had preoperatively. There were four major inhospital morbidities including one missed esophageal perforation, two
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gastroparesis, one deep vein thrombophlebitis, and one perioperative myocardial
infarction. There were no mortalities. The mean length of stay was 2 days for
the first 12 patients, and one-day for the last 192 patients.
Short Esophagus
There is conflicting data on the incidence of short esophagus in this disease.
In fact, there is considerable debate as to whether it exists or not. In my
experience, unless there is a documented stricture of the esophagus, a true short
esophagus does not exist. Total sac excision with mobilization of the esophagus
high into the mediastinum coupled with posterior closure of the crura fibers will
allow adequate intra-abdominal length of the esophagus. However, if adequate
length cannot be obtained, laparoscopic Collis-Nissen gastroplasty is indicated.
However, keep in mind that the long-term results of Collis-Nissen are not great
either. And there is a short-term incidence of leak and potential mortality from
the procedure itself.
Postoperative course
The patients are encouraged to ambulate the first postoperative night, and
they are allowed clear fluids. Pain control is adequate with Toradol®. Routine
barium esophagram is performed the morning after surgery in order to document
the presence of the stomach below the diagphram. Patients are re-laparoscoped
if the stomach is not below the diaphragm or if there is a question of the
stomach’s location. Resuturing of the hiatus is performed if an early recurrence
is documented. In my experience, if the patient vomits postoperatively, the
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incidence of recurrence has been 100%. Therefore, all patients are pre-treated
with anitemtics.
Controversy
There has been recent interest in using synthetic mesh as an on-lay graft over
closure of the diaphragmatic crus. There is data to support a low recurrence rate
in the short term. There is one randomized, prospective trial on the use of
posterior closure and fundoplication with on-lay DualMeash® (PTFE)showing no
recurrence at 2.5 years. However, there are numerous isolated reports of
erosion of mesh into the gastrointestinal tract. The exact incidence of this is
unknown, but it usually takes years for erosion to occur. It seems prudent to
express caution in the routine use of a synthetic mesh next to the gastrointestinal
tract, including the esophagogstric junction. If mesh is required, omentum should
be interposed between mesh and gastrointestinal tract. There has been some
early interest in bio-degradable mesh, but there are no long term level 1 data as
of yet to support it.
Conclusions
Laparoscopic repair of Type II, III, and IV hiatal hernia is feasible. Long term
follow up at a mean of 65 months demonstrates 95% clinical success relative to
the preoperative symptoms. Total sac excision and primary closure of the
diaphragm are the most important technical elements needed to effect proper
repair. These results compare favorably to open surgery. The use of prosthetic
mesh as a routine is probably not justified. Laparoscopic surgery is the
procedure of choice in the repair of Type II, III, and IV hiatal hernia.
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TABLE I
NO SAC EXCISION
PATIENT
#
RECURRENCE
PROCEDURE
TYPE
REOPERATION
RESULT
2
5
Pexy
Pexy
Weeks
Weeks
III
III
Open Surgery
Open Surgery
Poor
Good
21
22
Nissen
Nissen
Weeks
Weeks
III
III
Open Surgery
No Surgery
Good
Good
10
25
Nissen
Weeks
III
No Surgery
Poor
SAC EXCISION
74
Pexy
POD 1
IV
83
Nissen
Months
III
84
Pexy
POD 1
III
91
Pexy
POD 1
III
Lap Surg POD
1
Lap Surgery
Good
Lap Surg POD
1
Lap Surg POD
1
Good
Good
Good
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Andujar JJ, Papasavas PK, Birdas T, Robke J, Raftopoulos Y, Gagne DJ,
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Paraesophageal Hernia Is Associated with a Low Incidence of
Recurrence and Reoperation. Surg Endosc 2004 Mar;18(3): 114-7.
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the Open Approach? Surg Endosc 2004 Nov 11.
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