1.master Techniques in Surgery - Esophageal Surgery, 1E (2014)

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Master Techniques in Surgery
Series Editor: Josef E. Fischer
Also available in this series:
Breast Surgery
Kirby I. Bland
V. Suzanne Klimberg
Colon and Rectal Surgery: Abdominal Operations

Steven D. Wexner
James W. Fleshman
Colon and Rectal Surgery: Anorectal Operations

Steven D. Wexner
James W. Fleshman
Hernia
Daniel B. Jones
Gastric Surgery
Michael S. Nussbaum
Hepatobiliary and Pancreatic Surgery

Keith D. Lillemoe
William R. Jarnagin
Coming soon:
Thoracic Surgery
Douglas J. Mathisen
Christopher R. Morse
Vascular Surgery
R. Clement Darling III
C. Keith Ozaki
Cardiac Surgery
Frederick Grover
Michael J. Mack
LWBK1254-FM_i-xviii.indd 2 21/02/14 9:26 PM

LWBK1254-FM_i-xviii.indd Page 3 3/6/14 2:42 PM sudhir /SUBHAKANT/LWBK1254-Luketich/Chapters/FM
Edited by: Associate Editors
James D. Luketich, MD
Henry T. Bahnson Professor of Cardiothoracic Rodney J. Landreneau, MD
Surgery Medical Director, Ochsner Cancer Institute
Chairman, Department of Cardiothoracic Vice-chairman of Surgery - Ochsner
Surgery Medical Center
University of Pittsburgh School of Medicine Clinical Professor of Surgery
Pittsburgh, Pennsylvania LSU Medical Center
New Orleans, Louisiana
Senior Lecturer, University of Queensland -
School of Medicine
Series Editor Brisbane, Australia
Josef E. Fischer, MD Arjun Pennathur, MD, FACS

William V. McDermott Professor of Surgery Assistant Professor, Department of
Harvard Medical School Cardiothoracic Surgery
Chair, Department of Surgery University of Pittsburgh School of Medicine
Beth Israel Deaconess Medical Center, Emeritus Pittsburgh, Pennsylvania
Boston, Massachusetts
Illustrations by: BodyScientific International, LLC.

Anne Rains, Arains Illustration, Inc.
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Product Development Editor: Brendan Huffman
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Library of Congress Cataloging-in-Publication Data
Esophageal surgery / edited by James D. Luketich ; associate editors,

Rodney J. Landreneau, Arjun Pennathur ; illustrations by BodyScientific
International, Anne Rains.
p. ; cm. – (Master techniques in surgery)
Based on Mastery of surgery / editor, Josef E. Fischer. 5th ed. c2007.
Includes bibliographical references and index.
ISBN 978-1-4511-8373-3 (hardback)
I. Luketich, James D., editor of compilation. II. Landreneau, Rodney,
editor of compilation. III. Pennathur, Arjun, editor of compilation. IV.
Mastery of surgery. Based on (work): V. Series: Master techniques in
surgery.
[DNLM: 1. Esophagus–surgery. 2. Digestive System Surgical
Procedures–methods. WI 250]
RD539.5
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2014001211
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Acknowledgments
This textbook would not have been possible without my mentors in thoracic and
esophageal surgery, including Ernest Rosato (The Hospital of the University of
Pennsylvania), Robert Ginsberg (Memorial Sloan Kettering Cancer Center), Manjit Bains
(Memorial), Mike Burt (Memorial), David Skinner (New York Hospital), Nasser Altorki
(New York Hospital), Griffith Pearson (Toronto). Each of you contributed significantly
to my surgical skill and understanding of esophageal surgery and I feel blessed to have
been mentored by all of you.
This textbook was made possible by my two co-editors. Thanks to Arjun Pennathur
for his undying support and loyalty, and to Rod Landreneau for his support and help
during this process and for helping me to build a world-class center for thoracic surgery.
A special thanks to my assistants at Pitt, including Erin Dupree, Kathy Lovas and Shannon
Wyszomierski.
James D. Luketich
“I wish to recognize Jim Luketich for his exceptional clinical skills and his dedication
to advancing the care of patients with esophageal disease. I must also recognize my
surgical mentors, Walter Becker, Robert McClelland, William Fry, Marvin Kirsh, and
Mark Orringer, for their patience with me and their support through trying times.”
Rod Landreneau
I would like to thank my mentors—Dr. Alex G. Little, Dr. Ronald A. Malt, Dr. Leslie
W. Ottinger, Dr. James D. Luketich, and Dr. Pam A. Lipsett who, in addition to their
mentorship, encouraged me, and provided me with several opportunities. Finally I am
indebted to all my teachers, colleagues, students, residents and patients who have all
taught me the finer points in the care of the surgical patient.
Arjun Pennathur

Dedication
I would like to dedicate my contributions to this textbook of esophageal surgery to

my family, including my wife Christine, who gives so much meaning to my life and
makes it all worthwhile, and to the kids (now adults) Jim, Jr., Derek, Bobby, and
Patty. And of course, I must make special mention of our most recent additions to
the family, my wonderful Sam and Alex, who make life so much fun!

James D. Luketich
I dedicate this book to my wife, Sandy, who has been my inspiration and my most
important advisor and supporter. I also dedicate this effort to the “Js”; may they be
challenged, brave, and succeed along the “Road of Right”.

Rodney J. Landreneau
I am grateful to God for the Blessings and Grace.

I would like to dedicate this work to my family, in particular my parents for their
support and teaching us the value of hard work, honesty and education. I would like
to thank my family for their encouragement and support—my grandparents who
lived by setting an example, my brother, and sister, my wife Revathi and our children
Krithika and SriGanesh. I am indebted to their unwavering support, patience and
their persistence.

Arjun Pennathur

Contributors
Rafael S. Andrade, MD Jonathan Daniel, MD

Associate Professor of Surgery Assistant Professor of Surgery
Division of Thoracic and Foregut Surgery Department of Surgery
Department of Surgery Division of Cardiothoracic Surgery
University of Minnesota University of Arizona
Minneapolis, Minnesota Tucson, Arizona
Mara B. Antonoff, MD Gail E. Darling, MD

Cardiothoracic Surgery Fellow Professor of Thoracic Surgery
University of Minnesota Kress Family Chair in Esophageal Cancer
Minneapolis, Minnesota University of Toronto
Toronto General Hospital
Omar Awais, DO University Health Network
Assistant Professor of Cardiothoracic Surgery Toronto, Ontario, Canada
Department of Cardiothoracic Surgery
University of Pittsburgh School of Medicine Malcolm DeCamp, MD, FCCP, FACS
Chief, Division of Thoracic at UMPC Mercy Professor of Surgery
Department of Cardiothoracic Surgery Northwestern University Feinberg School of Medicine
University of Pittsburgh Medical Center Chief, Division of Thoracic Surgery
Pittsburgh, Pennsylvania Department of Surgery
Northwestern Memorial Hospital
Ankit Bharat, MD Chicago, Illinois
Fellow, Cardiothoracic Surgery
Washington University School of Medicine Alberto de Hoyos, MD, FCCP, FACS
St. Louis, Missouri Associate Professor
Northwestern University Feinberg School of Medicine
Shanda H. Blackmon, MD, MPH Director, Robotic and Minimally Invasive
Assistant Professor Thoracic Surgery
Weill Cornell Medical College Department of Surgery
New York, New York Division of Thoracic Surgery
Assistant Professor Northwestern Memorial Hospital
The Methodist Hospital Research Institute Chicago, Illinois
Assistant Professor
The University of Texas MD Anderson Tom R. DeMeester, MD
Cancer Center Emeritus Professor
Houston, Texas Department of Surgery
University of Southern California
Philip W. Carrott, Jr., MD, MSc Los Angeles, California
Thoraco-esophageal Fellow
Department of Surgery Attila Dubecz, MD
Virginia Mason Medical Center Assistant Professor
Seattle, Washington Department of Surgery
Paracelsus Medical University Nuremberg
Haiquan Chen, MD Nuremberg, Germany
Professor
Department of Thoracic Surgery Christy M. Dunst, MD
Fudan University Shanghai Cancer Center Esophageal Surgeon
Shanghai, China The Oregon Clinic
Portland, Oregon
vii

viii Contributors
André Duranceau, MD Blair A. Jobe, MD, FACS

Professor of Surgery Professor of Surgery
Department of Surgery Institute for the Treatment of Esophageal & Thoracic Disease
Division of Thoracic Surgery Department of Surgery
Centre Hospitalier de L’Université de Montreal The Western Pennsylvania Hospital
Montreal, Quebec, Canada West Penn Allegheny Health System
Pittsburgh, Pennsylvania
Felix G. Fernandez, MD
Assistant Professor of Surgery Andrew S. Kastenmeier, MD
Division of Cardiothoracic Surgery Minimally Invasive and Foregut Surgery Fellow
Emory University Hospital Legacy Health System
Atlanta, Georgia Portland, Oregon
Hiran C. Fernando, MD Michael Kent, MD, FACS

Professor of Surgery Instructor in Surgery
Chief, Thoracic Surgery Division of Thoracic Surgery and Interventional
Boston University School of Medicine Pulmonology
Boston, Massachusetts Beth Israel Deaconess Medical Center
Harvard Medical School
Peter F. Ferson, MD Boston, Massachusetts
Professor of Cardiothoracic Surgery
Charles Gray Watson Professor of Surgical Education Kevin P. Lally, MD, MS
University of Pittsburgh School of Medicine Chairman, Department of Pediatric Surgery
Pittsburgh, Pennsylvania A.G. McNeese, Chair in Pediatric Surgery
Richard Andrassy Distinguished Professor
Seth D. Force, MD The University of Texas Medical School at Houston
Associate Professor of Surgery Houston, Texas
Division of Cardiothoracic Surgery
Emory University Hospital Rodney J. Landreneau, MD
Atlanta, Georgia Medical Director, Ochsner Cancer Institute
Vice-chairman of Surgery - Ochsner Medical Center
Richard F. Heitmiller, MD Clinical Professor of Surgery
J.M.T. Finney Chairman of Surgery LSU Medical Center
Union Memorial Hospital New Orleans, Louisiana
Associate Professor Senior Lecturer, University of Queensland - School of
The Johns Hopkins University School of Medicine Medicine
Department of Surgery Brisbane, Australia
Baltimore, Maryland
Simon Law, MS, MA (Cantab), MBBChir, FRCSEd,
Wayne L. Hofstetter, MD FCSHK, FHKAM, FACS
Associate Professor Professor of Surgery
Department of Thoracic and CV Surgery Chief, Division of Esophageal and Upper
Director of Esophageal Surgery Gastrointestinal Surgery
The University of Texas MD Anderson Cancer Center The University of Hong Kong
Houston, Texas Queen Mary Hospital
Hong Kong, China
Toshitaka Hoppo, MD, PhD
Research Assistant Professor Ryan M. Levy, MD
Institute for the Treatment of Esophageal & Thoracic Disease Assistant Professor of Surgery
Department of Surgery Division of Thoracic and Foregut Surgery
The Western Pennsylvania Hospital Department of Cardiothoracic Surgery
West Penn Allegheny Health System University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania Pittsburgh, Pennsylvania
Haichuan Hu, MD Virginia R. Litle, MD

Postgraduate Associate Professor
Department of Thoracic Surgery Department of Surgery
Fudan University Shanghai Cancer Center Division of Thoracic Surgery
Shanghai, China Boston University School of Medicine

Contributors ix
Alex G. Little, MD Bryan F. Meyers, MD, MPH

Clinical Professor of Surgery Patrick and Joy Williamson Professor of Surgery
Department of Surgery Division of Cardiothoracic Surgery
Division of Cardiothoracic Surgery Washington University School of Medicine
University of Arizona Saint Louis, Missouri
Tucson, Arizona
Sumeet K. Mittal, MD, FACS
Donald E. Low, MD, FACS, FRCS(C) Associate Professor of Surgery
Clinical Assistant Professor of Surgery Department of Surgery
University of Washington School of Medicine Creighton University School of Medicine
Head, Thoracic Oncology and Thoracic Surgery Director, Esophageal Center
Department of Surgery Creighton University Medical Center
Virginia Mason Medical Center Omaha, Nebraska
Seattle, Washington
Darroch W.O. Moores, MD, FACS
James D. Luketich, MD Clinical Associate Professor of Surgery
Henry T. Bahnson Professor of Cardiothoracic Surgery Chief of Thoracic Surgery, St. Peter’s Hospital
Chairman, Department of Cardiothoracic Surgery Albany Thoracic and Esophageal Surgeons
University of Pittsburgh School of Medicine Albany Medical Center
Pittsburgh, Pennsylvania Albany, New York
Michael A. Maddaus, MD Christopher R. Morse, MD

Professor and Vice Chair of Education Instructor in Surgery
Chief, Division of Thoracic and Foregut Surgery Division of Thoracic Surgery
Program Director, General Surgery Massachusetts General Hospital
Garamella Lynch Jensen Chair in Thoracic Harvard Medical School
Cardiovascular Surgery Boston, Massachusetts
Co-Director, Minimally Invasive Surgery Center
University of Minnesota Sudish C. Murthy, MD, PhD
Minneapolis, Minnesota Surgical Director, Center of Major Airway Disease
Staff, Thoracic and Cardiovascular Surgery
Mary S. Maish, MD, MPH Cleveland Clinic
Chief, Thoracic and Foregut Surgery Cleveland, Ohio
Washington Hospital Healthcare System
Fremont, California Christopher J. Mutrie, MD
Fellow, Division of Thoracic Surgery
Ian Makey, MD Massachusetts General Hospital
Fellow, Division of Thoracic Surgery and Interventional Harvard Medical School
Pulmonology Boston, Massachusetts
Beth Israel Deaconess Medical Center
Harvard Medical School Katie S. Nason, MD, MPH
Boston, Massachusetts Assistant Professor
Department of Cardiothoracic Surgery
Konstantinos I. Makris, MD Division of Thoracic and Foregut Surgery
Minimally Invasive Surgery Fellow University of Pittsburgh School of Medicine
Legacy Health System Pittsburgh, Pennsylvania
Portland, Oregon
Ninh T. Nguyen, MD, FACS
Douglas J. Mathisen, MD Professor of Surgery and Chief
Chief, Thoracic Surgery Division of Gastrointestinal Surgery
Massachusetts General Hospital University of California
Hermes C. Grillo Professor of Thoracic Surgery Irvine Medical Center
Department of Surgery Orange, California
Harvard Medical School
Boston, Massachusetts F. Griffith Pearson, MD
Professor Emeritus
W. Scott Melvin, MD University of Toronto
Professor of Surgery Toronto, Ontario, Canada
Chief and Professor of Surgery
Division of General and Gastrointestinal Surgery
The Ohio State University
Columbus, Ohio

x Contributors
Arjun Pennathur, MD, FACS Lynne A. Skaryak, MD

Assistant Professor Thoracic Surgery
Department of Cardiothoracic Surgery and Department of Department of Surgery
Critical Care Medicine Union Memorial Hospital
University of Pittsburgh School of Medicine Assistant Professor
University of Pittsburgh Medical Center The Johns Hopkins University School of Medicine
Pittsburgh, Pennsylvania Baltimore, Maryland
Kyle A. Perry, MD Brian R. Smith, MD, FACS

Assistant Professor of Surgery Assistant Professor of Surgery & Associate Residency
Division of General and Gastrointestinal Surgery Program Director
The Ohio State University Division of Gastrointestinal Surgery
Columbus, Ohio University of California
Irvine Medical Center
Christian G. Peyre, MD Orange, California
Assistant Professor of Surgery Chief, General Surgery and Resident Director
Division of Thoracic and Foregut Surgery VA Long Beach Healthcare System
University of Rochester Long Beach, California
Rochester, New York
Hubert J. Stein, MD, FACS
Dennis J. Rassias, MD, FACS Professor of Surgery
Thoracic Surgeon Chairman, Department of Surgery
Albany Thoracic and Esophageal Surgeons Paracelsus Medical University Nuremberg
St. Peter’s Hospital Nuremberg, Germany
Albany Medical Center
Albany, New York Lee L. Swanstrom, MD
Clinical Professor of Surgery
Thomas W. Rice, MD Oregon Health Sciences University
Professor of Surgery Portland, Oregon
Cleveland Clinic Lerner College of Medicine Professor of Surgery
Case Western Reserve University University of Strasbourg
The Daniel and Karen Lee Endowed Chair Strasbourg, France
in Thoracic Surgery
Head of the Section of General Thoracic Surgery Thomas J. Watson, MD, FACS
Department of Thoracic and Cardiovascular Surgery Associate Professor of Surgery
Heart and Vascular Institute Chief of Thoracic Surgery
Cleveland Clinic University of Rochester School of Medicine
Cleveland, Ohio and Dentistry
Rochester, New York
Matthew J. Schuchert, MD
Assistant Professor Jie Zhang, MD
Division of Thoracic and Foregut Surgery Associate Professor
Department of Cardiothoracic Surgery Department of Thoracic Surgery
University of Pittsburgh School of Medicine Fudan University Shanghai Cancer Center
Pittsburgh, Pennsylvania Shanghai, China
Rachit D. Shah, MD
Assistant Professor of Surgery
Division of Cardiothoracic Surgery
Virginia Commonwealth University School of Medicine
Richmond, Virginia

Series Preface
This series of mini-atlases is an outgrowth of Mastery of Surgery. As the series editor,

I have been involved with Mastery of Surgery since the third edition, when I joined
two greats of American surgery, Lloyd Nyhus and Robert Baker, who were the editors
at that time. Surgical atlases were common in those days, and Mastery of Surgery was
one of several quality atlases which existed then; of particular quality were those by
Dr. John Madden of New York, Dr. Robert Zollinger of Ohio State, and two others, with
which the reader may be less familiar. The first was by Professor Pietro Valdoni, Profes-
sor of Surgery at the University of Rome, who ran 10 operating rooms simultaneously,
and as the Italians like to point out to me, a physician to three popes. One famous
surgeon said to me, what can you say about Professor Valdoni? “Professor Valdoni said
to three popes, ‘take a deep breath,’ and they each took a deep breath.” This superb
atlas, which is not well known, was translated from the Italian by my partner when I
was on the staff at Mass General Hospital, Dr. George Nardi. The second was a superb
atlas by Dr. Robert Ritchie Linton, an early vascular surgeon whose atlas was of very
high quality.
Atlases, however, fell out of style, and in the fourth and fifth editions of Mastery
of Surgery, we added more chapters that were “textbooky” types of chapters to increase
access to the growing knowledge base of surgery. In discussing with Brian Brown and
others at Lippincott Williams & Wilkins, as well as with some of the surgeons who
subsequently became editors of books in this present series, it seemed that we could
build on our experience with Mastery of Surgery by creating smaller, high-quality
atlases, each focusing on the key operations of a sharply circumscribed anatomical area.
This we have accomplished because of the incredible work of the editors who were
chosen for their demonstrated mastery in their fields.
Why the return of the atlas? Is it possible that the knowledge base is somewhat
more extensive with more variations on the various types of procedures—that as we
learn more about the biochemistry, physiology, genetics, and pathophysiology in these
different areas, there have come to be variations on the types of procedures that we do
on patients in these areas? This increase in the knowledge base has occurred simultane-
ously at a time when the amount of time available for training physicians—and espe-
cially surgeons—has been steadily declining. Although I understand the hypothesis that
brought the 80-hour work week upon us, which limits the time that we have for instruc-
tion (though I do believe that it is well-intentioned), I still ask the question: Is the
patient better served by a somewhat fatigued resident who has been at the operation
and knows what the surgeon is worried about, or a comparatively fresh resident who
has never seen the patient before?
I don’t know, but I tend to come down on the side that familiarity with the patient
is perhaps more important. And what about the errors of hand-off, which seem to be more
of an intrinsic issue with the hand-off itself (which we are not able to really remedy
entirely), rather than poor intentions?
This series of mini-atlases is an attempt to help fill the void created by inadequate
time for training. We are indebted to the individual editors who have taken on this
responsibility and to the authors who have volunteered to share their knowledge and
experience in putting together what we hope will be a superb series. We have chosen
surgeons who are inspired by their experience of teaching residents and medical stu-
dents (a high calling indeed), a quality matched only by their devotion and superb care
they have given to thousands of patients. It is an honor to serve as the series editor for
xi

xii Series Preface
this outstanding group of mini-atlases, which we hope will convey the experiences of
an excellent group of editors and authors to the benefit of students, residents, and their
future patients in an era in which time for education seems to be increasingly limited.
Putting a book together—especially a series of books—is not easy, and I wish to
acknowledge the staff at Lippincott Williams & Wilkins, including Brian Brown, Brendan
Huffman, and many others. I would also like to thank my personal staff in the office,
in particular, Edie Burbank-Schmitt, Ingrid Johnson, Abigail Smith, and Jere Cooper.
None of this would have been possible without them.
Josef E. Fischer, MD, FACS


Preface
“Whoever saves a single life, it is considered as if one saved the entire world.”
—from the Talmud
As part of the growing and well-known series, Master Techniques in Surgery, edited by
Dr. Fischer, this book focuses on esophageal surgery. These specialty volumes comple-
ment the well-known Mastery of Surgery book, also edited by Dr. Fischer. Although
there are many standard textbooks in general surgery, thoracic surgery, and some on
esophageal surgery, this book is unique in that it focuses on the technical aspects of
esophageal surgery. Esophageal surgery is complex, and this textbook, which is entirely
devoted to surgery of the esophagus, should serve as a useful complement to some of
the existing comprehensive textbooks in esophageal, general, and thoracic surgery, as
well as serve as link between a classical textbook and an atlas.
The contributions to the text are led by world-renowned surgeons with expertise
in complex esophageal surgery. This book is intended for anyone interested in esopha-
geal diseases—including medical students, gastroenterologists, general and thoracic
surgery residents and other trainees, faculty, and practicing surgeons. The textbook
covers the spectrum of surgical techniques to treat esophageal diseases, and is organized
in six sections, each covering a specific area of esophageal surgery.
Gastroesophageal reflux (GERD) is a very common condition in Western countries,
and surgeons are referred many patients who have failed medical therapy or have
developed complications related to reflux. Section 1 is devoted to the surgical treatment
of GERD. Surgical treatment of paraesophageal hernia is also discussed in this section.
There are a total of 13 chapters in this section by leading experts in the field, covering
a wide gamut of surgical approaches to GERD from commonly used procedures such
as the laparoscopic Nissen fundoplication to the Hill Repair to complex transthoracic
approaches such as the Belsey fundoplication. In addition, complex esophageal proce-
dures—the management of giant paraesophageal hernia and reoperative antireflux sur-
gery—are described in detail in this section. Further, an endoscopic approach to
fundoplication is also described. There is now increasing evidence that obesity corre-
lates with GERD, and therefore, we have included a chapter on gastric bypass in this
section as well.
In Section 2, the surgical treatment of esophageal motility disorders, such as acha-
lasia and esophageal diverticula, are addressed. Included in this section are chapters
describing both the open and the minimally invasive approaches to achalasia and repair
of cricopharyngeal (Zenker’s) and epiphrenic diverticula.
The incidence of esophageal cancer is increasing at an alarming rate, primarily
because of an increasing incidence of adenocarcinoma particularly in the Western coun-
tries. Surgical resection is an important component of treatment; however, it is a complex
operation. In Section 3, the techniques and approaches for esophageal resection are
addressed, and this includes a total of nine chapters describing the open approaches as
well as the minimally invasive approach to esophageal resection. Open and minimally
invasive resection of benign esophageal tumors are covered in Section 4.
In Section 5, endoscopic ablative therapies, such as radiofrequency ablation and
mucosal resection, for the treatment of Barrett’s esophagus are addressed. While
esophagectomy is the standard treatment for esophageal cancer, less invasive therapies
may be applicable in the high-risk patient with Barrett’s esophagus and high-grade
xiii

xiv Preface
dysplasia, as well as in very highly selected patients with intramucosal adenocarci-

noma. Finally, in Section 6, the techniques for the treatment of other conditions, such
as esophageal perforation and diaphragmatic hernia, and the techniques of stenting and
dilation are addressed.
The readers should find this text very useful in updating their knowledge, and it
will serve as a practical guide in esophageal surgery. We would like to thank the pub-
lisher, and in particular Brendan Huffman, Keith Donnellan, and Aptara project manager
Abhishan Sharma for their hard work and persistence in getting this work completed.
We would also like to thank Shannon Wyszomierski for the excellent editorial assistance
she provided in completing this work.
We hope readers find this book to be a very interesting and a valuable reference in
esophageal surgery.
James D. Luketich, MD
Rodney J. Landreneau, MD
Arjun Pennathur, MD

Contents
Acknowledgments v
Contributors vii
Series Preface xi
Preface xiii
Part I: S
urgical Treatment of
Gastroesophageal Reflux
and Paraesophageal Hernia
1 Laparoscopic Nissen Fundoplication 1
Sumeet K. Mittal
2 Laparoscopic Partial Fundoplications 15

Andrew S. Kastenmeier and Lee L. Swanstrom
3 Fundoplication: Open Transabdominal Approach 29

Thomas W. Rice
4 Transthoracic Nissen Fundoplication 43

Alex G. Little and Jonathan Daniel
5 Belsey Mark IV Partial Fundoplication 51

Arjun Pennathur and Tom R. DeMeester
6 Laparoscopic Collis Gastroplasty 65

Mara B. Antonoff, Rafael S. Andrade, and Michael A. Maddaus
7 Open Collis Gastroplasty 75

Ankit Bharat and Bryan F. Meyers
8 Reoperative Antireflux Surgery 85

Omar Awais, Arjun Pennathur, and James D. Luketich
9 Gastric Bypass 97
Brian R. Smith and Ninh T. Nguyen
10 Endoscopic Antireflux Repair—EsophyX 109

Kyle A. Perry and W. Scott Melvin
11 Laparoscopic Paraesophageal Hernia Repair 121

Katie S. Nason and James D. Luketich
xv

xvi Contents
12 Open Paraesophageal Hernia: Transthoracic Approach 137

Gail E. Darling and F. Griffith Pearson
13 Open Paraesophageal Hernia and Hill Repair: Open Abdominal

Approach 147
Philip W. Carrott, Jr. and Donald E. Low
Part II: S
urgical Treatment of Esophageal
Motility Disorders—Achalasia and
Esophageal Diverticula
14 Laparoscopic Heller Myotomy and Fundoplication for Achalasia 161
Rachit D. Shah, Toshitaka Hoppo, and Blair A. Jobe
15 Transthoracic Approach for Achalasia 173

Richard F. Heitmiller and Lynne A. Skaryak
16 Open Esophageal Myotomy and Resection of Epiphrenic Diverticula 183

André Duranceau
17 Minimally Invasive Approach to Resection of

Thoracic and Epiphrenic Diverticula 193
Virginia R. Litle, James D. Luketich, and Hiran C. Fernando
18 Open Cricopharyngeal Myotomy and Correction of Zenker’s

Diverticulum 203
André Duranceau
19 Transoral Repair of Zenker’s Diverticula 211

Christopher R. Morse and Peter F. Ferson
Part III: T
echniques and Approaches for
Esophageal Resection
20 Transhiatal Esophagectomy 217
Darroch W.O. Moores and Dennis J. Rassias
21 Ivor Lewis Esophagectomy 235

Christopher J. Mutrie, Christopher R. Morse, and Douglas J. Mathisen
22 En Bloc Esophagectomy 251

Simon Law
23 Left Thoracoabdominal Exposure for Esophagectomy and Complex

Hiatus Pathology 263
Sudish C. Murthy
24 Minimally Invasive Ivor Lewis Esophagectomy 273

Rachit D. Shah, Ryan M. Levy, and James D. Luketich
25 Esophagectomy with Substernal Pull-up 289

Jie Zhang, Haichuan Hu, and Haiquan Chen

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Contents xvii
26 Merendino Jejunal Interposition 297

Attila Dubecz and Hubert J. Stein
27 Long Segment Reconstruction with Jejunum 307

Shanda H. Blackmon and Wayne L. Hofstetter
28 Colon Interposition 317

Thomas J. Watson and Christian G. Peyre
Part IV: R
esection of Benign
Esophageal Tumors
29 Open Resection of Esophageal Leiomyoma and GIST 329
Alberto de Hoyos and Malcolm DeCamp
30 Resection of GIST and Leiomyoma: Thoracoscopic Approach 343

Ian Makey, Rodney J. Landreneau, and Michael Kent
Part V: Endoscopic Ablative

Therapies and Resection
31 Esophageal Radiofrequency Ablation for the Treatment of Barrett’s
Esophagus with and without Dysplasia 353
Felix G. Fernandez and Seth D. Force
32 Photodynamic Therapy, Lasers, and Cryotherapy for Esophageal

Neoplasia 363
Virginia R. Litle and Mary S. Maish
33 Endoscopic Mucosal Resection 373

Toshitaka Hoppo and Blair A. Jobe
Part VI: M
iscellaneous Esophageal
Procedures
34 Esophageal Stents 383
Matthew J. Schuchert
35 Bougie and Balloon Dilation of Esophageal Strictures—Malignant and

Benign 401
Konstantinos I. Makris and Christy M. Dunst
36 Esophageal Perforation 413

Christian G. Peyre and Thomas J. Watson
37 Congenital Diaphragmatic Hernia Repair: Open and

Thoracoscopic 425
Kevin P. Lally
Index 433
Part I
Surgical Treatment
of Gastroesophageal
Reflux and
Paraesophageal
Hernia
1 Laparoscopic Nissen
Fundoplication
Sumeet K. Mittal
Surgical fundoplication is the gold standard for the treatment of gastroesophageal reflux
disease (GERD). Incompetent lower esophageal sphincter (LES) complex and hiatus her-
nia (HH) play important roles in the pathophysiology of GERD. Although first described
nearly 70 years ago, antireflux procedures gained popularity with the recognition of the
pathophysiology of GERD and the ability to objectively document distal esophageal acid
exposure (24-hour pH). Minimally invasive techniques were adapted in early 1990’s to
allow for laparoscopic fundoplication and this has led to an exponential increase in the
number of antireflux procedures. A complete 360-degree fundoplication (Nissen fundop-
lication) is the most common antireflux procedure performed. The goal of the procedure
is to create a tension-free infradiaphragmatic fundoplication around the distal esopha-
gus. This chapter describes indications for Nissen fundoplication and the technique of
laparoscopic Nissen fundoplication (LNF).
Indications/Contraindications
Chronic or recurrent GERD with breakthrough symptoms on medical therapy is the most
common indication for LNF. LNF should only be considered in patients with docu-
mented evidence of pathologic GERD.
Objective evidence of GERD is given as follows:
n Reflux esophagitis–endoscopic/pathologic
n Peptic stricture
n Barrett’s esophagus (BE)
n Abnormal 24-hour pH score
n Abnormal impedance pH score
In patients with typical symptoms like heartburn and regurgitation, especially with
good relief with medical therapy, at least one type of objective evidence of reflux should
be sought before proceeding with surgery. In patients with atypical GERD symptoms, a
minimum of two types of objective evidence of GERD should be sought, in addition to
ruling out other causes, before LNF is offered to the patient. The best indicator of suc-
cess of LNF is a good response to medical therapy.
LWBK1254-ch01_p01-14.indd 1 19/02/14 6:53 AM

2 Part I Surgical Treatment of Gastroesophageal Reflux and Paraesophageal Hernia
Indications for LNF are as follows:

n Breakthrough symptoms of heartburn and regurgitation on maximal medical therapy.
n Respiratory symptoms attributable to pathologic GERD.
n Laryngopharyngeal reflux symptoms with documented pathologic GERD.
n Volume regurgitation associated with nocturnal symptoms.
n Drug-dependent patients with documented abnormal 24-hour pH score especially
with a mechanically defective LES.
n Evidence of esophageal damage: Stricture, reflux esophagitis, or BE.
LNF is contraindicated in patients with severely impaired esophageal motility or

scleroderma. In patients with severely delayed gastric emptying and a competent LES/
no HH, a gastric drainage procedure rather than LNF should be considered. In patients
with both delayed gastric emptying and pathologic GERD, an LNF with distal gastrectomy
and Roux-en-Y (RNY) reconstruction should be planned. The presence of high-grade
dysplasia (HGD) or esophageal adenocarcinoma (EAC) is an absolute contraindication for
LNF. In patients with a history of HGD and/or superficial adenocarcinoma that has been
documented to regress with endoscopic ablative or resection therapy, LNF can be care-
fully considered. There is uncertain evidence that LNF significantly decreases the pro-
gression of BE to EAC, and LNF should not be done for that reason alone. Patients with
undilatable peptic stricture or short esophagus are better served with esophageal resection
or Collis gastroplasty with fundoplication respectively, rather than LNF.
Preoperative Planning
In addition to general preoperative evaluation to assess patient fitness to undergo sur-
gery, a detailed assessment should be done. History of symptoms and response to med-
ical therapy should be carefully documented. It is important to remember that
patient-perceived symptoms can be due to different etiologies. For example, it is com-
mon for a patient with achalasia to be treated medically for GERD prior to correct
diagnosis. In such situations though, delay in diagnosis is erroneous, but mere institu-
tion of medical therapy would not be harmful, while proceeding with fundoplication
would be disastrous. Hence it is imperative that the operating surgeon plays an active
role in establishing diagnosis and completely understanding individual patient patho-
physiology. As mentioned previously, surgery should only be undertaken after the
objective documentation of GERD in an appropriate clinical setting.
n Esophagogastroduodenoscopy (EGD): An upper endoscopy should always be per-
formed prior to surgical intervention. This allows for direct assessment of esophageal
mucosa and cardia competence/HH and histologic diagnosis of BE (if present).
n Contrast study: An upright and supine barium esophagram delineates the size and type
of HH. We routinely use both liquid and solid material to help assess esophageal motil-
ity. The 13-mm tablet helps reveal subtle strictures that might be missed on endoscopy.
n Esophageal manometry: Esophageal motility helps determine the type of fundoplica-
tion that should be performed. Though there is no evidence to support a tailored
fundoplication based on esophageal motility, most surgeons in the United States
proceed with partial fundoplication in patients with ineffective esophageal motility.
Introduction of high-resolution manometry holds the promise to better delineate
motility disorders and aid the surgical decision process.
n 24-hour pH: Prolonged distal esophageal acid exposure is the gold standard for objec-
tive assessment for GERD. Impedance pH is used to document nonacidic reflux and,
in my opinion, is of real use only in very select patients. One must note that distal
esophageal pH changes are a marker of reflux, not the disease itself (which is reflux
of gastric contents). Dual pH monitoring is used to document proximal esophageal
acid exposure in patients with extraesophageal symptoms.
n Wireless (Bravo) 48-hour pH: Recently, wireless pH monitoring using a radiotele-
metric capsule, attached to the wall of the esophagus (Bravo pH monitoring system;
LWBK1254-ch01_p01-14.indd 2 19/02/14 6:53 AM

Chapter 1 Laparoscopic Nissen Fundoplication 3
Medtronic, Minneapolis, MN), has become widespread. The Bravo capsule allows
Part I: Surgical Treatment of Gastroesophageal

prolonged monitoring and is better tolerated by patients than pH probes placed on
a transnasal catheter. Although the Bravo probe does not assess impedance pH (non-
Reflux and Paraesophageal Hernia

acidic reflux), it promotes a more typical diet and daily activities during the monitor-
ing period, and is a useful tool for assessing esophageal acid exposure.
n Gastric emptying study: A nuclear medicine gastric emptying study should be done
in patients with significant bloating and also in patients with pathologic GERD if
they appear to have a competent LES and no HH. These results should be interpreted
cautiously as there may be poor symptom correlation.
Surgery
The goal of surgery is to create a tension-free infradiaphragmatic fundoplication over
the distal esophagus. This recreates a 2 to 3 cm intra-abdominal length of the esophagus
and places the high-pressure gastric fundus around the gastroesophageal junction (GEJ),
restoring a competent LES complex.
Patients with documented delayed gastric emptying are asked to be on a clear liq-
uid diet for 2 to 3 days before surgery. Antiplatelet agents and anticoagulants are with-
held appropriately. A single dose of a first generation cephalosporin (cefazolin, 1 g) is
given within 30 minutes of incision. Deep vein thrombosis (DVT) prophylaxis is admin-
istered with 5000 U subcutaneous heparin and lower extremity sequential compressive
devices. Surgery is done under general anesthesia and specific precautions should be paid
to prevent aspiration during induction. We routinely give ondansetron iv 30 minutes
before finishing the case. In patients with history of postoperative nausea, we have low
threshold to use propofol drip and give dexamethasone iv at induction.
Room Setup
Use of dedicated minimally invasive operating room suite is helpful. We use three over-
head hanging monitors near the head of the bed. The surgeon stands between the legs
of the patient, first assistant to his/her right (left side of the patient), and the camera
holder on the left (right side of the patient). After the start of the case, the instrument
Mayo stand is placed from the left of the patient over the chest. The instrument table is
on the left near the foot-end. The instrument cords are over the right shoulder of the
patient. In addition, endoscopic equipment should be available for assessment (Fig. 1.1).
Positioning
The patient is positioned in an inverted-Y (modified lithotomy) position. An operating
bed with a great deal of vertical range and degree of incline capacity should be used.
We use the AlphaMaxx bed (Maquet Getinge AB, Rastatt, Germany). Legs are on split
extensions with footboards. Both arms are tucked in; if there is a need to extend one
or both arms, the arm boards should be positioned to prevent hyperextension at the
shoulders (one must keep in mind that the patient may slide downward when the
reverse Trendelenburg position is used during the case). The patient is prepped, draped
from mid-chest down to the pubis symphysis (Fig. 1.2). If there is a high degree of
suspicion for short esophagus, the left chest is also prepped in the field as we use a left
thoracoscopic Collis gastroplasty.
Peritoneal Access
Peritoneal access is obtained as per surgeon’s preference. We use a Veress step needle to
obtain pneumoperitoneum through a 5-mm skin incision made just to the left of midline,
a third of the way up between the umbilicus and the xiphoid. An Optiview 5-mm can-
nula (Endopath Ethicon Endosurgery, Cincinnati, OH) is inserted using a zero-degree
5-mm laparoscope. Alternatively, an open technique using a Hasson cannula can be
used. A pneumoperitoneum of 12 to 15 mm Hg is achieved. After initial diagnostic
LWBK1254-ch01_p01-14.indd 3 19/02/14 6:53 AM

Figure 1.1 This shows the room

set up. Scrub table (ST) comes
across the patient’s chest from
the left side. Monitor (A) is over
the head of the bed; monitor (B)
and (C) on the left and right of the
patient near the head of the bed
are adjusted for use by the cam-
era holder and the first assistant,
respectively. The endoscopy
system (ES) is available to be
placed from the left near the
anesthesiologist. Patient is posi-
tioned in inverted-Y position.
laparoscopy, the table is slowly positioned in a steep reverse Trendelenburg position. The
patient’s blood pressure should be closely monitored as increased intra-abdominal pres-
sure and positioning significantly decrease cardiac venous return and can affect homody-
namic status. In such a situation, pneumoperitoneum is evacuated and the table is flattened.
Resuming abdominal insufflation and repositioning the table more slowly after a fluid
bolus is usually uneventful. Further, cannulae are inserted under laparoscopic guidance.
Remaining Cannula and Liver Retractor

A 5-mm cannula is placed one to two fingerbreadth below the costal margin in the left
anterior axillary line; this is for the assistant’s instruments. A 5-mm incision is made
Figure 1.2 Surgical field extends

from above the xiphoid to the
pubic symphysis and from the
mid axillary line on each side.
The surgeon stands between the
patient’s legs.
LWBK1254-ch01_p01-14.indd 4 19/02/14 6:53 AM

Figure 1.3 Trocar placement sites.

The liver retractor can be seen
secured on the right of the patient.

The camera port (C) is above and to
the left of umbilicus. The liver retrac-
tor (LR) is placed just to the left and
below the xiphoid. The surgeons
working ports (R-right hand) and
(L-left hand) are in left midclavicle
line and just to the right of the epi-
gastrium, respectively. An assistant
(A) port is in the left anterior axillary
line one fingerbreadth below the
costal margin. The scrub table is
coming over the left side of the
patient.
and the fascial opening created with a trocar just to the left of the xiphoid. Through
this, a Nathanson liver retractor is inserted and positioned to retract the left lobe of
liver superiorly. The retractor is attached to a table-mounted system using the Iron Intern
(Automated Medical Products, Edison, NJ). Another 5-mm cannula is placed (using the
surgeon’s left hand) 4 cm to the right of midline between the camera port and the
xiphoid. It is directed toward the hiatus, and may traverse the falciform ligament. Finally
we use a 12-mm cannula in the left upper quadrant below the costal cartilage in the
midclavicular line. Using a 12-mm cannula allows the use of needles without “skiing,”
though some surgeons use all 5-mm trocars (Fig. 1.3). Different liver retractors are avail-
able and can be used depending on surgeon preference and familiarity. Many different
cannula placements have been described and the surgeon should use the one they feel
most comfortable with.
Procedure
The steps of the Nissen fundoplication include: (1) Hiatal dissection; (2) Division of the
short gastrics; (3) Esophageal mobilization; (4) Crura closure; and (5) 360-degree complete
fundoplication. In the following descriptions, the directions are mentioned as they
pertain to the patient.
Dissection of the Hiatus

Using an atraumatic grasper, the assistant retracts the gastric fat pad inferiorly and to
the left stretching the gastrohepatic ligament. The hepatic branch of the anterior vagus
nerve can be identified traversing from the stomach to the liver. The dissection starts
with hook cautery above the nerves, preserving them. The nerves can be sacrificed to
increase exposure, though routine division is not required. In one out of five patients,
an aberrant left hepatic artery is present in the gastrohepatic ligament alongside the
vagal branches. If less than 4 mm in diameter, the vessel may be divided between clips
or with a harmonic scalpel. However, larger vessels should be preserved. It is our
policy to routinely preserve the hepatic branches of the vagus nerve and the left aber-
rant hepatic artery (if present). The gastrohepatic ligament is divided up to the arch of
the crus (Fig. 1.4).
The hook cautery is used to incise the peritoneum and the phrenoesophageal mem-
brane at the right limb of the crus. It is of utmost importance to identify the correct
plane between the right limb of the crus and the esophagus. The closed tip of grasping
LWBK1254-ch01_p01-14.indd 5 19/02/14 6:53 AM

Figure 1.4 The gastrohepatic liga-

ment has been divided above the
aberrant left hepatic artery, and
the caudate lobe of the liver can
be seen.
forceps in the surgeon’s left hand is placed in this defect to retract the crus to the right
of the patient. The right hand of the surgeon bluntly dissects the crus from top to bot-
tom (Fig. 1.5). If one is in the correct plane, this dissection proceeds rapidly and with
no bleeding. The dissection is carried down to the dissection of the crus posteriorly
and along the arch on to the left crus anteriorly. Retraction on the gastric fat pad by the
assistant is adjusted to provide maximal tension for exposure as needed. Extreme care
is taken in this dissection as if to dissect the crus away from the esophagus and not
vice versa. Staying close to the crus will also avoid injury to the vagi. With experience,
this can proceed rather rapidly.
Dissection is carried along the arch of the crus on to the left side. Occasionally,
starting a new plane at the topmost part of the left limb of the crus is needed for this.
The gastric fat pad is retracted by the surgeon’s left hand instrument and dissected off
the crus to enter the mediastinum. The anterior vagus nerve is identified and preserved.
Dissection is carried along the left limb of the crus to connect with the previous dis-
section. The posterior vagus nerve is identified.
Figure 1.5 The right crus dissec-

tion is started by dividing the
peritoneum and phrenoesopha-
geal ligament near the arch.
LWBK1254-ch01_p01-14.indd 6 19/02/14 6:53 AM

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.
Division of short gastric vessels can be done prior to dissection along the left limb
of the crus. This exposes the left limb of the crus, allowing for better visualization, and
is especially beneficial in obese patients.
Division of Short Gastric Vessels

The next step is adequate mobilization of the gastric fundus in preparation for a tension-
free fundoplication (Fig. 1.6). This is done by dividing the short gastric vessels close to
the greater curvature for a distance of 12 to 15 cm from the angle of His. After measur-
ing the distance to identify the most distal aspect of dissection, a blunt atraumatic
grasper in the left hand of the surgeon is used to grasp the stomach 1 to 2 cm away
from the greater curvature. An atraumatic grasper in the assistant’s hand retracts the
omentum opposite to suspend and expose the greater curvature. A harmonic scalpel is
used to divide 1 cm away from the gastric edge to enter the lesser sac. Through this
opening, the instrument controlled by the left hand of the surgeon then grasps the back
of the stomach lifting and rotating it as short gastric vessels are divided in a cephalad
fashion. The assistant’s instrument is vital and is repositioned as needed for optimal
visualization and traction. It is important to lift the stomach anteriorly with the left
hand. Placing the patient in a steep reverse Trendelenburg position greatly improves
exposure with gravity retracting the often bulky omentum.
As the top of the fundus is reached, the assistant retracts the posterior gastric wall
toward the patient’s right lower quadrant while the surgeon retracts the anterior fundus
using his or her left hand. This stretches the highest short gastric vessels for division.
If the fundus is closely adhered to the spleen, the electrocautery is used to incise the
peritoneum between the fundus and the spleen. This increases the distance between
the fundus and the spleen to safely proceed with the harmonic scalpel. Posterior short
gastric vessels (also called pancreaticogastric vessels) are also divided. Complete mobi-
lization of the fundus is performed exposing the left limb of the crus. Hiatus dissection
is now completed, if it was not done earlier.
Creating a Retroesophageal Window

With the assistant retracting the esophagus cephalad, a retroesophageal window is made
just anterior to the decussation of the crus (Fig. 1.7). A 15-cm one-fourth inch Penrose
drain is placed in the window and the two ends are secured using an endoloop. Care is
taken to identify and include both vagi along with the esophagus in the Penrose drain.
This is used as a handle for further retraction of the esophagus. The window is enlarged
in cephalocaudal direction bluntly.
LWBK1254-ch01_p01-14.indd 7 19/02/14 6:53 AM

Figure 1.7 A window has been made

behind the esophagus and posterior
vagus nerve.
Some authors do not use a Penrose drain; however, we believe this is especially
useful when extensive mediastinal dissection is required as it allows for atraumatic
retraction of the esophagus.
Esophageal Mobilization
Circumferential mobilization of the esophagus is carried in to the mediastinum. This
can be done with a “chopsticks” motion using two blunt dissectors; however, perforat-
ing esophageal arteries from the aorta may need to be divided with harmonic scalpel
or between clips. The assistant provides retraction using the Penrose drain as a handle.
Gentle dissection avoids bleeding, which can quickly obscure dissection planes. The
instruments should move parallel to the esophagus. Dissection is carried until at least
3 cm of intra-abdominal length of the esophagus is obtained. Care is taken to avoid
entering either pleural cavity. Mediastinal dissection is quite easy in most cases. How-
ever, in patients with long-standing disease, there can be significant periesophageal
adhesions requiring more deliberate mobilization.
If either pleural cavity is entered, the anesthesiologist is informed and asked to
watch for hypotension and/or increased peak airway pressures. Usually, intermittent
aspiration of the pleural cavity is done and lowering of insufflation pressure to 10 or
12 mm Hg is all that is needed. Pleural drains are not usually required. Very rarely, if
hemodynamic status warrants, a small diameter chest tube may need to be inserted and
can be removed in the recovery room.
Assessing Esophageal Length

The traction on the esophagus is released and the distance from the arch of the crus to
the GEJ is measured (Fig. 1.8). The exact location of the GEJ is of considerable debate
but the most accurate is to dissect the gastric fat pad at the angle of His and identify
the junction of the longitudinal muscle of the esophagus to the smooth gastric serosa.
Alternatively, endoscopic identification of GEJ can be used but may be less accurate in
patients with BE. If at least 3 cm of intra-abdominal esophageal length cannot be achieved,
a Collis gastroplasty is performed and has been described elsewhere (including Chapter 6
in this text).
Crus Closure
The right and left limbs of the crus are approximated with interrupted braided nonab-
sorbable suture. We use 0 Ethibond (Ethicon, Inc, Johnson and Johnson, Somerville, NJ)
in a figure-of-eight fashion (Fig. 1.9). Alternatively, simple stitches can be used. The
closure is started posteriorly and carried anteriorly and sutures tied as they are placed.
Extra care is needed with the first stitch on the left limb to avoid injuring the aorta. We
recommend placing the left grasper between the aorta and the left crus as a precaution.
LWBK1254-ch01_p01-14.indd 8 19/02/14 6:53 AM

Figure 1.8 The esophageal length

is assessed without any down-
ward traction on the GEJ or

stomach. The distance from the
arch of the crus to the GEJ is
measured (arrow).
For the right limb, the needle is grasped in the middle with the needle holder and the
hand is pronated as the needle is inserted in the hiatus. The curved shaft of the needle
faces the esophagus. The left hand grasper retracts the caudate lobe of the liver. The
right hand is supinated, driving the needle though the crus. The needle is let go off and
then regrasped on the other side, while traction on the caudate lobe is maintained to
allow continued exposure. Stitches are either tied (extracorporeal or intracorporeal) or
secured using mechanical devices (e.g., Ti-knot ® LSI solutions, Victor, NY).
We do not recommend using autosuturing devices as the depth of the bites may be
suboptimal. Crus closure is calibrated snug around a 60F bougie.
The posterior vagus nerve is then dissected gently off the distal esophagus, and a
new Penrose drain is placed encircling just the esophagus and the anterior vagus nerve.
The window is widened for the infradiaphragmatic portion of the esophagus (Fig. 1.10).
Complete 360-degree Nissen Fundoplication

The posterior limb is identified 6 cm away from the angle of His and 2 cm posterior to
the greater curvature (as identified by the divided short gastric vessels) (Fig. 1.11). This
Figure 1.9 Crus closure is done

with nonabsorbable braided 0
sutures starting posterior to
anterior. Figure-of-eight sutures
are used and secured with a
Ti-Knot device.
LWBK1254-ch01_p01-14.indd 9 19/02/14 6:53 AM

Figure 1.10 The crus has been

completely closed.
is delivered through the window between the posterior vagus and the esophagus onto
the right side of the patient. Marking the proposed posterior fundoplication site with a
2-0 suture greatly simplifies this step. The posterior limb is then released to see if it
lays there without tension or retraction. This is called the “drop test”. The posterior
fundus is then grasped with the instrument in the left hand of the surgeon and the
gastric fat pad is retracted in the anterior–caudal direction by the assistant. An appro-
priate part of the anterior fundus is grasped by the right hand and “shoeshine” maneu-
ver performed to make sure there is no redundant fundus. After a 60F bougie is placed
by the anesthesiologist orally and it is tracked laparoscopically as it traverses through
the GEJ into the stomach. The right and left limbs of the fundoplication are overlapped
and the correct part of anterior fundus is identified so that the two limbs of fundoplica-
tion overlap for 1 to 2 cm around the esophagus (distended with 60F bougie) with
minimal tension. A test stitch is placed, incorporating the anterior and posterior fundus,
with 2-0 prolene and tied with a Ti-Knot device (LSI solutions, Victor, NY). The goal
is to have the two fundoplication limbs meet in a 9 o’clock orientation. The fundoplica-
tion is then assessed.
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.
LWBK1254-ch01_p01-14.indd 10 19/02/14 6:53 AM

Figure 1.12 A 360-degree fundop-

lication with a pledgeted U-stitch.
The two limbs of the U-stitch are

1 cm apart.
With a correctly constructed fundoplication, the greater curvature lays in its natural
position rather than rolling behind superiorly. Secondly, there is space to comfortably
insert a grasper between the fundoplication and the esophagus.
The bougie is removed and the test stitch is replaced with a pledged fundoplication
U-stitch. This is placed anchoring the fundoplication limbs to each other and to the
distal esophagus. We use a double-armed, 2-0 prolene with 1- × 0.5-cm pledgets (Fig.
1.12). First, the stitch is passed through the anterior fundus, then a partial thickness bite
of the esophagus 2 cm above the GEJ at about 9 o’clock position, and then through the
posterior fundus. The second needle is passed in similar sequence about 1 cm below the
previous stitch. The stitch is tied. Our preference is to place one more stitch incorpo-
rating just the anterior and posterior fundus 1 cm below the pledged stitch. A
completed fundoplication lays tension free below the hiatus in 9 o’clock orientation
(Fig. 1.13).
An intraoperative endoscopic evaluation is done to evaluate the fundoplication
intraluminally (Fig. 1.14) and, if distorted, the fundoplication is dismantled and redone.
The liver retractor is removed. The fascial defect at the 12-mm cannula site is closed
using an exit device. The remaining trocars are removed under direct vision and the
Figure 1.13 The completed fundopli-

cation lays tension free below the
closed hiatus and around the distal
esophagus. The (divided) short gastric
vessels lay in their native position
facing the spleen. The fundoplication
is oriented at the 9 o’clock position
and is about 1.5 cm long.
LWBK1254-ch01_p01-14.indd 11 20/02/14 10:30 PM

Figure 1.14 An intraoperative endos-

copy is done and the fundoplication
assessed. An adequate fundoplication
sits snuggly around the endoscope
and has symmetrical tucks as seen
on retrograde view.
pneumoperitoneum evacuated. Skin is closed with absorbable subcuticular stitches and

local anesthetic is infiltrated for analgesia.
Postoperative Management
n Nausea/gagging: It is important to prevent postoperative nausea, which may result
in gagging and retching. We prescribe metoclopromide (10 mg) and ondansetron
(4 mg) to be given intravenously, alternating every 3 hours. Higher doses of ondanset-
ron are used as needed. Additional measures include use of promethazine supposi-
tory, scopolamine patch, and oral dexamethasone (10 mg q6h). In patients with
persistent nausea, an abdominal x-ray is done to rule out gastric distension. Nasogas-
tric decompression is needed if gastric distention is present.
n Pain control: Oral liquid pain medication is used as needed. Essential home medications
are usually started on day 1 and are given in either liquid form or have to be crushed.
n Diet: We routinely start patients on clear liquid diet on the first day postoperatively
that is advanced as tolerated to a mechanical soft diet by the next day.
n Bloating: Postoperative bloating is managed with simethicone gel tabs given every 2
to 4 hours as needed. Acute gastric distension is an extreme presentation with patient
in extremis and requires emergent decompression.
Most patients are discharged on postoperative day 1 or 2 on a soft diet. Oral antiemet-
ics, pain medications, along with a laxative to be taken as needed, are given. Patients are
instructed to avoid lifting objects greater than 9 kg (20 lbs) for 4 to 6 weeks after surgery.
The first follow-up visit is usually 2 weeks after discharge, when the diet is advanced
as tolerated.
Complications
n Intraoperative:
1. Bleeding, especially from short gastric vessels or solid organ damage (liver and
spleen).
2. Esophagogastric perforation: If there is any question of perforation, intraoperative
endoscopy is done.
n Acute postoperative:
1. Acute gastric distension—needs quick diagnosis and urgent decompression.
2. Gagging and retching can lead to acute herniation and should be prevented.
LWBK1254-ch01_p01-14.indd 12 19/02/14 6:53 AM

3. Esophagogastric leak.

4. Acute dysphagia even to liquids: Unusual, but is probably due to hematoma/
edema at the fundoplication. Usually resolves with conservative management in

1 to 3 days. An oral contrast study may be done to rule out a slipped wrap that
would require surgical reintervention.
n Long-term postoperative:
1. Gas-bloat syndrome: Bloating and increased flatulence are not infrequently reported,
and nothing more than reassurance is needed in most cases.
2. Dysphagia: If dysphagia persists beyond 6 weeks, an endoscopy with dilation may
be needed.
3. There is a continued need to prevent gagging and retching.
Results
Patient satisfaction and symptom resolution has been reported in more than 85% to
95% of patients from centers of expertise during long-term follow-up (5 to 10 years).
There are also several reports of high use of postoperative proton pump inhibitor (PPI)
medications; however, most of the patients who resume PPI treatment do not have objec-
tive evidence of continued reflux. Up to 5% to 10% of patients may need reoperative
intervention.
Conclusions
LNF is an excellent procedure for durable cure of GERD when performed at experienced
centers.
Recommended References and Readings reflux disease (GERD)-related airway disorder. Surg Endosc.
2006;20:1824–1830.
1. Brouwer R, Kiroff GK. Improvement of respiratory symptoms fol- 8. Mittal S K, Awad ZT, Tasset M, et al. The preoperative predict-
lowing laparoscopic Nissen fundoplication. ANZ J Surg. 2003; ability of the short esophagus in patients with stricture or
73:189–193. paraesophageal hernia. Surg Endosc. 2000;14:464–468.
2. Campos GM, Peters JH, DeMeester TR, et al. Multivariate analy- 9. Peters JH, DeMeester TR. Indications, benefits and outcome of
sis of factors predicting outcome after laparoscopic Nissen fun- laparoscopic Nissen fundoplication. Dig Dis. 1996;14(3):169–
doplication. J Gastrointest Surg. 1999;3(3):292–300. 179.
3. Cowgill SM, Gillman R, Kraemer E, et al. Ten-year follow up 10. Tsuboi K, Gazallo J, Yano F, et al. Good training allows excellent
after laparoscopic Nissen fundoplication for gastroesophageal results for laparoscopic Nissen fundoplication even early in the
reflux disease. Am Surg. 2007;73:748–752; discussion 752–753. surgeon’s experience. Surg Endosc. 2010;24:2723–2729.
4. DeMeester TR, Peters JH, Bremner CG, et al. Biology of gastro- 11. Tutuian R, Castell DO. Reflux monitoring: Role of combined
esophageal reflux disease: Pathophysiology relating to medical multichannel intraluminal impedance and pH. Gastrointest
and surgical treatment. Annu Rev Med. 1999;50:469–506. Endosc Clin N Am. 2005;15(2):361–371.
5. Hinder RA. Surgical therapy for GERD: Selection of procedures, 12. Yang H, Watson DI, Lally CJ, et al. Randomized trial of division
short- and long-term results. J Clin Gastroenterol. 2000;30(3 Suppl): versus nondivision of the short gastric vessels during laparo-
S48–S50. scopic Nissen fundoplication: 10-year outcomes. Ann Surg. 2008;
6. Hinder RA, Filipi CJ, Wetscher G, et al. Laparoscopic Nissen fun- 247:38–42.
doplication is an effective treatment for gastroesophageal reflux 13. Yano F, Stadlhuber RJ, Tsuboi K, et al. Preoperative predictabil-
disease. Ann Surg. 1994;220:472–481; discussion 481–483. ity of the short esophagus: Endoscopic criteria.Surg Endosc.
7. Kaufman JA, Houghland JE, Quiroga E, et al. Long-term out- 2009;23:1308–1312.
comes of laparoscopic antireflux surgery for gastroesophageal
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LWBK1254-ch01_p01-14.indd 14 19/02/14 6:53 AM
2 Laparoscopic Partial
Fundoplications
Andrew S. Kastenmeier and Lee L. Swanstrom
Introduction
In 1956, Rudolph Nissen published the results of his 360-degree “gastroplication” in two
patients. This quickly spawned a “gold rush” of alternative procedures that were uni-
formly claimed to be more physiologic than the effective but side-effect–prone classic
Nissen. The procedures designed by Ronald Belsey and Lucius Hill were based on large
clinical trials (Belsey), detailed cadaveric studies (Hill), and endoscopic investigation
(Belsey and Hill). Central to these procedures was the restoration of intra-abdominal
esophageal length and recreation of the esophagogastric angle to restore the reflux barrier.
In the 1960s, two French surgeons independently developed novel partial fundoplications:
Jacques Dor at the University of Marseilles described an anterior partial wrap and Andre
Toupet at the city hospitals of Paris described a posterior partial wrap; each proposed to
decrease side effects of the Nissen, such as gas bloat, dysphagia, and the inability to belch.
Since Dallemagne described the laparoscopic Nissen in 1991, the volume of antire-
flux surgeries worldwide has dramatically increased. Laparoscopic versions of most par-
tial fundoplications were soon reported. Partial fundoplications that have stood the test
of time and have successfully been modified to a laparoscopic technique include the
Hill, the Dor, and the Toupet. Each of these will be discussed in detail. The Belsey Mark
IV is also occasionally utilized; however, because this procedure is performed transtho-
racically it will be discussed in detail in another chapter of this book (Chapter 5).
Indications
There are three schools of thought regarding the indications for a partial fundoplication:
(1) That they are unneeded, since the 360-degree Nissen fundoplication has been shown
to work with normal and abnormal esophageal motility; (2) that they are better tolerated
than a Nissen and should be universally applied, and finally (3) that they are useful in
select cases based on an individual’s esophageal motility status (tailored approach). For
the sake of this chapter, we will take the position that a tailored approach to antireflux
surgery is reasonable, recognizing that there are good arguments for both extremes as
well. Because a complex dynamic exists between esophageal motility, lower esophageal
15
LWBK1254-ch02_p15-28.indd 15 20/02/14 10:31 PM

sphincter function, gastric function, parasympathetic input, anatomic orientation, and

eating behavior, the optimal procedure should be selected for each individual based on
a thorough preoperative interview, physical examination, and physiologic evaluation.
Indications: A partial fundoplication should be considered in patients who have a
documented need for antireflux surgery and one or more of the following indications.
n Patients undergoing an esophagomyotomy (for achalasia, hypertensive lower esopha-
geal sphincter (LES), epiphrenic diverticulum, etc.)
n Presence of a named primary esophageal motility disorder
n Very poor esophageal body motility (peristaltic amplitude <30 mm Hg, >50% simul-
taneous or dropped peristaltic waves in the esophageal body)
n Severe aerophagia
n Inadequate fundus for a full fundoplication
n Psychological or physical disorders that would not allow the patient to tolerate dif-
ficulties with vomiting, belching, or eating large volumes
n Failure of a full fundoplication due to dysphagia
n Surgeon preference
Contraindications
Although there are no absolute contraindications to a partial fundoplication compared
with a full fundoplication, there are absolute contraindications to antireflux surgery.
These include the following.
n Inability to tolerate general anesthesia
n Severe chronic obstructive pulmonary disease (COPD)
n Uncorrected coagulopathy
n Advanced pregnancy
n Inability to provide informed consent
The goals of the preoperative evaluation are to confirm the need for an antireflux oper-
ation, identify associated pathology that may alter the surgical approach (behavioral,
psychological, or associated foregut pathology), and assess overall operative risk. Eval-
uation always begins with a detailed history and physical examination.
n A standardized symptom assessment questionnaire is a useful tool for documenting
primary and associated pathology as well as for postoperative follow-up.
n Every patient being considered for an antireflux operation should have a complete
physiologic evaluation that includes 24-hour pH monitoring (± impedance) and
esophageal manometry.
n The pH monitoring provides objective evidence of whether reflux exists, rates the
severity of reflux, and provides a baseline against which postoperative pH studies
can be measured in the event that symptoms fail to resolve or if symptoms recur.
n Esophageal manometry is used to identify the type and severity of esophageal motil-
ity disorder and evaluate the characteristics of the lower esophageal sphincter. Man-
ometry can also provide important clues regarding esophageal length and the
presence of a hiatal hernia (Fig. 2.1). Dysfunctional esophageal motility can be the
primary reason for the presenting complaint or it can be a subclinical manometric
finding. In either case, manometric findings are often the primary factor guiding the
selection of an antireflux technique. Surgeons are strongly encouraged to learn man-
ual interpretation of esophageal manometry tracings, as computer interpretation is
unable to differentiate a primary intrinsic motility disorder from a reversible distal
esophageal hypocontractility that is secondary to chronic reflux.
LWBK1254-ch02_p15-28.indd 16 20/02/14 1:35 PM

Chapter 2 Laparoscopic Partial Fundoplications 17
Figure 2.1 High-resolution

manometry is useful to assess
esophageal body motility and to

screen for hiatal hernia.
n Every patient should have an upper endoscopy to evaluate for cancer, Barrett’s
esophagus, a hiatal hernia, diverticula, strictures, esophagitis, and gastric pathology.
It is also useful to grade the esophagogastric flap valve as seen in retroflexion based
on the Hill standardized scale (Fig. 2.2). Any mucosal lesion should be photographed,
biopsied, and described in detail in the endoscopy report. The preoperative endo-
scopic evaluation is optimally performed by the operating surgeon, because relevant
surgical information is often not included in the report when endoscopy is done
by someone who is not involved in surgical planning. Upper gastrointestinal contrast
studies can provide additional information regarding pharyngeal function, esopha-
geal dilation, esophageal length, hiatal hernia size, and hiatal hernia configuration.
Such imaging studies are not mandatory, but should be ordered at the discretion of
the operating surgeon if concerns for an alternate or additional pathology are raised
during the initial phase of the work-up.
n Gastric emptying studies, computed tomography (CT) scans, and direct laryngoscopy
are examples of additional tests that are occasionally necessary to arrive at a com-
prehensive diagnosis (Table 2.1).
A B

Figure 2.2 A: Retroflexed endoscopic view of a competent (Hill grade I) valve. B: Retroflexed endoscopic view showing a Hill grade
IV valve.
LWBK1254-ch02_p15-28.indd 17 20/02/14 1:35 PM

T able 2 . 1
Preoperative Esophageal Tests Vary According to Presentation
Examination Asymptomatic Classic GERD Dysphagia Atypical Symptoms

Barium upper GI 0 0 + +
Upper endoscopy + + + +
Esophageal manometry + + + +
24-hr pH + + + +
Dx-pH probe (RESTECH) 0 0 0 +
Gastric emptying study 0 0 0 +
Surgery
General Considerations
Positioning
After induction of general anesthesia, the patient is placed in a split-leg position. The patient
will be placed in a steep reverse Trendelenburg position during the operation, so it is imper-
ative to secure the patient to the bed and eliminate the possibility of sliding on the table.
These goals can be achieved with the aid of tape, a vacuum beanbag mattress, and/or foot-
boards. The arms can be tucked or placed on arm boards and be slightly abducted. The
surgeon stands to the patient’s left and the assistant between the legs as seen in Figure 2.3.
Figure 2.3 Typical OR positioning

for a laparoscopic partial fundopli-
cation.
Port sites
LWBK1254-ch02_p15-28.indd 18 20/02/14 1:35 PM

Also, note the locations of video monitors at the patient’s head and to the right of the

head in the direct sight line of both the surgeon and the assistant surgeon. Alterna-
tively, the surgeon can operate from between the legs and the assistant from the

patient’s left.
Port Placement
The technique for intra-abdominal access is based on surgeon preference, but is gener-
ally similar for all fundoplications. The authors prefer using a Veress needle to insuf-
flate the abdomen. Trocar size is also a matter of preference. The authors’ first port is
the camera port, a 10-mm trocar placed 12 cm from the xiphisternum and 3 cm left of
the midline. This trocar should be well above the level of the umbilicus. The laparo-
scope is then inserted and visual exploration of the abdominal cavity is undertaken.
Prior to placement of the remaining trocars, the patient is placed in a steep reverse
Trendelenburg position. This position allows gravity to gently pull the abdominal vis-
cera out of the hiatus and toward the pelvis. The locations of the remaining trocars are
shown in Figure 2.4. Each of these trocars is 5 mm in size and placed under direct
visualization. An articulated liver retractor is placed through the right upper quadrant
trocar and is used to elevate the left lobe of the liver; the retractor handle is then
secured to a table-mounted instrument holder. The surgeon’s left hand instrument
works through the trocar that is just below and to the right of the xiphoid process, while
the right hand works through the 5 mm trocar in the left upper quadrant. The assistant’s
left hand works through the trocar that is 10 cm from the xiphisternum and in the
midline.
Dissection
n The assistant uses an atraumatic instrument to grasp the epigastric fat pad and retract
the stomach downward. Ultrasonic shears are then used to divide the hepatogastric
ligament over the caudate lobe. Approximately 15% of patients have a replaced left
hepatic artery arising from the left gastric artery and coursing through the hepato-
gastric ligament. This vessel should be spared if possible, as there are instances,
albeit rare, where division results in hepatic ischemia. Dissection is carried toward
the hiatus until the right crus is identified.
Figure 2.4 Typical laparoscopic port

placement for fundoplication.
5 mm
5 mm 5 mm
5 mm 10 mm
LWBK1254-ch02_p15-28.indd 19 20/02/14 1:35 PM

Figure 2.5 Mediastinal dissection

usually allows adequate mobilization
of the gastroesophageal junction
(2.5 to 4 cm).
2.5 cm
n The phrenoesophageal ligament is incised at the apex of the hiatus allowing entrance
into the mediastinum. The mediastinal esophagus is then mobilized using a combi-
nation of blunt dissection and ultrasonic dissection. Division of the phrenoesopha-
geal ligament proceeds first along the right crus. Care must be taken to preserve the
peritoneal covering of the crura, as this allows a more robust crural closure. Through-
out the dissection, the vagi are repeatedly identified and protected by keeping them
closely approximated to the esophagus.
The dissection is then carried into the retroesophageal space. From here, the
attachments to the left crus and the fundus can be taken down. The mediastinal dis-
section is complete when there is 2.5 to 4 cm of tension-free intra-abdominal esopha-
gus (Fig. 2.5). Attention is then turned to the short gastric vessels, which we routinely
divide to a variable extent for partial fundoplications to ensure that there is no unto-
ward tension on the wrap. Short gastrics are taken with the ultrasonic shear, starting
at the caudal aspect of the upper third of the greater curvature for Toupet, the mid-
point of the splenic hilum for Dor, and only the proximal few centimeters for the Hill
repair. The stomach is retracted toward the patient’s right, allowing visualization of
the retrogastric attachments, which are divided for complete mobilization of the
fundus.
The Toupet Fundoplication

The Toupet repair was described as a more physiologic alternative to the Nissen in
1963. Initially a 180-degree posterior wrap with no primary crural closure, it was
quickly modified to be a 270-degree wrap with hiatal closure.
n Modifications: Crural repair, increased wrap circumference from 180 degrees to 270
degrees
Operative Technique—The Repair

For the Toupet, the gastric fundus must be completely mobilized, both by dividing the
short gastric vessels of the upper third of the stomach and by freeing the stomach off
the retroperitoneum. With the assistant providing caudal traction on the epiphrenic fat
pad, the mobilized fundus is approached from the right, through the retroesophageal
LWBK1254-ch02_p15-28.indd 20 20/02/14 1:35 PM

Figure 2.6 The “shoeshine” maneuver

checks for adequate esophageal
length, optimal wrap fixation points,

and floppiness of the fundoplication.
window, and brought posterior to the esophagus from left to right. This portion of the
fundus is then grasped along the line of divided short gastric vessels with the surgeon’s
left hand, while the greater curvature on the left side is held with the right hand and
a “shoeshine” maneuver is performed. With the two ends of the wrap retracted away
from the esophagus and cephalad toward the diaphragm, the surgeon slides the fundus
back and forth behind the esophagus (Fig. 2.6). This maneuver should result in a 1:1
reciprocal movement within each hand. This ensures that the wrap is fully mobilized,
is not twisted, and is neither too tight nor too floppy.
The assistant then grasps the right side of the wrap and retracts it over the esopha-
gus and toward the left upper quadrant. Retraction of the fundus in this manner dis-
places the esophagus to the left and exposes the posterior hiatus. This allows
simultaneous crural closure and fixation of the posterior fundus. A 2-0 woven polyester
suture on a curved, GI needle is cut to a length of 6 inches. Using an intracorporeal
suturing technique, each suture incorporates the posterior fundus, the left crus, and the
right crus. All knots should be tied so that there is approximation of the crura without
strangulation. The crural closure begins posteriorly and typically requires three to four
stitches. Care must be taken to avoid approximating the crura too tightly around the
esophagus in order to prevent resistance to emptying. The right side of the wrap is then
approximated to the right crus using several interrupted sutures, the last being high on
the right crus. These sutures are then repeated on the opposite side to approximate the
left side of the wrap to the left crus. By fixing the wrap to the hiatus, tension is relieved
from the sutures placed between the fundus and esophagus.
Prior to placement of the final sutures, a 56-French bougie is advanced in the
esophagus and the right wing of the wrap is sutured to the 10-o’clock position of the
esophagus over a length of 3 to 4 cm. These sutures are repeated between the left wing
of the wrap at the 2-o’clock position of the esophagus. A well-constructed Toupet fun-
doplication should cover 270 degrees of the distal esophagus, have a length of 3 to
4 cm, be tension free, be secured to the diaphragm, and have no esophageal impinge-
ment at the hiatus (Fig. 2.7).
The Dor Repair

n Modifications: Crural repair, laparoscopic
n Minimize dissection posteriorly, still take short gastric vessels as this can reduce torsion/
dysphagia
LWBK1254-ch02_p15-28.indd 21 20/02/14 1:35 PM

Figure 2.7 The final view of a well-

constructed Toupet fundoplication.
Short gastric
vessels

If there is no hiatal hernia, only the anterior 180 degrees of the hiatus needs to be opened.
If there is a hiatal hernia, the entire hiatus and distal esophagus have to be mobilized as
described above. Once the esophageal dissection and mobilization are complete, the
esophagus is gently retracted to the left, exposing the posterior hiatus. Any hiatal defects
are closed posteriorly using a 2-0 woven polyester suture on a curved, tapered GI needle
to gently reapproximate the posterior hiatus. All crural sutures should be tied such that
there is approximation without strangulation or narrowing of the hiatus.
Upon completion of the crural closure, attention is turned to the fundoplication.
The upper gastric fundus is mobilized by dividing the uppermost short gastric vessels.
A point on the greater curvature of the fundus that is 3 cm from the angle of His is
sutured to the midpoint of the left crus. The right margin of the gastric fundus is then
sutured to the left margin of the esophagus using several interrupted stitches. This
maneuver establishes appropriate intra-abdominal esophageal length and accentuates
the angle of His, allowing recreation of the gastroesophageal flap valve (Fig. 2.8).
A 56-French esophageal dilator is then inserted and carefully advanced into the
stomach. The greater curvature of the fundus is wrapped anteriorly over the esophagus.
The superior portion of the fundus is sutured to the anterior hiatus. Sutures are then
placed between the greater curvature and the right margin of the esophagus. A well-
constructed Dor fundoplication should cover 180 degrees of the anterior distal esophagus
(Fig. 2.9).
The Hill Repair

More properly termed an “esophagogastropexy,” the Hill repair has several characteris-
tics in common with partial fundoplications. Hill’s intent was to stably fix the gastro-
esophageal junction (GEJ) into the abdominal cavity and to restore and accentuate the
angle of His. Laparoscopic practitioners have described some slight modifications from
the original description by Hill including no celiac dissection or mobilization of the
median arcuate ligament, no intraoperative manometry, and a crural closure.
n Standard hiatal dissection is performed as has been described, with the goal of 2.5
to 3 cm of intra-abdominal esophageal length.
LWBK1254-ch02_p15-28.indd 22 20/02/14 1:35 PM

Figure 2.8 Attaching the greater

gastric curvature to the left crus
accentuates the angle of His and the

internal “flap valve.”
n With the exception of the most cephalad one or two vessels, the short gastric vessels
are not routinely divided in the Hill repair. However, the back of the gastric cardia
is completely mobilized off of the retroperitoneum.
n The esophagus is retracted to the left to expose the posterior hiatus and crural decus-
sation. The crura are then gently approximated posteriorly using interrupted woven
polyester sutures that are tied intracorporeally. This usually can be done with two
to four sutures.

n The repair consists of four interrupted woven polyester sutures that imbricate the
anterior phrenoesophageal bundle and the posterior phrenoesophageal bundle. With
the same stitch, this is approximated to the crural decussation overlying the aorta.
These sutures are full length, and both ends are brought out of the trocars and
Figure 2.9 The finished 180-degree

anterior (Dor) fundoplication.
LWBK1254-ch02_p15-28.indd 23 20/02/14 1:35 PM

carefully clipped to the drape. Once the sutures have been placed, they are tied
down, starting with the first one placed, over a 48-French bougie. An extracorporeal
knot-tying technique is used. These sutures serve to reconstruct the angle of His by
tightening the oblique sling musculature of the GEJ. The 48-French bougie was deter-
mined by Hill to be the proper size to prevent obstructive stenosis of the GEJ. Finally,
the anterior gastric cardia is folded up over the repair and tacked to the anterior rim
of the hiatus with interrupted sutures—somewhat like a Dor repair, but without any
“wrapping.” This further accentuates the reconstructed angle of His (Fig. 2.10). Hill
Figure 2.10 The Hill esophagogas-

tropexy.
Anterior
vagus nerve
Posterior
vagus nerve
Preaortic
fascia
Posterior fundus
of stomach
Fat pad overlying

median arcuate
Anterior and
ligament
posterior bundles
Preaortic
fascia
Stomach
Esophagus
Valve
Aorta
LWBK1254-ch02_p15-28.indd 24 20/02/14 1:35 PM

was an advocate of intraoperative manometry to tailor the repair for each patient.

Although we do not routinely utilize manometry, we do frequently evaluate the qual-
ity of the repair with intraoperative endoscopy and not infrequently will remove the

fourth Hill stitch if endoscopically it seems too tight.
An overnight stay is typical after a partial fundoplication. Immediately after surgery,
patients are kept NPO, but are generally started on a liquid diet 6 hours after surgery
and advanced to a puree diet if no nausea is present. Nausea can lead to retching and
vomiting, which can cause acute wrap herniation and early wrap failure; therefore,
these symptoms must be treated aggressively with antiemetics.
In more complex cases (redo surgery, myotomy, large paraesophageal hernia, inad-
vertent gastrotomy, etc.), patients have a closed-suction drain placed at the time of
surgery. On postoperative day 1, the drain fluid is evaluated for amylase and a water-
soluble contrast swallow study is performed. If the results are normal, patients are
started on a liquid diet and subsequently advanced as mentioned above. These patients
typically are discharged home on the second postoperative day.
Patients are maintained on a puree diet for at least 2 weeks. In addition, they are
instructed to avoid bread, meat, raw vegetables, and large pills. Medications are gener-
ally crushed or converted to a liquid form until the patient tolerates solid food. Patients
are advised to expect some dysphagia for 2 to 6 weeks. Patients are also instructed to
avoid heavy lifting for 6 weeks.
Complications
Complications can occur at any point in the course of surgery. They can be general,
associated with any operation (myocardial infarction, deep vein thrombosis, pulmonary
embolism, bleeding, infection), or can be those that are more specific to laparoscopy
(access injuries to vascular or hollow visceral structures and physiologic reactions to
pneumoperitoneum). Finally, there are those that are specific to the dissection and
fundoplication.
Intraoperative complications during a laparoscopic fundoplication include dissec-
tion injuries to a hollow viscus, injuries to the vagus nerves, and bleeding. The most
common visceral injuries are to the stomach, followed by the GEJ, and more rarely the
esophagus itself. Injuries most often occur as a result of traumatic retraction, and proper
tissue handling is the most effective prevention. Atraumatic instruments should always
be used and grasping of the hollow viscera should be minimized. The anterior fat pad
can provide a safe retraction point, or a Penrose drain can be used to encircle the
esophagus and provide atraumatic retraction. Injury can also occur as a result of bougie
insertion. This occurs in less than 1% of cases, but can occur due to anatomic distor-
tion, poor tissue quality, associated pathology (esophagitis, diverticulum, kyphosis,
strictures), poor communication between the surgeon and the person advancing the
bougie, or inexperience with bougie insertion. Should an injury occur, early detection
is imperative to avoid further morbidity. With adequate skills, a laparoscopic suture
repair is preferred, but consideration should be given to an open repair based on sur-
geon experience and the clinical scenario. Gastric perforations are easily oversewn in
a single layer with an absorbable suture or can be stapled. Esophageal perforations can
usually be oversewn laparoscopically or a thoracotomy or laparotomy can be performed
to gain appropriate access and exposure. Closure of the esophageal mucosa and mus-
cularis is imperative after an esophageal perforation in order to prevent a future diver-
ticulum. It is our practice to routinely leave a drain near such a perforation, and
consideration of a protective covered stent can be entertained. On postoperative day 1,
LWBK1254-ch02_p15-28.indd 25 20/02/14 1:35 PM

T able 2 . 2
Postoperative Complications and Their Possible Causes
Dysphagia Reflux Recurrence

Tight wrap Wrap herniation
Poor motility Wrap disruption
Wrap herniation/disruption Diarrhea
Bloating Vagal injury
Vagal injury Idiopathic
Delayed gastric emptying
Idiopathic
we then obtain a contrast imaging study and routinely measure drain amylase levels in
search of postoperative leaks.
Bleeding during a partial fundoplication procedure is generally limited to the short
gastric vessels, the spleen, the liver, or an unrecognized replaced/accessory left hepatic
vessel. The harmonic scalpel, ligasure, clips, suture ligation, endoloop, and/or direct
pressure can usually be employed laparoscopically to gain control of bleeding. Conver-
sion to open surgery should be considered, but is rarely necessary. Although rare, an
uncontrollable splenic laceration would be one indication for rapid conversion to an
open procedure. Again, if prevention fails, then early recognition and immediate repair
is imperative to prevent further morbidity.
An unrecognized perforation can manifest as abdominal pain, tachycardia, hypo-
tension, or fever in the early postoperative period. Any of these symptoms warrant
immediate concern and should prompt an immediate localization study, such as a
CT scan, a water-soluble contrast swallow study, or an immediate return to the oper-
ating room for exploration. Ongoing bleeding can also have a similar presentation.
Sources include those previously described, as well as trocar sites. Resuscitation,
correction of coagulopathy, and close monitoring can be appropriate; however,
a return to the operating room for exploration and control of hemorrhage may be
necessary.
Late postoperative complications related to partial fundoplication can be trouble-
some and frustrating for surgeon and patient alike. Dysphagia is the most common
complaint and should be expected in all patients during the initial first few postop-
erative weeks. Tissue dissection causes tissue edema and swelling that often results
in an expected transient dysphagia. We therefore counsel our patients preoperatively
regarding this phenomenon and maintain them on a puree diet for at least 2 weeks
after surgery. If significant dysphagia persists after 6 weeks, we generally recommend
upper endoscopy and empiric dilation. Persistent severe symptoms are rare and
should prompt a repeat physiology work-up and consideration of a wrap takedown.
Return of reflux symptoms may indicate a wrap failure and warrants repeating the
pH study, esophageal manometry, upper endoscopy, and the contrast esophagram.
These studies help determine if there is an objective evidence of recurrent reflux,
an underlying motility disorder that has progressed, and wrap disruption or hernia-
tion. These studies are imperative before attempting any sort of revisional surgery
(Table 2.2).
Results
The results of partial fundoplications vary based on indication. In the context of a Hel-
ler myotomy, a partial fundoplication is almost universally accepted as the standard of
care for reflux prevention. Although both the Dor and the Toupet are currently used in
the context of a Heller myotomy, the Dor fundoplication has the largest body of litera-
ture supporting its use in this setting. Advocates of the Dor claim the added theoretical
benefit of covering the anterior esophageal mucosa in case an inadvertent perforation
has occurred. The Toupet is advocated based on the idea that it may hold the edges of
LWBK1254-ch02_p15-28.indd 26 20/02/14 1:35 PM

the myotomy open. There is, however, very little literature directly comparing the Dor

and the Toupet. No studies are randomized and the few that exist have small study
sizes.

Controversy also remains regarding the efficacy of partial fundoplications as a
treatment for primary reflux disease. As noted, the Dor is primarily used in the setting
of a myotomy and there is little evidence to support its use as a primary antireflux
operation. The Hill has been shown to have good results and durability for reflux dis-
ease; however, there is little data regarding the results of the laparoscopic Hill. Only
one comparative study between the laparoscopic Hill and laparoscopic Nissen is avail-
able and it showed equivalence between the procedures. There is equal controversy
surrounding the use of the Toupet as a primary treatment for reflux disease, with US
surgeons reporting poor results and surgeons of most other countries reporting equiv-
alence or superiority. This disagreement exists for several reasons. First, there is dis-
crepancy between existing studies. Second, studies report different measurements of
success. For example, success can be measured by the rate of side effects (dysphagia,
gas bloat, inability to belch, inability to vomit), recurrence/persistence of subjective
reflux symptoms, objective evidence of reflux, wrap disruption/herniation, return to
proton pump inhibitor use, or patient satisfaction scores. As has been frequently noted,
symptom recurrence is not necessarily associated with objective evidence of reflux
recurrence. In the short term (<12 months), the Toupet appears to have a lower inci-
dence of dysphagia and gas bloat and equivalent control of reflux. The literature is
contradictory regarding outcomes a year or more after surgery. Many of recent Euro-
pean studies show that over the long term, the Toupet is an equivalent antireflux
operation to the Nissen. Other studies, mainly performed in North America, suggest
that there is a high rate of objectively measured recurrent reflux. In addition, some
studies suggest that the higher incidence of side effects associated with the Nissen is
transient and that rates equilibrate between the approaches after approximately one
year. Other studies suggest that the lower side effect rate in the Toupet persists over
time.
The practice of performing a tailored approach to fundoplication has also been
called into question of late. While some surgeons tailor the degree of lower esophageal
sphincter augmentation to the individual’s esophageal motility, there is little agreement
regarding this practice. Some have avoided this argument all together by performing a
Toupet fundoplication on all patients. Others, who primarily perform the Nissen fun-
doplication, will perform a partial fundoplication in instances where dysphagia is sig-
nificant and manometry shows ineffective esophageal motility (IEM). Still others will
perform a Nissen on those with IEM, which suggests that most of the dysmotility and
dysphagia are secondary to reflux and is therefore reversible after effective antireflux
surgery. The literature does not clearly support one method versus the other. What is
clear is that we are not good at predicting who is at risk of postoperative dysphagia
among patients without a named motility disorder. It is our practice to consider all
aspects of the preoperative work-up in the decision regarding the type of antireflux
surgery. Dysphagia and distal IEM are most commonly secondary to reflux and it is
believed that they are usually reversible with a proper antireflux operation. That being
said, there are some patients with profound symptoms or manometric findings that are
unusual enough that we recommend a partial fundoplication.
Conclusions
Partial fundoplications are essential techniques in the armamentarium of any dedicated
antireflux surgeon. Regardless of whether one prefers a partial fundoplication over the
Nissen in all cases, as an alternative for dysmotility, or only in cases of the most extreme
esophageal dysfunction, the techniques of partial fundoplication are essential to master.
As with any antireflux surgery, the patient outcomes are dependent on the meticulous
performance of the partial wrap.
LWBK1254-ch02_p15-28.indd 27 20/02/14 1:35 PM

Recommended References and Readings 7. Myers JC, Jamieson GG, Sullivan T, et al. Dysphagia and gastro-
esophageal junction resistance to flow following partial and total
1. Aye RW, Mazza DE, Hill LD. Laparoscopic Hill repair in patients fundoplication. J Gastrointest Surg. 2012;16(3):475–485.
with abnormal motility. Am J Surg. 1997;173(5):379–382. 8. Novitsky YW, Wong J, Kercher KW, et al. Severely disordered
2. Broeders JA, Roks DJ, Jamieson GG, et al. Five-year outcome esophageal peristalsis is not a contraindication to laparoscopic
after laparoscopic anterior partial versus Nissen fundoplication: Nissen fundoplication. Surg Endosc. 2007;21(6):950–954.
Four randomized trials. Ann Surg. 2012;255(4):637–642. 9. Ramos RF, Lustosa SA, Almeida CA, et al. Surgical treatment of
3. Cao Z, Cai W, Qin M, et al. Randomized clinical trial of laparo- gastroesophageal reflux disease: Total or partial fundoplication?
scopic anterior 180° partial versus 360° Nissen fundoplication: systematic review and meta-analysis. Arq Gastroenterol.
5-year results. Dis Esophagus. 2012;25(2):114–120. 2011;48(4):252–260.
4. Khajanchee YS, Kanneganti S, Leatherwood AE, et al. Laparo- 10. Raue W, Ordemann J, Jacobi CA, et al. Nissen versus Dor fun-
scopic Heller myotomy with Toupet fundoplication: Outcomes doplication for treatment of gastroesophageal reflux disease: A
predictors in 121 consecutive patients. Arch Surg. 2005;140(9): blinded randomized clinical trial. Dig Surg. 2011;28(1):
827–833. 80–86.
5. Mardani J, Lundell L, Engström C. Total or posterior partial fun- 11. Rawlings A, Soper NJ, Oelschlager B, et al. Laparoscopic Dor
doplication in the treatment of GERD: Results of a randomized versus Toupet fundoplication following Heller myotomy for
trial after 2 decades of follow-up. Ann Surg. 2011;253(5):875–878. achalasia: Results of a multicenter, prospective, randomized-
6. Mucio M, Rojano M, Herrera JJ, et al. Novel surgical concept in controlled trial. Surg Endosc. 2012;26(1):18–26.
antireflux surgery: Long-term outcomes comparing 3 different
laparoscopic approaches. Surgery. 2012;151(1):84–93.
LWBK1254-ch02_p15-28.indd 28 20/02/14 1:35 PM

3 Fundoplication: Open
Transabdominal Approach
Thomas W. Rice
Indications
Reconstruction of the esophagogastric junction (EGJ) that includes fundoplication is
indicated in the treatment of (1) gastroesophageal reflux disease (GERD) and (2) symp-
tomatic mechanical obstruction resulting from Type III and Type IV (paraesophageal)
hiatal hernia.
GERD
To avoid the pitfalls of indiscriminate surgery seen in the laparoscopic experience of
the recent past, surgery for GERD must be used in highly selected patients to treat spe-
cific symptoms and reverse or halt documented, severe mucosal damage resulting from
quantified abnormal reflux of gastric contents into the esophagus. Surgery for GERD
should be considered only if (1) a trial of aggressive medical treatment using proton
pump inhibitors (PPI) with dose escalation and lifestyle modifications has failed, (2)
mucosal damage has been identified and quantified, (3) abnormal gastroesophageal
reflux has been documented, and (4) a repairable problem in the reflux barrier has been
found.
Symptom Control
Heartburn is the main symptom indication for surgery in GERD patients. There are three
typical clinical scenarios: (1) Heartburn initially controlled by PPI therapy that has
become refractory or is poorly controlled despite dose escalation, (2) heartburn well
controlled, but side effects of PPI therapy are intolerable, and (3) volume regurgitation
despite effective heartburn control. GERD-related dysphagia in the above scenarios may
not be as effectively treated by surgery, but it is an indication nonetheless. Beware of
patients with typical symptoms that do not respond to medication, those demanding
immediate surgery for relief of intolerable symptoms, and those with scleroderma,
because their outcome with surgery is poor. Age itself should not change these indica-
tions. Need for lifelong medical therapy in a young patient with well-controlled symp-
toms is an indication for surgery only if a durable repair can be ensured.
29
LWBK1254-ch03_p29-42.indd 29 19/02/14 7:09 PM

Atypical symptoms, such as cough, laryngitis, hoarse voice, sore throat, asthma,
chest pain, and abdominal bloating, should be associated with typical GERD symptoms
and responsive to PPI therapy if surgery is to be considered. If symptoms are only
atypical, they must be proven to be GERD related and responsive to PPI therapy or
demonstrated to be the result of acid reflux before surgery is prescribed.
Mucosal Injury
Poorly controlled or recurrent ulcerative esophagitis after aggressive PPI therapy is an
indication for surgery. Other causes that result in lack of healing, such as pill-induced
injury, must be ruled out. Most strictures can be managed initially with medical therapy
and dilatation. As with esophagitis, unsuccessful medical therapy or recurrent strictures
despite effective medical therapy are indications for surgery. The ability of any therapy
to completely reverse Barrett’s esophagus (BE) or prevent its progression to cancer has
not been demonstrated; therefore, indications for surgery in a GERD patient with non-
dysplastic BE are identical to those for the GERD patient without BE.
Mechanical Obstruction
Mechanical obstruction caused by paraesophageal hernias, typically with organoaxial
volvulus, is an indication for repair of the EGJ with fundoplication. Uncommonly, this is
an acute presentation with ischemia or infarction. More typically, the symptoms are
chronic and progressive and include early satiety, postprandial discomfort, attack of unre-
lenting postprandial epigastric pain, and chronic blood loss secondary to Cameron ulcers.
Contraindications
Obesity
An often ignored but essential part of physical examination is measuring and recording
weight and height and calculating body mass index (BMI). Overweight (BMI 25 to 29)
and obese (BMI 30 to 34) GERD patients should be counseled on weight loss and encour-
aged to reach their ideal weight before elective surgery. Because obesity and GERD are
interrelated, successful and sustained weight loss may eliminate need for surgery.
Although there is disagreement concerning impact of obesity on outcome of antireflux
surgery, the health benefits of weight loss in severely (BMI 35 to 39) and morbidly (BMI
≥ 40) obese GERD patients should make weight loss surgery the operation of choice in
these patients.
Investigations
The preoperative barium esophagram has been neglected, misused, and in some cases
abandoned, with the advent of modern investigations of GERD and hiatal hernia. How-
ever, it provides valuable information about the mucosa, esophageal complications,
reflux of gastric contents, reflux barrier, and esophageal function. It should, whenever
possible, be ordered by the surgeon and performed by a radiologist, experienced in
preoperative assessment of GERD and hiatal hernia, who is a member of the multidis-
ciplinary team evaluating and treating the patient. If dysphagia is the predominant
symptom and the diagnosis is in question, the examination should start as a timed
barium esophagram.
Esophagogastroduodenoscopy (EGD) with biopsy has replaced the upright air-
contrast phase of the barium esophagram for mucosa evaluation. EGD and biopsy both
LWBK1254-ch03_p29-42.indd 30 19/02/14 7:09 PM

Chapter 3 Fundoplication: Open Transabdominal Approach 31
diagnose and assess esophageal injury by visual and histopathologic mucosal exami-

nation. Visual assessment of esophageal injury is graded using the Los Angeles
classification. Histopathologic findings, although nonspecific, are confirmatory in

the clinical setting of GERD. The finding of specialized columnar epithelium (BE) in
the tubular esophagus is secondary to GERD. In the absence of dysplasia, surveillance
esophagoscopy and biopsy are required in patients with BE regardless of therapy. EGD
should be performed by the surgeon prior to surgery. The finding of a hiatal hernia
identifies failure of two elements of the reflux barrier: loss of (1) intra-abdominal
esophagus and (2) extrinsic sphincter. The following must be recorded: measurements
from the incisor teeth to the squamocolumnar junction, gastric rugal folds, and dia-
phragmatic hiatus; length of hiatal hernia; length of the esophagus; type of hiatal hernia;
presence of volvulus of the intrathoracic stomach; presence of mucosal abnormalities
(strictures, rings, etc.); and presence of mural abnormalities (submucosal tumors,
leiomyoma, etc.).
The definition of GERD requires causation of symptoms or complications by abnor-
mal reflux of gastric contents into the esophagus. Ambulatory pH monitoring performed
off medication both quantifies acid reflux and relates symptoms to acid exposure. It has
evolved from an in-hospital test to an ambulatory wireless 48-hour study. Once reserved
for diagnostic dilemmas, in the 21st century it is essential before any proposed opera-
tion. It is invaluable in diagnosing GERD and documenting the preoperative state for
later comparison. Excessive acid exposure on pH testing is a surrogate for reflux of
gastric contents into the esophagus, and in the majority of patients it is adequate to
diagnose GERD. Abnormal pH monitoring is the investigation most predictive of suc-
cessful outcome of surgery for GERD.1 In the uncommon patient in whom duodenal
reflux must be confirmed and quantified, ambulatory bilirubin monitoring is required.
Similarly, in the patient in whom nonacid reflux must be assessed, combined imped-
ance and pH monitoring is necessary.
Esophageal manometry excludes unsuspected motility disorders or motility disor-
ders masquerading as GERD, confirms adequate esophageal peristalsis for GERD surgery,
and quantifies preoperative resting pressure and relaxation of the lower esophageal
sphincter for later comparison. High-resolution manometry has replaced conventional
manometry because it provides a spatially enhanced pressure topogram, which is a
dynamic representation of the esophageal body and reflux barrier. It isolates the esopha-
geal hiatus from the lower esophageal sphincter (LES), increasing understanding of
function of the EGJ and facilitating treatment decision-making. For modern esophageal
evaluation, high-resolution manometry is invaluable and highly recommended.
If gastric emptying abnormalities are suspected by history or investigations, gastric
clearance assessment with radionucleotide tracers is necessary.
Patient Preparation
Patient preparation for surgery is that for general anesthesia and upper GI abdominal
surgery. Lifelong smoking cessation and realization of ideal weight and adequate nutri-
tion are important for avoidance of complications following elective surgery and opti-
mizing long-term outcome. A bowel prep is not standard and is reserved for special
situations, such as the chronically constipated patient. Perioperative antibiotics and
DVT prophylaxis are prescribed.
Surgery
Positioning and Instrumentation

After placement of an epidural catheter for perioperative pain management and induc-
tion of general anesthesia, the patient is placed supine on the operating table. The arms
are placed at the patient’s side and secured. The operating table, initially flat, will be
LWBK1254-ch03_p29-42.indd 31 19/02/14 7:09 PM

placed in 20-degree anti-Trendelenburg position to facilitate exposure. Both a sternal

retractor, which lifts the sternum and costal arch up and cephalad, and an abdominal
wall retractor, which separates the abdominal wound edges laterally, are used.
Technique
A midline abdominal incision starting at the xiphoid process and extending half the
distance to the umbilicus is usually adequate for exposure and repair. Reconstruction
of the EGJ follows three principles: restoration of intra-abdominal esophagus, recon-
struction of an extrinsic sphincter, and reinforcement of the intrinsic sphincter.
Restoration of Intra-abdominal Esophagus

The left lateral segment of the liver is mobilized by dividing the triangular ligament, then
retracted laterally to expose the esophageal hiatus. The pars lucida of the lesser omentum
over the caudate lobe of the liver is divided. If possible, but not mandatory, the hepatic
branch of the vagus and accompanying vasculature should be preserved. This exposes the
right crus. Dissection of the right crus is performed on its medial surface inside the hiatus
to protect its peritoneal covering. The dissection is carried anteriorly to define the apex of
the hiatus and posteriorly to define the confluence of the crura (Fig. 3.1).
The stomach is delivered into the abdomen using a hand-over-hand technique. The
short gastric vessels are divided, including the highest branch that typically obscures the
inferior portion of the left crus as this vessel passes posteriorly into the retroperitoneum.
This vessel is frequently not divided, leading to difficulty with later steps in the opera-
tion. This fundic mobilization allows the stomach to be retracted medially, exposing the
left crus, which is prepared similarly to the right crus. The dissection inside the hiatus
proceeds anteriorly to meet the right crural mobilization at the apex of the hiatus and
posteriorly to define the confluence of the crura. These steps divide the “hernia sac.”
Division, not removal of the hernia sac (removal is never complete from an infra-
diaphragmatic approach), is a key element of this dissection.
Figure 3.1 The left lateral segment of

the liver has been mobilized and the
lesser omentum divided. Dissection of
the right crus is performed on its
medial surface inside the hiatus to
protect its peritoneal covering. The
dissection is carried anteriorly to
define the apex of the hiatus and
posteriorly to define the confluence
of the crura. The hernia sac is divided
but not necessarily completely
excised. (Reprinted with permission,
Cleveland Clinic Center for Medical
Art & Photography © 2013. All Rights
Reserved.)
LWBK1254-ch03_p29-42.indd 32 19/02/14 7:09 PM

The hiatal dissection indirectly mobilizes the distal esophagus, which is encircled

with an umbilical tape or penrose drain. The dissection of the esophagus then proceeds
both bluntly and sharply in the posterior mediastinum until adequate length of intra-

abdominal esophagus is obtained. If the pleura is breached, particularly with large
paraesophageal hernia mobilization, drains may be placed into the respective pleural
spaces.
In certain patients, such as those with the much disputed diagnosis of short esopha-
gus, this esophageal dissection alone is inadequate to restore a sufficient length of intra-
abdominal esophagus. The diagnosis of a short esophagus should be made preoperatively.
It is suspected in patients with a history of peptic stricture or repeated esophageal
dilatation, long-segment BE, sliding (Type I) hiatal hernia more than 4-cm long,
paraesophageal (Type III and Type IV) hiatal hernia, or nonreducible hiatal hernia on
upright air-contrast barium esophagram. In such patients, adequate intra-abdominal
length is obtained by adding a Collis gastroplasty. This begins with dissection of the
esophagogastric fat pad, which is a key component of the preparation of the abdominal
esophagus, regardless of the need for a Collis gastroplasty (Fig. 3.2). This mobilization
selectively vagotomizes the gastroplasty segment. A 50-Fr bougie is passed orally and
held against the lesser curve and used as a guide and mold for formation of the gastro-
plasty tube. A 3- to 6-cm long tube of stomach is constructed along its lesser curve using
surgical staplers. With adoption of laparoscopy, esophageal lengthening has evolved
into a simple wedge gastroplasty, because of technical difficulties presented by lapar-
oscopy and misunderstanding of the principles of constructing a Collis gastroplasty.
Predictably, acid production in this unprepared gastric segment perpetuates GERD. A
Collis gastroplasty must be added in patients with short esophagus to assure sufficient
intra-abdominal esophageal length and thus eliminate one cause of the repair being
under tension (Fig. 3.3).
Failure to restore adequate intra-abdominal esophageal length produces a repair
under tension that will eventually fail. In patients with failed surgery, review of the
operative report may identify inadequate restoration of the intra-abdominal esophagus
as a reason for failure of the initial surgery.
Figure 3.2 mobilization of the

esophagogastric fat pad is essen-
tial to both identify the EGJ and
permit direct apposition of the
peritoneal surface of the fundus to
the bare surface of the distal
esophagus. This selectively vagot-
omizes the segment, allowing its
use as a gastroplasty tube if
necessary. (Reprinted with per-
mission, Cleveland Clinic Center
for Medical Art & Photography
© 2013. All Rights Reserved.)
LWBK1254-ch03_p29-42.indd 33 19/02/14 7:09 PM

A B
Figure 3.3 A Collis gastroplasty is constructed if necessary to provide a sufficient intra-abdominal length of esophagus in patients
with short esophagus. A 50-Fr bougie is passed orally and held against the lesser curve and used as a guide and mold for forma-
tion of the gastroplasty tube. A: The first step is production of the linear stapler entry site using a circular stapler approximately 3
to 5 cm below the esophagogastric junction. B: A linear cutting endostapler is then used to create a gastric tube along the lesser
curve. The bougie is removed after construction of the gastroplasty. (Reprinted with permission, Cleveland Clinic Center for Medical
Art & Photography © 2013. All Rights Reserved.)
Reconstruction of Extrinsic Sphincter

The esophageal hiatus, which serves as the extrinsic sphincter, is composed of a right
and left crus arising from the right crus of the diaphragm (Fig. 3.4A). The right crus of
the esophageal hiatus is nearly vertical and lies over the vertebrae, the left crus of the
esophageal hiatus is slightly more semicircular, slightly longer, and has no underlying
support. Progressive herniation of the stomach into the posterior mediastinum results
in minimal change of the length of the right crus but bowing and further elongation of
the left crus (Fig. 3.4B).
Suture closure of the esophageal hiatus to approximate its normal size is the essence
of hiatal reconstruction. The bougie placed to facilitate Collis gastroplasty is removed.
Its presence gives a false sense of security, since a tight repair can still be constructed
about a bougie regardless of its size. Also by stiffening the EGJ the chance for injury
during reconstruction is increased. Posterior to the esophagus, deep suture bites into
each crus, with slightly wider spacing on the left crus, constitutes standard reconstruc-
tion (Fig. 3.5). Although debated, an anterior stitch placed at the apex of the hiatus is
highly recommended. This repair should be done with robust (size 0 or 1) nonabsorb-
able suture. On completion of this reconstruction, the hiatal aperture should permit the
insertion of the surgeon’s index finger to its distal interphalangeal joint posterior to the
esophagus containing an 18F nasogastric (NG) tube. For a severely disrupted hiatus, a
complex reconstruction is required. The left crus is plicated to normalize crural length,
permitting a standard hiatal reconstruction (Fig. 3.6).
The importance of hiatal reconstruction was not appreciated or stressed in the early
laparoscopic experience (Figs. 3.5 and 3.6). Recurrent hiatal hernia was the most com-
mon cause of failure in early experience of laparoscopic GERD surgery. Attempts to
solve this problem led to reinforcing of marginal hiatal reconstructions or primary
reconstruction of the esophageal hiatus with prosthetic mesh. This strategy presents
three problems: (1) It treats the hiatus as a hole to be covered, ignoring its function in the
reflux barrier; (2) it disregards the dynamic nature of the reflux barrier, resulting in the
disastrous complication of mesh erosion into the gastrointestinal tract; and (3) it
obstructs if applied aggressively. The use of biosynthetic mesh to reinforce hiatal recon-
struction has not reduced recurrence in repair of paraesophageal hiatal hernia in
LWBK1254-ch03_p29-42.indd 34 19/02/14 7:09 PM

Figure 3.4 The esophageal hiatus.

A: The esophageal hiatus lays to
the patient’s left of the inferior vena

cava and above and typically to the
right of the aorta. It arises from the
right diaphragmatic crus and is
composed of a right and left crus.
The right crus of the esophageal
hiatus (yellow) is nearly vertical
and lies over the vertebrae, and the
left crus of the esophageal hiatus
(blue) is slightly more semicircular,
slightly longer, and has no underly-
ing support. B: The left crus.
A Abdominal forces (large blue
arrow) acting on the left crus.
These forces stretch and elongate
the left crus and displace it to the
left and posterior (small blue
arrows). (Reprinted with permis-
sion, Cleveland Clinic Center for
Medical Art & Photography
© 2013. All Rights Reserved.)
long-term follow-up.2,3 The use of mesh in reconstruction of the external sphincter

should be discouraged.
Reinforcement of Intrinsic Sphincter

The most problematic, variably conducted, and operator-dependent portion of recon-
struction of the EGJ is fundoplication, reinforcement of the LES. The prior steps attempt
to restore and reconstruct; however, reinforcing the LES produces an unnatural and
potentially problematic volvulus of the gastric fundus, which utilizes the capacitance
portion of the stomach. Typically in North America, this involves division of short
gastric vessels and a 360-degree total fundoplication (Nissen) (Fig. 3.7). Although con-
troversial and cited as a cause of postoperative dysphagia, for accomplished surgeons,
constructing a fundoplication without division of short gastric vessels (Rossetti modi-
fication) can produce results similar to those reported with division of these vessels.
Similarly, agreement over the extent of fundoplication has not been reached. Some
surgeons, mostly outside the United States, have favored 270-degree partial posterior
fundoplication (Toupet), citing less dysphagia, fewer postprandial fundoplication symp-
toms, and similar reflux control compared with total fundoplication. However, a study
with long-term follow-up reported resolution of post-fundoplication symptoms with
time and similar long-term results regardless of the extent of fundoplication.4 In the
United States, the general feeling is that Nissen fundoplication provides better reflux
control with more, but transient symptoms. The debates continue, but these issues
illustrate how surgeon dependent and subjective this portion of the operation can be.
LWBK1254-ch03_p29-42.indd 35 19/02/14 7:09 PM

Figure 3.5 Standard reconstruc-

tion of the esophageal hiatus.
A: Nonabsorbable sutures are
placed with deep bites into each
crus, avoiding the inferior vena
cava on the patient’s right and
aorta on the left. Anteriorly 1 to 2
sutures are necessary for durable
hiatal reconstruction. Posteriorly,
unequal spacing of sutures is
required: normal distance between
sutures in the left crus, and
slightly smaller distance between
sutures in the right crus. This
serves to shorten the minimally
elongated left crus. A sufficient
number of sutures is placed to
return the hiatus to its original,
normal size. B: The sutures are
tied, completing the reconstruc-
tion. (Reprinted with permission,
Cleveland Clinic Center for Medi-
cal Art & Photography © 2013.
A
All Rights Reserved.)
For Nissen and Toupet fundoplications, the previously mobilized fundus is passed
posterior to the intra-abdominal esophagus to lie freely on the right side of the patient’s
intra-abdominal esophagus. The to-and-fro rocking of the fundus, the so-called “shoe-
shine” maneuver, assures the tension-free delivery and positioning of the fundus. The
prior esophagogastric fat pad mobilization 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.
Total fundoplication requires encircling the distal 2 to 3 cm (2 cm anteriorly) of the
esophagus or Collis gastroplasty with the fundus (Fig. 3.7B). The first (lowest) fundopli
cation suture passes through the anterior seromuscular layer of the fundus lying on
the patient’s left adjacent to the esophagus. The suture is then passed through the ante-
rior esophageal musculature at 12 o’clock just above the EGJ and through the adjacent
anterior seromuscular layer of the fundus lying on the patient’s right adjacent to the
esophagus. A second suture is similarly placed 1 cm above this. The final (highest)
fundoplication suture is placed 1 cm above the second suture (2 cm above the first
fundoplication suture) in an identical fashion. These sutures are tied, creating a loose,
LWBK1254-ch03_p29-42.indd 36 19/02/14 7:09 PM

Figure 3.6 Complex reconstruction

of the severely disrupted hiatus as
necessary in paraesophageal

(Type III and Type IV) hiatal her-
nias. A: The massively elongated
left crus is plicated to normalize
crural length. B: A standard hiatal
reconstruction is then possible,
between the crura, now of equal
length. (Reprinted with permission,
Cleveland Clinic Center for Medi-
cal Art & Photography © 2013. All
Rights Reserved.)
floppy, 360-degree, total fundoplication that covers the distal 2 cm of the esophagus
and lies in the abdominal cavity under no tension. The superior aspect of the right and
left leaves of the fundoplication may be sutured to the diaphragm to reinforce the intra-
abdominal location of the fundoplication.
Toupet fundoplication requires posterior 270-degree encirclement of the distal
3 cm of the esophagus or Collis gastroplasty with the fundus. The portion of the fun-
doplication that lies on the patient’s left may be constructed first. The first (lowest)
fundoplication suture passes through the anterior seromuscular layer of the fundus
lying on the patient’s left, adjacent to the esophagus. The suture is then passed through
the anterior esophageal musculature at 2 o’clock just above the EGJ. A second suture
is similarly placed 1.5 cm above this. The final (highest) fundoplication suture is
placed 1.5 cm above the second suture (3 cm above the first fundoplication suture)
and passes through the anterior seromuscular layer of the fundus lying on the patient’s
left adjacent to the esophagus, through the anterior esophageal musculature at
2 o’clock, and finally through the left crus just below its apex. These sutures are tied,
LWBK1254-ch03_p29-42.indd 37 19/02/14 7:10 PM

A B
Figure 3.7 Nissen fundoplication. A: It is advisable to divide the short gastric vessels to facilitate fundoplication and maintain the
orientation of the fundus. The orientation and later approximation of the anterior wall (pink) and the posterior wall (blue) should be
maintained. B: The fundus is passed posterior to the esophagus to lie on its right. It is critical to maintain the correct orientation of
the stomach. Sutures are passed through the greater curve aspect of the rightward lying fundus, then through anterior muscularis
propria of the esophagus, and finally through the greater curve aspect of the leftward lying fundus. Usually three sutures are used
to construct a 2 cm long (measured anteriorly) fundoplication. The use of a bougie during construction of the fundoplication is
discouraged, since it does not guarantee either a loose or floppy fundoplication. In fact, it may foster poor technique by allowing
the surgeon to assume that the presence of a bougie will prevent misconstruction of the fundoplication. (Reprinted with permission,
Cleveland Clinic Center for Medical Art & Photography © 2013. All Rights Reserved.)
creating the left anterior aspect of the fundoplication. The right-sided sutures are
placed next. The first (lowest) fundoplication suture passes through the anterior
seromuscular layer of the fundus lying on the patient’s right adjacent to the esopha-
gus. The suture is then passed through the anterior esophageal musculature at 10
o’clock, just above the EGJ. A second suture is similarly placed 1.5 cm above this. The
final (highest) fundoplication suture is placed 1.5 cm above the second suture (3 cm
above the first fundoplication suture) and passes through the anterior seromuscular
layer of the fundus lying on the patient’s right adjacent to the esophagus, through the
anterior esophageal musculature at 10 o’clock, and finally through the right crus just
below its apex. These sutures are tied, creating a loose, floppy, 270-degree, partial
posterior fundoplication that covers the distal 3 cm of the esophagus and lies in the
abdominal cavity under no tension.
Components of fundoplication—length, looseness, floppiness, position, and extent
of fundoplication—have to be meticulously, precisely, and repeatedly constructed despite
variable gastric dimensions and anatomy. The potential for error and post-fundoplication
problems is enormous (Fig. 3.8).
Closure of the abdominal wound completes the surgery.
LWBK1254-ch03_p29-42.indd 38 19/02/14 7:10 PM


A B
C D
Figure 3.8 Some fundoplication mistakes. A: A tight fundoplication, B: A twisted fundoplication, C: A slipped fundoplication,
D: A tight and slipped fundoplication. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2013.
All Rights Reserved.)
LWBK1254-ch03_p29-42.indd 39 19/02/14 7:10 PM

Smooth reversal of the anesthetic and prompt extubation without retching is crucial to
avoid early stressing of the repair. An NG tube, although not mandatory, is preferable
to avoid gastric distension early in the postoperative course. It may be removed promptly
when gastric function is sufficient to avoid distension. With return of bowel function,
liquids are started and the patient is advanced to a soft diet prior to discharge, typically
on the fourth or fifth postoperative day. The patient is instructed to avoid diaphragmatic
stressors, i.e., activities that raise intra-abdominal pressure excessively, such as heavy
lifting and straining at stool.5
Complications
Intraoperative complications specific to dissection at the esophageal hiatus include
pneumothorax and injury to the esophagus, stomach and spleen. Immediate intraop-
erative esophagogastroscopy is imperative to access for any suspected upper gastroin-
testinal injury. Care must be taken in mobilization of the liver and dissection about the
inferior vena cava and aorta. These dissections are more problematic at reoperation.
Early postoperative complications include bleeding, early disruption of the repair with
recurrent hiatal hernia, leakage from the esophagus or stomach, subphrenic abscess, and
pancreatitis. In the past, barium esophagram has been used in early postoperative imag-
ing for investigation of possible complications; however, chest and abdominal CT scans
with contrast provide exquisite anatomic display while evaluating for GI and vascular
contrast abnormalities. A review of Swedish administrative databases reported that in
comparable patients mortality and morbidity were similar between open and laparo-
scopic surgery.6
Dysphagia and gas bloat (post-fundoplication syndrome) are bothersome postop-
erative complications. Establishing realistic expectations at initial evaluation and pre-
operative education and preparation will facilitate management of these usually early
and transient problems. Rarely will dilatation be necessary in the management of dys-
phagia and should be avoided if possible. Gas bloat can be more problematic, particu-
larly in patients who have developed the habit of aerophagia and belching as an
element of their GERD. This troublesome symptom is the result of loss of the capaci-
tance function of the fundus and the establishment of a substantial antireflux barrier
in place of the defective preoperative sphincter mechanism. Persistent gas bloat despite
the passage of time and dietary and lifestyle modification may signal a malformed
fundoplication. As with all hernia surgery, a repair under tension or persistence
of preoperative aggravating factors will produce a recurrent hernia and the need for
reoperation.
Results
Randomized Trials
A randomized controlled study reported by Spechler and colleagues may be dismissed
today because it compared open surgery with H2 blocker medical therapy.7 However, it
provides an excellent picture of the results of surgery. Follow-up at a mean of 10.6 years
demonstrated that 63% of surgical patients were taking antireflux medication, compared
with 92% of medically treated patients. Symptom control on medication was no different
between groups; however, symptom control off medication was significantly worse for
surgical patients. There was no difference between the groups in grade of esophagitis,
frequency of treatment of esophageal stricture, subsequent surgery, quality of life (SF-36
survey), and overall satisfaction with therapy. For the surgical group, 16% required at least
LWBK1254-ch03_p29-42.indd 40 19/02/14 7:10 PM

one reoperation and 14% required treatment of esophageal stricture. The authors con-

cluded “antireflux surgery should not be advised with the expectation that the patient
with GERD will no longer need to take antisecretory medication.” Since this study was

conducted in the late 1990s, more effective medical therapy has become available; the
same cannot be said for surgery.
A randomized study comparing open surgery to PPI therapy in GERD was con-
ducted by Lundell and colleagues.8 Treatment failure was the outcome measure. It was
defined as (1) moderate-to-severe heartburn or acid regurgitation in the 7 days prior to
assessment, (2) at least grade II esophagitis, (3) moderate or severe dysphagia or
odynophagia in combination with mild heartburn or regurgitation more than 3 months
after operation, or (4) reoperation or PPI required for more than 8 weeks for symptom
control or consideration or request for surgery by a physician or patient. There were
significantly more treatment failures in the medical group (55% vs. 47%) at 12 years
following randomization. With dose escalation of PPI, this difference still remained
significant. Although GERD control was superior with open surgery, dysphagia, rectal
flatulence, and inability to belch or vomit were significantly more common than in the
medical group. Change in therapeutic strategy was less common in PPI patients (15%
vs. 38%). Quality of life was similar, and within normal range, for both therapies.
Nonrandomized Trials
An interesting query of the VA database identified 5,606 patients who had esophagitis
with ulcers and strictures; 542 had fundoplication.9 At a mean follow-up of 4.2 years,
surgery in the ulcer or stricture patients was better than nonsurgical therapy, with
esophagitis reported in 46% versus 56% (p <0.001), ulcers 33% versus 38% (p <0.05),
and strictures 32% versus 43% (p <0.001), respectively. There was no difference in
number of outpatient visits and procedures between groups. The clinical significance
of these statistically significant improvements is questionable. In 30,119 nonerosive
esophagitis patients, 605 had fundoplication. There was no difference in esophagitis
between surgery and nonsurgical therapy, 24% versus 25%. However, in the surgical
group without strictures or ulcers, there was more dysphagia, 4.6% versus 2.6% (p not
given), more outpatient visits, 40 versus 34 (p <0.05), and more outpatient procedures,
4.3 versus 2.7 (p <0.01). Repeat surgery was required in 2.3% of surgery patients with-
out ulcers and strictures and 5.1% with.
Rantanen and associates10 reported the outcomes of 45 patients in community-based
practices who underwent open GERD surgery and were followed a mean of 78 months.
Eighty-five percent were free of or had mild reflux, 31% reported dysphagia, 67% flatu-
lence, and 46% bloating. Of 35 who had esophagoscopy, 37% had a defective fundoplica-
tion and 29% erosive esophagitis. Thirteen percent required antireflux medication and 13%
were scheduled for reoperation; two had reoperation in the follow-up period. The frequency
of GERD surgery for six surgeons ranged from 0.08 per year to 1.8 operations per year.
The problem of recurrence after paraesophageal hernia repair was highlighted early in
the laparoscopic experience.11 At this time, laparoscopic repair was associated with triple
the recurrence of open surgery. With acceptance of the principles of hiatal hernia repair,
including addition of esophageal lengthening and attention to crural closure, the rates of
recurrence are now reported to be similar between open and laparoscopic approaches.
However, the reported recurrence in 18% of patients at 12- to 18-month follow-up in the
hands of world-renowned surgeons illustrates the problems with durable paraesophageal
hernia repair. Mesh reinforcement of the hiatal repair is not the answer.2,3
Conclusions
Reconstruction of the EGJ that includes fundoplication is indicated in the treatment
of GERD and symptomatic paraesophageal hiatal hernia, except in the severely obese
or morbidly obese patient. History and physical examination are essential in patient
selection. Mandatory investigations include EGD and biopsy, barium esophagram,
LWBK1254-ch03_p29-42.indd 41 19/02/14 7:10 PM

high-resolution manometry, and pH monitoring. Repair requires reconstruction of the

EGJ. The principles of repair are restoration of the intra-abdominal esophagus, recon-
struction of the extrinsic sphincter, and reinforcement of the intrinsic sphincter. Dys-
phagia and gas bloat are typically transient. Long-term results are good if the above
steps are followed. Recurrence is a particularly troublesome problem in the repair of
paraesophageal hernias. However, as with all hernia surgery…
“Never do a hernia repair once that you are not prepared to do again.”
Anonymous
Recommended References and Readings 6. Rantanen TK, Oksala NKJ, Oksala AK, et al. Complications in
antireflux surgery: National-based analysis of laparoscopic and
1. Campos GM, Peters JH, DeMeester TR, et al. Multivariate analy- open fundoplications. Arch Surg. 2008;143:359–365.
sis of factors predicting outcome after laparoscopic Nissen fun- 7. Spechler SJ, Lee E, Ahnen D, et al. Long-term outcome of med-
doplication. J Gastrointest Surg. 1999;3:292–300. ical and surgical therapies for gastroesophageal reflux disease:
2. Oelschlager BK, Pellegrini CA, Hunter JG, et al. Biologic Follow-up of a randomized controlled trial. JAMA. 2001;285:
prosthesis to prevent recurrence after laparoscopic paraesopha- 2331–2338.
geal hernia repair: Long-term follow-up from a multicenter, 8. Lundell L, Miettinen P, Myrvold HE, et al. Comparison of out-
prospective, randomized trial. J Am Coll Surg. 2011;213: comes twelve years after antireflux surgery or omeprazole main-
461–468. tenance therapy for reflux esophagitis. Clin Gastroenterol Hepatol.
3. Rice TW, Blackstone EH. Biologic prosthesis and laparoscopic 2009;7:1292–1298.
paraesophageal hernia repair: “It ain’t over till it’s over”. J Am 9. El-Serag HB, Sonnenberg A. Outcome of erosive reflux esophagi-
Coll Surg. 2012;215:157–158. tis after Nissen fundoplication. Am J Gastroenterol. 1999;94:
4. Mardani J, Lundell L, Engström C. Total or posterior partial 1771–1776.
fundoplication in the treatment of GERD: Results of a rand- 10. Rantanen TK, Halme TV, Luostarinen ME, et al. The long term
omized trial after 2 decades of follow-up. Ann Surg. 2011;253: results of open antireflux surgery in a community-based health
875–878. care center. Am J Gastroenterol. 1999;94:1777–1781.
5. Kakarlapudi GV, Awad ZT, Haynatzki G, et al. The effect of dia- 11. Zehetner J, Demeester SR, Ayazi S, et al. Laparoscopic versus
phragmatic stressors on recurrent hiatal hernia. Hernia. 2002; open repair of paraesophageal hernia: The second decade. J Am
6:163–166. Coll Surg. 2011;212:813–820.
LWBK1254-ch03_p29-42.indd 42 19/02/14 7:10 PM

4 Transthoracic Nissen
Fundoplication
Alex G. Little and Jonathan Daniel
Introduction
Thoracic surgeons have demonstrated a consistent interest in the treatment of gastro-
esophageal reflux disease (GERD) and hiatal hernia and in fact were the pioneers of
antireflux surgery. Allison first addressed the challenge, operating through a left thora-
cotomy with a transthoracic repair of the hiatal hernia that was present in symptomatic
patients. His procedure resulted in an anatomically successful herniorrhaphy but did
not improve patients’ symptoms as they continued to have both heartburn and endo-
scopic esophagitis after surgery. This experience led him to the conclusion that the
necessary surgical approach would have to rearrange the tissues to restore competence
to the cardia and curtail acid reflux, not just address the hernia. The two major con-
tributors to this step were Ronald Belsey and Rudolf Nissen. Belsey in Bristol, England
applied principles derived from his clinical experience and thoughtful analysis to a
transthoracic approach. After less satisfactory earlier versions, he settled on his Mark IV
procedure in the 1950s. Considering publishing of early results anathema, he held off
reporting his outcomes until he had accrued an experience with over 1,000 patients with
long-term evaluation of nearly all patients in his follow-up clinic. Nissen in 1937 first
identified the reflux curtailing effect of a gastric wrap of the distal esophagus when he
implanted the esophagus into the stomach with a “gastroplication” following transtho-
racic resection of the cardia in a young man in Istanbul. Nissen evolved his operation
during subsequent stays in the United States and Switzerland into a gastric wrap around
the distal esophagus, performed through a thoracotomy or laparotomy and frequently
accompanied by a gastropexy attaching the gastric fundus to the anterior abdominal wall.
Both these procedures have documented efficacy over the years, albeit each with
its own results and side effects. Ultimately, the Nissen became the more popular oper-
ation as it could be performed through a laparotomy, so the patient could avoid the
pain and discomfort typically associated with a thoracotomy. The advent of laparo-
scopic surgery has even further established the abdominal approach and consequently
the Nissen procedure as the preferred one for almost all patients. The Nissen operation,
with significant modifications from the original description, remains the antireflux
operation of choice. Alternative options such as the Hill, Toupet, and Dor procedures
have their advocates but have not yet supplanted Nissen’s procedure.
43
LWBK1254-ch04_p43-50.indd 43 19/02/14 6:58 AM

Indications for Transthoracic Approach

Consideration of antireflux surgery is appropriate under several circumstances, which
are well documented in Chapters 1 and 3. Briefly, operation is reasonable to consider
when the patient’s symptoms persist despite medical management, there are reflux
complications such as continuing regurgitation, persistent esophagitis or stricture, or
repair of a giant hiatal hernia is necessary.
Absolute Indications
The majority of patients needing first operations for GERD or giant hiatal hernia can
and should be operated with a laparoscopic approach. There are few absolute indica-
tions for a thoracic approach. An important instance is when the need to resect the
distal esophagus is a distinct possibility. Examples of this scenario include patients
with a chronic stricture that is resistant to dilation or who have a distal esophagus
anatomically or functionally damaged by prior operations. Preserving a poorly or non-
functional esophagus is not a surgical victory. Replacing the diseased esophagus with
a healthy and functional alternative such as a colonic or jejunal interposition, while a
significant undertaking, is preferable as it gives the patient the best postoperative qual-
ity of life. Patients particularly at risk for needing and benefitting from resection and
reconstruction with healthy tissue, such as the left colon, are those having a second or
even third reoperation (i.e., a third or fourth operation). If resection is required and the
surgeon is in the abdomen through a laparotomy, it may not be possible to get cephalad
to the damaged esophagus to perform an anastomosis to healthy, functional esophagus
through the hiatus. Of course, if the surgeon has performed a left thoracotomy but a
resection is not necessary, nothing is lost as an antireflux operation is performed
through the left chest with the transthoracic exposure providing the opportunity to
generously mobilize the esophagus and add a Collis gastroplasty. Another occasional
reason for a thoracic approach, in addition to the concern that a resection will be
required, is when a patient has other thoracic pathology requiring attention, such as a
lung mass.
Relative Indications
Relative indications for choosing a thoracic approach include the uncommon short
esophagus associated with chronic reflux and/or stricture or giant hiatal hernia. My
experience is that the short esophagus is an acquired condition caused by chronic and
uncontrolled reflux producing fibrosis and scarring, rather than being a congenital
condition. Although a laparoscopic approach, including performance of a Collis gas-
troplasty is possible, in this situation a surgeon may feel that the thoracic approach
allows helpful access to perform mobilization of the mediastinal esophagus and pro-
vides the historically standard approach for performance of a Collis gastroplasty, two
steps in ensuring a tension-free reduction of the gastric wrap below the diaphragm, an
essential component of a successful antireflux procedure. Another relative indication
for choosing to operate through a thoracotomy is a patient having a redo procedure
and the surgeon considers a thoracic approach necessary because of improved access
to the cardia and the ability to mobilize the thoracic esophagus to obtain sufficient
length for a tension-free reduction of the fundoplication below the diaphragm. This is
an issue of surgical judgment and experience as reoperation can be carried out by
laparotomy or even laparoscopy. The same scenario applies to repair of giant or
paraesophageal hiatal hernias, which some surgeons still prefer to repair transthoraci-
cally. Finally, significant obesity increases the challenge of the abdominal approach;
however, if patients are morbidly obese, they are better served by a bariatric procedure
which addresses both the obesity and the reflux. These relative indications for a trans
thoracic approach are all issues of the judgment and experience of the operating
surgeon.
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Chapter 4 Transthoracic Nissen Fundoplication 45

Preoperative pLANNING

To delineate the anatomy and assess the status of the esophagus and stomach, both
upper gastrointestinal x-rays and upper gastrointestinal endoscopy (ideally by the oper-
ating surgeon) should be performed. Depending on the preoperative diagnosis, func-
tional studies including pH monitoring and esophageal motility studies are important.
If the planned procedure is a reoperation, the operative notes from the earlier operations
should be reviewed, so there is knowledge of what and how tissues have been dissected
and/or divided and motility evaluation is essential so the surgeon can predict the abil-
ity of the esophagus to function sufficiently postoperatively.
Surgery
Surgical Access
Thoracic antireflux procedures are performed through a left lateral thoracotomy in the
sixth or seventh interspace. A posterior extension is not necessary. If access to the abdo-
men is required, the lower interspace provides better visibility below the diaphragm
and the incision is carried anteriorly to within 5 cm of the costal margin, but not across,
as dividing the costal margin is quite painful and not necessary. For adequate exposure
of the operative field, I encourage dividing the latissimus dorsi routinely. The serratus
is partially divided as necessary for visibility. Resecting a portion of the inferior rib
posteriorly, beneath the mobilized erector spinae muscle allows rib spreading without
unintended fractures, again minimizing postoperative pain.
The ipsilateral lung is deflated with the use of a double-lumen endotracheal tube, all
adhesions from previous operations are lysed, the inferior pulmonary ligament is divided
up to the inferior pulmonary vein, and the collapsed lung is packed out of the field with
a moist laparotomy pad. The mediastinal pleura is incised, and the esophagus is delivered
with finger dissection and held with a Penrose drain. If there is scarring from previous
operative dissection, it is best to start the mediastinal dissection cephalad to areas of
previous dissection, so the esophagus can be identified and mobilized easily and safely.
Both vagus nerves should be surrounded with the Penrose drain and brought with the
esophagus as dissection proceeds to free the esophagus from just inferior to the aortic
arch to the hiatus.
If this is the patient’s first operation, the cardia can be mobilized through the hiatus.
The dissection is begun by incising the phrenoesophageal membrane and peritoneum
anteriorly (Fig. 4.1). The surgeon then can control the dissection with the index finger of
the left hand and thumb grasping the distal esophagus in the abdomen and controlling
the cardia through the incision in the phrenoesophageal membrane (Fig. 4.2). With this
control, the hiatus is dissected until the distal esophagus and cardia are completely free.
The vagus nerves are protected both by tactile and visual tracking during the mobiliza-
tion. To construct a Belsey Mark IV fundoplication, no further dissection is usually
required. For a Nissen fundoplication, division of enough of the short gastric vessels to
allow the fundus to be adequately delivered into the chest is necessary. This is done by
exerting gentle traction on the fundus so that these vessels can be sequentially identified,
ligated, and divided as they emerge through the hiatus (Fig. 4.3). This sufficiently mobi-
lizes the fundus so that a wrap can be performed. It must be kept in mind that the wrap
is being constructed in an artificial location, that is, the chest, but will be returned to and
reside in the abdomen, which means truly needing a “floppy” fundus so it can reach up
through the hiatus.
In the instance of a reoperation, this complete mobilization at the hiatus and of the
fundus cannot be adequately and safely completed through the hiatus because of scar-
ring and adhesions to the hiatus and, intra-abdominally, between the cardia/fundus and
the diaphragm, retroperitoneum, and liver. The original gastric wrap is also typically
LWBK1254-ch04_p43-50.indd 45 19/02/14 6:58 AM

Figure 4.1 After fully mobilizing the

esophagus, the phrenoesophageal mem-
brane is identified beneath the hiatal
muscle rim anteriorly and incised, provid-
ing access to the abdomen.
Hiatal
muscle
Phrenoesophageal Esophagus
membrane
Figure 4.2 With the surgeon’s left index

finger passed posterior to the esopha-
gus in the abdomen, the remaining
posterior attachments of the cardia to
the hiatus are divided. The vagus
nerves are protected from harm by
being sequestered within the surgeon’s
hand.
Figure 4.3 Gentle cephalad traction

Left vagus nerve
delivers the fundus through the hiatus.
Short gastric vessels are sequentially
Short gastric ligated and divided until a generous
arteries amount of fundus has been released
and lies easily within the chest.
LWBK1254-ch04_p43-50.indd 46 19/02/14 6:58 AM

Diaphragm Figure 4.4 This illustrates the left upper

quadrant exposure after peripheral
incision of the diaphragm. Diaphragm

function is not impaired as the incision
Stomach is parallel to and does not transect
branches of the phrenic nerve.
Spleen Esophagus
Aorta
adhesed to the fundus and terminal esophagus and original sutures are still present,
even if the wrap has herniated and/or partially dehisced. To safely attain needed mobi-
lization, dissection within the abdomen is necessary. This access is gained by incising
the diaphragm peripherally, 2 to 3 cm from the chest wall attachment, starting anteriorly
at the pericardial fat pad and going posteriorly as needed, usually far enough to provide
exposure of the gastrosplenic ligament and its short gastric vessels (Fig. 4.4). Dissection
then proceeds from above and below the hiatus until the distal esophagus, cardia, and
proximal fundus are free of adhesions and are mobile. The preexisting wrap, which is
typically partially dehisced and/or around the stomach rather than the esophagus, is
taken down. This requires cutting the original fundus-to-fundus sutures. At the conclu-
sion of the operation, the diaphragmatic incision is closed with a series of interrupted
or near/far–far/near sutures.
Nissen Fundoplication
The Nissen procedure entails a 360-degree transversely oriented wrap of fundus around
the distal esophagus for a length of approximately 2 cm with subsequent closure of the
hiatus. Other than the surgeon’s visual perspective and the need to deliver the fundus
sufficiently to construct the wrap in the chest before returning it to its final home
below the diaphragm, there are no differences in the steps and final appearance of this
operation because of the approach used for it, abdominal or thoracic. When full mobi-
lization of esophagus, cardia, and fundus has been accomplished, the surgeon
assesses the ability to reduce without tension, the terminal few centimeters of the
esophagus below the hiatus. If this is not possible, a Collis gastroplasty is necessary
as described below.
The initial steps are described in the Surgical Access section. Whether the fundus
is approached through the hiatus only or through a combined hiatal and transdiaphrag-
matic dissection, division of all attachments—to the distal mediastinum, the hiatus
itself, and upper abdominal structures, including division of several proximal short
gastric vessels—is required. These release steps allow the fundus to be drawn into the
chest where the wrap will be performed, prior to its return to the abdomen.
After mobilization, the ability to reduce the distal esophagus is determined. If this
is the case, stout sutures, such as 0 silk, are placed in the hiatus posterior to the esopha-
gus but not yet tied. The fundus is then rotated in counterclockwise fashion around the
LWBK1254-ch04_p43-50.indd 47 19/02/14 6:58 AM

A B
Stomach
Figure 4.5 A: The Nissen wrap is constructed by rotating the mobile fundus around the distal esophagus. B: Three sutures between
the two fundic limbs of the wrap for a suture line length of approximately 2 cm are ideal.
distal esophagus where it is secured with three sutures separated by 1 cm, resulting in
a 2-cm wrap (Fig. 4.5). The sutures are placed between the anterior and posterior aspects
of the fundus while holding the posterior fundus in place with the left hand and incor-
porating a bite of esophageal muscle with each suture. Typically the surgeon is aware
of some vertical tension on the fundus because of the necessity to tug it into the chest;
however, once the wrap is reduced to its home below the diaphragm, all tension
resolves. The routine placement of an esophageal dilator during the wrap construction
is not as helpful as for a laparoscopic Nissen procedure, as the “stretch” of the fundus
into the chest results in sufficient looseness of the wrap when returned into the abdo-
men; however, this step can be added if desired.
When esophageal lengthening is appropriate to achieve a final vertical tension-free
placement of the gastric wrap and the surrounded distal esophagus below the diaphragm,
a Collis gastroplasty is constructed (Fig. 4.6). The anesthesiologist transorally passes a
Maloney bougie, usually size 36 French, which the surgeon guides into the stomach.
The mobilized fundus is lifted, and a GIA stapler is pressed firmly against the bougie,
which is pressed against the lesser curve of the stomach. When the stapler is fired, a
gastric tube is created of the same caliber as the esophagus, effectively producing a
“neoesophagus.” The remainder of the operation is as described above with the final
gastric wrap surrounding this neoesophagus, resulting in the Collis–Nissen procedure.
The final step, with the wrap lying peacefully in the abdomen and demonstrating
no tendency to herniate, is to sequentially tie the previously placed sutures in the hia-
tus, starting posteriorly and moving anteriorly. The final size of the hiatal opening
around the esophagus should be sufficient to accommodate the esophagus and the tip
of the surgeon’s index finger but with resistance when the distal interphalangeal joint
encounters the hiatal muscle.
As no lung resection has been performed, patients are typically extubated in the
operating room. The chest tube is removed when drainage is acceptable. I leave a
LWBK1254-ch04_p43-50.indd 48 19/02/14 6:58 AM

Figure 4.6 A Collis type gastroplasty

to functionally lengthen the esopha-
gus in preparation for a Collis–Nissen

procedure is depicted. It is important
to firmly press the stapler and dilator
against the lesser curve of the stom-
5 cm ach so the diameter of the created
gastric tube (the neoesophagus) is
not larger than the diameter of the
esophagus.
nasogastric tube in place for the first night, or longer if drainage is excessive, to be
sure the stomach is emptying satisfactorily to prevent gastric distension, which chal-
lenges the wrap and a staple line if a Collis gastroplasty is present. Oral feeding is
started with liquids 1 day after nasogastric tube removal and the patient is sent home
when taking sufficient amounts of liquids. Subsequently the diet is advanced as toler-
ated with most patients on an unrestricted diet within 2 weeks.
Complications
In addition to the nonspecific risks, such as deep vein thrombosis and postoperative
bleeding, the complications specific to this operation are pulmonary and gastroesopha-
geal. The lung is deflated during the operation, producing some residual atelectasis, and
the thoracotomy-induced pain discourages deep breathing and coughing. Consequently,
attention to pulmonary toilet is essential. Gastroparesis with delayed gastric emptying
can occur if the vagus nerves are contused or divided, distinct possibilities if a reop-
eration has been performed. Therefore, I leave a nasogastric tube until I am confident
the stomach is functioning satisfactorily. If delayed gastric emptying becomes a chronic
issue, prokinetic agents are useful as well as Botox injections of the pylorus.
Results
The outcomes of this operation depend in large part on the indications for it. Most fre-
quently, a transthoracic Nissen procedure is performed as a reoperation following one or
two failed prior operations for reflux. Experiences show that depending on the number of
previous operations, good to excellent results are obtained in between 50% and 85% of
patients. The more prior operations, the worse the outcome, stressing the need for the sur-
geon to carefully balance the desire to “save” the esophagus against the benefits of resection
of the nonfunctional esophagus and replacing it with healthy stomach, colon or jejunum.
LWBK1254-ch04_p43-50.indd 49 19/02/14 6:58 AM

Conclusions
n A succinct history of antireflux surgery shows the leadership role of thoracic sur-
geons.
n Indications for antireflux procedures include recalcitrant GERD and repair of giant
(paraesophageal) hiatal hernia.
n An absolute indication for a transthoracic approach is the potential need for an
esophageal resection because of stricture or functional or anatomic injury from previ-
ous surgery.
n Relative indications for a transthoracic approach are a short esophagus, prior surgery,
and obesity.
n Operative principles include a left thoracotomy, generous mobilization of the esopha-
gus and cardia, construction of a loose and short Nissen wrap, and secure closure of
the hiatus.
n Postoperative morbidity is reasonable and long-term results vary according to the
original surgical indications.
Recommended References and Readings 4. Nissen R. Gastropexy and “fundoplication” in surgical treatment
of hiatal hernia. Am J Dig Dis. 1961;6:954–961.
1. Allison PR. Reflux esophagitis, sliding hiatal hernia, and the 5. Skinner DB, Belsey RH. Surgical management of esophageal
anatomy of repair. Surg Gynecol Obstet. 1951;92:419–431. reflux and hiatus hernia. Long-term results with 1030 patients.
2. Liebermann-Meffert D. Rudolf Nissen: Reminiscences 100 years J Thorac Cardiovasc Surg. 1967;53:33–54.
after his birth. Dis Esoph. 1996;9:237–246. 6. Stirling MC, Orringer MB. Continued assessment of the com-
3. Little AG, Ferguson MK, Skinner DB. Reoperation for failed antire- bined Collis-Nissen operation. Ann Thorac Surg. 1989;47:224–
flux operations. J Thorac Cardiovasc Surg. 1986;91:511–517. 230.
LWBK1254-ch04_p43-50.indd 50 19/02/14 6:58 AM

5 Belsey Mark IV Partial
Fundoplication
Arjun Pennathur and Tom R. DeMeester
Introduction
Philip Allison, in 1951, linked the symptoms associated with a sliding hiatal hernia to
the reflux of gastric juice into the esophagus and the likelihood of developing esophag-
itis.1,2 He advocated the repair of the hiatal hernia as a surgical therapy for reflux
esophagitis. This required reducing the hernia and repositioning the gastroesophageal
junction into its normal intra-abdominal location. During the 1950s, surgeons devised
a variety of procedures to more effectively place the gastroesophageal junction in an
intra-abdominal position. A posterior gastropexy was devised by Lucious Hill in 1967,
which anchored the gastroesophageal junction and its associated phrenoesophageal
membrane to the median arcuate ligament of the aortic hiatus.3 The Nissen full fundop-
lication was introduced by Rudolf Nissen in 1956,4 and the Belsey Mark IV partial
fundoplication by David Skinner and Ronald Belsey in 1961.5 The Nissen and Belsey
fundoplications were designed to establish an intra-abdominal segment of esophagus
surrounded by a cuff of stomach in hopes of forming a functional flap valve. The Belsey
Mark IV repair is performed through a thoracic incision; the Hill repair through an
abdominal incision; and the Nissen repair through either an abdominal or thoracic
incision.
In 1957, Dr John Leigh Collis provided an important contribution to the repair of a
hiatal hernia. He introduced a method to manage the shortening of the esophagus that
occurred with advanced disease due to reflux-induced intramural fibrosis by describing
a technique that adds 3 to 4 cm to the esophageal length by the creation of a short
proximal gastric tube along the lesser curvature of the stomach.6 This ingenious tech-
nique relieved the tension on a hiatal hernia repair caused by a shortened esophagus
and reduced the incidence of reherniation. In 1987, Dr Griffith Pearson modified the
procedure to include a Belsey-type partial fundoplication over the gastroplasty tube.7
In the 1990s, the Nissen fundoplication started to be performed using laparoscopic
techniques, and today this approach has become commonplace along with the proce-
dure’s reputation of being safe and effective.8 At present, many surgeons are comfort-
able performing the procedure by the laparoscopic approach, doing a transhiatal
mediastinal dissection to mobilize the distal esophagus, and performing a laparoscopic
Collis gastroplasty if at least 2 to 3 cm of distal esophagus does not lie comfortably and
51
LWBK1254-ch05_p51-64.indd 51 19/02/14 10:00 AM

free of tension in the abdomen after the mobilization. Only the most complex multiple
redo operations (e.g., a redo operation in a patient with multiple prior antireflux surger-
ies) require an open operation, which is usually done through a transabdominal inci-
sion. Today, open transthoracic Nissen fundoplication (discussed in Chapter 4 by Alex
Little) and the Belsey fundoplication (discussed in this chapter) are infrequently
performed.
Although the indications for an antireflux repair and the biomechanics of an antireflux
repair done by laparoscopic and open approaches are similar, there are some specific
situations in which a transthoracic Belsey Mark IV fundoplication or a transthoracic
Nissen fundoplication provides an advantage. These include the following.
n A repeat open transthoracic operation can be technically easier in a patient with
intrathoracic stomach and a history of multiple failed antireflux repairs.
n A transthoracic fundoplication is a particularly useful approach in patients who
require fundoplication but have a “hostile” abdomen due to multiple previous sur-
geries. It is also of use in patients who have had multiple transabdominal antireflux
procedures.
n A transthoracic approach is useful when a partial fundoplication is planned after a
transthoracic myotomy for motility disorders such as diffuse esophageal spasm or
pulsion diverticula.
n A transthoracic approach is useful for a patient who has extensive shortening of the
esophagus. In this situation, the thoracic approach allows for maximum mobilization
of the esophagus in order to place the repair, without tension, in the abdomen with
or without a gastroplasty to lengthen the esophagus.
n A transthoracic approach is useful for a patient with reflux disease who requires a
thoracotomy for another reason, such as pulmonary disease. If the pulmonary disease
is on the left side, an open transthoracic approach allows both problems to be
addressed through one incision.
The propulsive power of the esophageal body should exceed the resistance to flow
through the antireflux repair.9,10 Consequently, the choice between a 360-degree fundop-
lication (Nissen) or partial 240-degree fundoplication (Belsey) is influenced by the
strength of the peristaltic contractions. An esophageal body that has normal wave pro-
gression and good contraction amplitude will do well with a complete 360-degree fun-
doplication. When the prevalence of peristaltic wave progression is reduced to <50%
or esophageal contraction amplitudes in the distal half of the esophagus are ≤20 mm
Hg, a partial 270-degree fundoplication is recommended as this degree of fundoplica-
tion has no measurable resistance to esophageal emptying. Inappropriate matching of
the body of the esophagus to the resistance imposed by the antireflux procedure can
cause a delay in the passage of food through the repair and symptoms of dysphagia. To
avoid excessive outflow resistance, the antireflux repair should be performed in such a
manner that the postoperative sphincter pressure is not in the hypertensive range and
the length of the sphincter measures 3 to 4 cm.
The identification of a patient for an antireflux surgery includes both a complete clini-
cal evaluation consisting of a history, physical examination, and an upper gastrointes-
tinal barium contrast video, and an objective evaluation consisting of an upper
gastrointestinal endoscopy, esophageal manometry, and pH testing. If the patient
requires a redo antireflux procedure, a more thorough and comprehensive evaluation
is done. This requires determining the indication for the initial antireflux surgery,
reviewing the patient’s clinical history prior to and after the operation, and thoroughly
LWBK1254-ch05_p51-64.indd 52 19/02/14 10:00 AM

Chapter 5 Belsey Mark IV Partial Fundoplication 53
studying the operative report. A specific note should be made of the location of the

gastroesophageal junction in relation to the location of the fundoplication. The surgeon
should also determine if the fat pad was dissected, if the vagi were preserved, and if the

crura were closed. The technical details of the construction of the fundoplication itself
should be noted. With this information in mind, an endoscopy, upper gastrointestinal
barium contrast video, esophageal manometry, pH testing, and a gastric emptying study
should be done. Patients who will undergo a transthoracic fundoplication, should also
have an assessment of their ability to tolerate a thoracotomy and single-lung anesthesia.
Surgery
Initial Steps and Thoracotomy

The Belsey operation requires approximately 4 cm of tension-free intra-abdominal
esophagus. Consequently, the clinical success of a Belsey repair decreases progressively
from 90% in patients who have no esophageal shortening to 50% in those who have
significant shortening and a repair under tension. In those patients with shortening, a
Collis gastroplasty is added to the repair to gain additional length and alleviate any
tension on the repair. A step-by-step description of the Belsey antireflux procedure is
detailed below.9,10,11
n An epidural catheter is placed to optimize the patient’s postoperative pain control.
n The patient is intubated with a double-lumen endotracheal tube for anesthesia in the
operating room with precautions taken to avoid aspiration. The position of the tube
is verified by bronchoscopy. The left lung is selectively deflated. Adequate venous
access, a Foley catheter, and an arterial line are placed. An on-table endoscopy is
then performed if the surgeon did not perform an endoscopy prior to the surgery to
evaluate the hiatal hernia and exclude the existence of Barrett’s esophagus, neo-
plasm, a stricture, or any other complications of reflux disease.
n Patient is placed in a right lateral decubitus position, the usual position for left pos-
terior thoracotomy. The pressure points are padded, and pillow is placed between
the lower extremities. A sequential compression device is also placed for deep vein
thrombosis prophylaxis.
n The table is flexed above the hip, and the patient is secured to the table with a belt.
n The diaphragmatic hiatus is approached through a left posterolateral thoracotomy
in the sixth intercostal space (i.e., along the upper border of the seventh rib).
n For patients who had a previous failed antireflux repair, we prefer to use the sev-
enth intercostal space. This allows better exposure of the abdomen through a
peripheral diaphragmatic incision.
n The incision is made circumferentially in the anterolateral portion of the dia-
phragm, 2 to 3 cm from the chest wall, for a distance of 10 to 15 cm.
n A sufficient fringe of diaphragm must be left along the chest wall to allow for easy
closure of the diaphragmatic incision.
n If further abdominal exposure is necessary, the thoracic incision can be extended
across the costal margin and diagonally down to the abdominal midline, dividing
the fibers of the left rectus abdominis muscle.
Esophageal Mobilization
The esophagus is mobilized from the diaphragm to underneath the aortic arch. Care is
taken not to injure the vagal nerves. Branches of the vagal plexus going to the left and
right lung must be divided to obtain maximal esophageal length. This allows construc-
tion, without tension, of a partial fundoplication over a 4-cm segment of abdominal
esophagus. Two vessels arise from the proximal descending thoracic aorta just distal to
the arch and pass over the esophagus to the left main stem bronchus. They are the left
superior and inferior bronchial arteries. Ligation of these arteries is also necessary to
LWBK1254-ch05_p51-64.indd 53 19/02/14 10:00 AM

fully mobilize the esophagus. In addition to these arteries, two to three direct esopha-
geal branches come off the distal descending thoracic aorta and pass directly to the
esophagus. These are also ligated and divided without concern about ischemic necrosis
of the esophagus. There is sufficient blood supply to maintain the integrity of the
esophagus through its intrinsic arterial plexus, fed by the inferior thyroid artery in the
neck and by branches from the right bronchial artery in the thorax. This degree of
mobilization is necessary to place the repair into the abdomen without undue tension.
Failure of adequate mobilization is one of the major causes for subsequent breakdown
of a repair and the return of symptoms. Therefore, if after adequate mobilization, there
is insufficient intra-abdominal length or any tension, a Collis gastroplasty should be
added to the repair.
Mobilization of the Gastroesophageal Junction and Cardia

Freeing the gastroesophageal junction and gastric cardia from the diaphragmatic hiatus
is the most difficult portion of the procedure, but can usually be completed through the
esophageal hiatus. It is unnecessary to make a counter incision through the central
tendon of the diaphragm or to enlarge the hiatus by an incision through the crura. When
there is no hiatal hernia, the rim of the hiatus is grasped with an Allis clamp, and the
dissection is started by gaining access to the abdominal cavity with the division of
the phrenoesophageal membrane. It can be difficult at times to find the correct tissue
plane once the membrane has been divided due to the protrusion of the preperitoneal
fat. Persistence and dissection underneath the retracted left crus, away from the gastric
vessels, eventually yields entry into the free peritoneal space. Entering the abdominal
cavity is easier when a hiatal hernia is present. When a hiatal hernia is present, the
hernia sac can be entered near the hiatus. It is again important to be careful to preserve
the vagus nerve during the dissection of the sac. In moderate to large hernia, the sac is
excised.
The proper stance of the surgeon at the operating table aids in freeing the hiatus.
With the patient in the left posterior thoracotomy position, the surgeon should stand
adjacent to the patient’s back, facing the head of the table. The left index and middle
fingers are placed through the diaphragmatic hiatus into the abdominal cavity, with the
palm facing the patient’s feet. The surgeon’s line of vision is down and backward under
his or her left axilla. With judicious use of the left thumb, index and middle fingers,
the surgeon is able to spread the hiatal tissues and divide them with a scissors control-
led by the right hand. In this position, the left hand is also used to retract the esopha-
gus and protect the vagal trunks. Although it sounds somewhat awkward, this stance
greatly facilitates the most difficult part of the operation.
All the attachments between the gastric cardia and diaphragmatic hiatus are divided.
An inconstant artery (Belsey’s Artery) communicating between the left gastric and the
inferior phrenic artery should be divided. This is encountered in the posteromedial
dissection, and it is important to control this vessel before division. The short gastric
vessels are divided and ligated one by one to allow good mobilization of the fundus.
When free, the fundus and part of the body of the stomach are drawn up through the
hiatus into the chest (Fig. 5.1). The vascular fat pad, which lies on the anterior and
lesser curvature surface of the cardia, is dissected. Care must be taken during this dis-
section to avoid injury to the vagal nerves. The fundus of the stomach must adhere
firmly to the lower esophagus and the dissection of the fat pad facilitates this.
The completely mobilized esophagus is encircled with a Penrose drain and retracted
toward the anterior border of the hiatus to give exposure for closure of the posterior
hiatus. The right and left crura of the diaphragmatic hiatus are identified and approxi-
mated with interrupted figure-eight nonabsorbable 0 sutures (Ethibond), taking gener-
ous bites of muscle. Usually there is a decussation of muscle fibers from the right crus
that passes anteriorly over the aorta to join muscle fibers from the left crus, but occa-
sionally the aorta lies free within the enlarged hiatus. In either situation, the first crural
suture is placed close to the aorta. Traction on this first posterior crural stitch elevates
the right crus toward the surgeon and facilitates the placement of subsequent crural
LWBK1254-ch05_p51-64.indd 54 19/02/14 10:00 AM

Figure 5.1 Mobilization of the

esophagus and stomach through a
left posterolateral thoracotomy. The

esophagus, gastroesophageal fat pad,
stomach, diaphragmatic hiatus, aorta,
pericardium, and lung are depicted.
The fundus of the stomach is drawn
through the hiatus into the chest with
a Babcock clamp. The forceps is on
the fat pad at the gastroesophageal
junction, which is then dissected.
sutures. Occasionally, it is necessary to mobilize the pericardium off the diaphragm to

give better exposure of the fascia and muscle making up the right crus. The subsequent
crural sutures should incorporate the fascia from the periphery of the central tendon
that blends in with the muscle fibers making up the right crus.
On the left side, the sutures are passed through the muscle fibers of the left crus
and the firmly adherent overlying pleura. Approximately 3 to 4 figure-eight sutures,
placed 1 cm apart, are necessary to approximate the crura and to adequately reduce the
size of the hiatus. All sutures are initially placed before tying because it is easier to
remove those not needed than to add additional sutures after the hiatus has been closed.
These sutures are placed but not tied; tying these crural sutures is the last step in the
repair (Fig. 5.2).
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.
LWBK1254-ch05_p51-64.indd 55 19/02/14 10:00 AM

Construction of the Fundoplication

The construction of the gastric fundoplication is the keystone of the antireflux repair
in that its proper function is responsible for re-establishing the competence of the car-
dia. In the Belsey Mark IV operation, the fundus of the stomach is plicated around the
anterior two-thirds of the lower 4 cm of esophagus. The partial fundoplication is held
in place by two rows of three horizontal mattress sutures placed equidistant from each
other and into the seromuscular layers of the stomach and the muscular submucosal
layers of the esophagus. Number 3-0 silk sutures are used, and each suture obtains a
firm grip of the esophageal muscle fibers by passing down to, but not through, the
muscularis mucosae. The first row of sutures is placed 1.5 cm above the cardia and is
tied only tight enough to obtain tissue apposition without strangulation. It is important
to remember that the hiatus is approached surgically from the left lateral position. To
construct the fundoplication over the anterolateral two-thirds of the esophagus, it is
necessary that the far right suture be placed in the right lateral wall of the esophagus.
This is out of the surgeon’s view and requires rotation of the esophagus before place-
ment of the suture. A common mistake is placing this suture too far anteriorly, resulting
in an anterolateral fundoplication displaced to the left (Fig. 5.3).
A second row of 3-0 sutures is placed 2 cm above the first row, through the esopha-
gus and the stomach as detailed above, using the position of the previously placed first
row of sutures as a guide (Fig. 5.4). In the original description of the Belsey procedure,
these sutures were not tied at this juncture, but tied after placement through the dia-
phragm. We carefully tie the sutures in the second row, so as to give tissue apposition
without strangulation. The tails of these sutures are not cut, but are separately rethreaded
on a large thin Ferguson needle and each of the tails is passed 0.5 cm apart from each
other through the diaphragm from the abdominal to the thoracic surface 1 to 1.5 cm from
the edge of the hiatus. The three sutures, each with its two tails, are placed at the 4-, 8-,
and 12-o’clock positions on a clock face, oriented with the 6-o’clock position at the pos-
terior hiatus between the right and left crura just anterior to the aorta (Fig. 5.5). Again,
it is important to place the right lateral, or 4 o’clock, suture properly to avoid the com-
mon error of putting this suture too far anteriorly, in the 1- or 2-o’clock position, and
constructing an anterolateral fundoplication displaced to the left. These sutures must be
carefully placed to avoid injury to the abdominal structures. A spoon retractor has become
a popular instrument to aid in placing these sutures without snagging abdominal mesen-
tery or omentum. The needle is guided along the inner surface of a spoon held firmly
against the undersurface of the diaphragm before it is passed through the diaphragm.
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 gastro-
esophageal junction. Particular atten-
tion must be given to placement of
the right lateral suture as detailed in
the text.
LWBK1254-ch05_p51-64.indd 56 19/02/14 10:00 AM

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.
The partial fundoplication is massaged through the hiatus and into the abdomen.
It is not dragged down into the abdomen by pulling on the diaphragmatic sutures, but
rather is placed into the abdomen by compressing the fundic ball with the hand and
manually maneuvering it through the hiatus. Resistance to placing the repair into the
abdomen can result from the shoelace obstruction of the previously placed crural
sutures. Opening the crural sutures, as loosening the laces of a shoe, relieves the
obstruction and helps in placing the partial fundoplication into the abdomen. Once in
the abdomen, the fundoplication should remain there without tension on the holding
sutures. A gentle up-and-down hand motion on the diaphragm should not encourage
the fundoplication to pop back through the esophageal hiatus. If the repair remains in
Figure 5.5 Continued construction of

a Belsey 240-degree partial fundopli-
cation showing the tails of the previ-
ously 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. Note the placement
of the sutures at the 4-, 8-, and
12-o’clock positions on an imaginary
clock face oriented with the 6-o’clock
position posterior in the hiatus
between the right and left crura just
anterior to the aorta.
LWBK1254-ch05_p51-64.indd 57 19/02/14 10:00 AM

Figure 5.6 A completed Belsey

240-degree partial fundoplication
showing the right and left crura
approximated after tying the previ-
ously placed crural sutures. The
positions of the tied holding sutures
are also shown.
the abdomen unaided, the previously placed crural sutures are tied. The holding sutures
are then tied, approximating the knot against the previously tied knot so as to avoid
any redundancy in the suture between the repair and the diaphragm (Fig. 5.6). An
additional safety factor of the double-knot technique is that if one of the tails of the
holding sutures breaks while it is being tied, it is not necessary to take the repair down,
pull the stomach back up into the chest, and insert a new suture. Simple anchoring of
the single remaining tail to the diaphragm is sufficient to hold the cardia in position.
The technique also prevents tying the sutures too tight and causing necrosis of the
incorporated esophageal and gastric tissue.
If the fundoplication tends to ride up through the hiatus, the tension on the repair
is too great. This is usually caused by inadequate mobilization of the esophagus. If the
tendency remains after further mobilization, a Collis gastroplasty is usually necessary.
Belsey Fundoplication with Collis Gastroplasty

In 1957, Dr John Leigh Collis described a technique that adds 3 to 4 cm to the esopha-
geal length by the creation of a short proximal gastric tube along the lesser curvature
of the stomach.10 Dr Collis initially introduced the concept of gastroplasty as an antire-
flux procedure. The concept was modified in 1987 by Dr Griffith Pearson to include a
Belsey-type partial fundoplication over the gastroplasty tube.11 The modified Collis pro-
cedure was called the Collis–Belsey repair and was typically performed in patients who
had gastroesophageal reflux disease (GERD) complicated by esophageal fibrosis and
shortening. As a result, many of these patients present with dysphagia in addition to
heartburn and regurgitation. The Collis gastroplasty portion of the procedure lengthens
the esophagus by constructing a tube along the lesser curve of the stomach to create a
“neoesophagus.” A tension-free, Belsey partial fundoplication could then be constructed
over the gastric tube. Combining the procedures reduces the risk of subsequent retrac-
tion of the fundoplication into the chest. The gastroplasty component of the procedure,
in addition to adding esophageal length, provides relatively normal tissue to which the
stomach can be sewn in performing the partial fundoplication. The operation improves
the competency of the lower esophageal sphincter sufficiently to heal reflux-induced
esophagitis, ulceration, and soften the fibrotic strictures. With settling of the inflamma-
tion, there can be some restoration of esophageal body compliance and contraction
amplitude, but commonly the loss is irreversible.
To perform the Collis gastroplasty procedure, the esophageal and gastric mobiliza-
tions are performed as described for the Belsey Mark IV partial fundoplication. The
LWBK1254-ch05_p51-64.indd 58 19/02/14 10:00 AM

Figure 5.7 Position of the stomach

for performing a Collis gastroplasty.
A 48-French bougie is passed into the

stomach. The dashed line indicates
the proposed site for stapling and
cutting the gastric wall to form a
gastric tube in continuity with the
esophagus.
Collis gastroplasty tube is created along the lesser curvature of the stomach, in continu-
ity with the distal esophagus and for a length of 4 to 5 cm. The tube is constructed over
a 48-French Maloney bougie using a single fire of the GIA stapler (Fig. 5.7). To achieve
a uniform tube diameter along the lesser curvature, traction is exerted on the greater
curvature before the jaws of the stapler are closed adjacent to the bougie (Fig. 5.8). The
resultant staple line creates a wedge of fundus that is resected by stapling across the
fundus, starting from the greater curvature to the end of the staple line on the gastric
tube, in a line perpendicular to the staple line on the gastric tube (Fig. 5.9). The staple
line is oversewn with a running absorbable suture. A Belsey partial fundoplication
(Figs. 5.10–5.12) is then performed as described previously.
Final Steps
n Once the repair is in the abdominal position, the previously placed crural sutures
are tied, starting posteriorly at the aortic hiatus and progressing anteriorly until the
size of the hiatal opening just allows insertion of the surgeon’s index finger adjacent
to the empty esophagus. Any unused sutures are removed (Fig. 5.6). Leaving the
hiatus too open encourages reherniation. In the Belsey repair, the closure of the crura
provides a posterior buttress against which the intra-abdominal segment of the
esophagus is compressed.
n At the completion of the procedure, a nasogastric tube is passed by the surgeon into
the stomach to ensure that there has been no angulation of the fundoplication in
relationship to the distal esophagus.
n A chest tube for drainage of the pleural cavity is placed and the chest incision is
closed.
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. This
ensures that the gastric tube closely
approximates the diameter of the
indwelling 48-French bougie through-
out its length.
LWBK1254-ch05_p51-64.indd 59 19/02/14 10:00 AM

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. This
effectively lengthens the esophagus
by approximately 4 to 5 cm. The
wedge of the stomach is removed by
stapling vertically from the greater
curvature down to the horizontal
staple line along the dotted line.
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. The first row of sutures is placed
1.5 cm above the end of the gastro-
plasty tube. Particular attention must
be given to place the right lateral
suture far to the right to avoid con-
structing a partial fundoplication that
covers only the left anterior lateral
portion of the gastroplasty tube.
Figure 5.11 Continued construction of

the Belsey 240-degree partial fundopli-
cation 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.
LWBK1254-ch05_p51-64.indd 60 19/02/14 10:00 AM

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.
Note the placement of the sutures at
the 4-, 8-, and 12-o’clock positions on
an imaginary clock face oriented
with the 6-o’clock position posterior
in the hiatus between the right and
left crura just anterior to the aorta.
n Antiemetics are given prophylactically to avoid retching or vomiting in the postop-
erative period. On recovery from anesthesia, the patient usually notes relief from his
or her heartburn and regurgitation.
n Nasogastric suction is used to avoid over distention of the stomach during the
immediate postoperative period, as excessive gastric distention can cause acute
herniation of a Belsey partial fundoplication into the chest. When gastrointestinal
function resumes and the nasogastric tube drainage is low, the nasogastric tube is
removed.
n A barium swallow is performed to check the repair and the free passage of barium
into the stomach. If the findings are acceptable, the patient is started on clear
liquids. Patients often experience slight dysphagia when oral intake is resumed,
but this usually disappears as the postsurgical edema subsides. Occasionally,
intramural gastric hematoma at the site of the fundoplication can cause dysphagia
that persists for a longer period. When this occurs, it will generally absorb within
4 to 6 weeks, and the dysphagia subsides. Patients are typically discharged on a
soft diet.
n Before discharge, the patient is counseled that until the habit of air swallowing is
broken, he or she may experience increased abdominal distention and flatus. Early
satiety is common until the patient gains confidence in his swallowing ability and
takes fewer swallows to ingest their meal and, as a consequence, ingests in less air
with their food.
We have evaluated our patients after surgery with esophageal manometry, 24-hour
esophageal pH monitoring, and a questionnaire about their esophageal symptoms and
eating habits. Comparison of the results of these studies with results of similar studies
obtained from healthy volunteers has helped to objectively evaluate what has been
accomplished by the surgical repair. Consequently, the described technique represents
a refinement of the method initially published by the originators of the operation. The
surgeon must keep in mind that the operation is designed to improve the function of
the gastroesophageal barrier and offhanded alterations in technique can cause deleteri-
ous on postoperative function. No change in technique should be made unless its effects
on function are known.
LWBK1254-ch05_p51-64.indd 61 19/02/14 10:00 AM

Complications
In a seminal article published in 1967, Skinner and Belsey reported on over 1,000
patients who received treatment for hiatal hernia including 632 patients who under-
went a Belsey partial fundoplication.5 Operative mortality occurred in 1% of patients
who underwent the Belsey procedure. The complications leading to mortality included
pulmonary embolism, myocardial infarction, bleeding, and necrosis of lower esopha-
gus. Nonfatal complications during hospitalization occurred in 5% of patients and
included thromboembolism or infections in nine, leak in two patients, and distal
esophageal necrosis requiring resection in one. Other complications included atrial
fibrillation, atelectasis, urinary tract infection, and gastrointestinal bleeding.
Pearson et al.7 assessed the utility of Belsey fundoplication with a Collis gastro-
plasty for complicated GERD in 430 patients in a classic 1987 publication. The study
population included patients with short esophagus with stricture or esophagitis
(n = 215), reoperation (n = 118), stricture or esophagitis associated with motor disorder
(n = 37), and giant paraesophageal hernia with intrathoracic stomach (n = 54). The
overall mortality was 0.46%. Complications of the thoracotomy included atelectasis,
wound infection and pneumonia; esophageal fistula occurred in 1.4% (half of these
were in patients who underwent a redo operation), and there was no mortality from
these leaks.
Results
Of the 632 patients who underwent Belsey partial fundoplication in Skinner and Bel-
sey’s classical article, long-term follow-up was obtained in 95% of patients, with only
5% of patients lost to follow-up at intervals of 5 years after surgery. In addition, 53% of
the 632 patients had a barium esophagogram more than 1 year after surgery. Control of
reflux symptoms was excellent. Symptomatic recurrence of a hernia occurred in 5.6%
of patients, and an asymptomatic recurrence occurred in 1.2% of patients during long-
term follow-up. A poor symptomatic result without a recurrent hernia occurred in 4%
of patients. A young age at the time of fundoplication and severe esophagitis leading
to esophageal shortening were associated with recurrence. According to the authors the
most common cause of recurrence was related to the technique used in placing
the sutures in the esophagus when constructing the partial fundoplication and into the
crura when closing the posterior hiatus.
In Pearson’s paper assessing the utility of Belsey fundoplication with a Collis gas-
troplasty in 430 patients with complex GERD, including patients with short esophagus
with stricture or esophagitis (215 patients), reoperations (118 patients), giant paraesopha-
geal hernia with intrathoracic stomach (54 patients), and stricture or esophagitis associ-
ated with motor disorder (37 patients), the follow-up was complete in 90% of patients
at a median time well above 5 years.7 Remarkably, more than 100 patients were followed
for more than 10 years. The clinical results were reported as good in 93% of patients
who had a short esophagus with stricture or esophagitis, 91% of patients with giant
paraesophageal hernia and intrathoracic stomach, and 80% of patients who had a redo
surgery. In contrast to these good results, only 54% of patients with a stricture or
esophagitis associated with motor disorder were reported to have a good result. Of
particular interest is the landmark publication of Maziak and Pearson on the use of the
Collis–Belsey procedure in patients with a giant paraesophageal hernia.12 The study
population consisted of 94 patients. An open transthoracic approach was used in 97%
of patients and consisted of a Belsey partial fundoplication in all with the addition of
a Collis gastroplasty in 75 patients (80%) who had a short esophagus. The mean follow-
up of the study population was 94 months and is one of the longest reported in the
literature. Ninety-three percent of the patients were classified as having a good to excel-
lent outcome and 4% with a fair outcome. Two patients had a poor result, and both
required reoperation with the addition of gastroplasty for a short esophagus.
LWBK1254-ch05_p51-64.indd 62 19/02/14 10:00 AM


Conclusions

In the current era of minimally invasive surgery, the laparoscopic approach to antireflux
surgery has become standard. The transthoracic Belsey partial fundoplication has
become an operation of the past; however, it has an important role in some patients
with complex esophageal problems, where it can provide a useful alternative approach.
In selected patients with complex esophageal problems such as an epiphrenic or mides-
ophageal diverticulum, the rare patients with diffuse esophageal spasm, and patients
with complex situations, such as previous multiple transabdominal antireflux repairs
or with a “hostile” abdomen from multiple previous operations, a transthoracic approach
can become a necessity. The Belsey partial fundoplication, with or without a Collis
gastroplasty, is a complex operation, and when done by an experienced surgeon, the
results are excellent and have been documented by meticulous studies with long-term
follow-up. However, this is a complex operation, and only surgeons with a focused
interested in esophageal surgery, trained in thoracic surgery, and who have accumulated
extensive experience in the surgical treatment of esophageal disease should consider
performing a Belsey partial fundoplication with or without a Collis gastroplasty.
Recommended References and Readings 8. Dallemagne B, Weerts JM, Jehaes C, et al. Laparoscopic Nissen
fundoplication: Preliminary report. Surg Laparosc Endosc.
1. Allison PR. Reflux esophagitis, sliding hiatal hernia, and anat- 1991;1:138.
omy of repair. Surg Gynecol Obstet. 1951;92:419. 9. DeMeester TR. Transthoracic Antireflux Procedures. In:
2. Allison PR. Hiatus hernia (a 20 year retrospective survey). Ann Fischer JE, et al. eds. Fischer’s Mastery of Surgery, 6th ed.
Surg. 1967;166:273. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams
3. Hill LD. An effective operation for hiatal hernia: An eight year & Wilkins; 2012: 810–822.
appraisal. Ann Surg. 1967;166:681. 10. DeMeester TR, Wernly JA, Bryant GH, et al. Clinical and in vitro
4. Nissen R. Eine einfache Operation zur Beeinflussung der Reflux- determinants of gastroesophageal competence: A study of the
esophagitis. Schwieze Med Wochenschr. 1956;86:590. principles of antireflux surgery. Am J Surg. 1979;137:39.
5. Skinner DB, Betsey RHR. Surgical management of esophageal 11. Pennathur A, Luketich JD. Belsey Fundoplication. In: Khatri VP,
reflux with hiatus hernia: Long-term results with 1,030 cases. ed. Atlas of Advanced Operative Surgery, Philadelphia, PA:
J Thorac Cardiovasc Surg. 1967;53:33. Elsevier/Saunders, 2012.
6. Collis JL. An operation for hiatus hernia with short esophagus. 12. Maziak DE, Todd TR, Pearson FG. Massive hiatus hernia: Evalu-
J Thorac Cardiovasc Surg. 1957;34:768. ation and surgical management. J Thorac Cardiovasc Surg.
7. Pearson FG, Cooper JD, Patterson GA, et al. Gastroplasty and fun- 1998;115(1):53–60; discussion 61–62.
doplication for complex reflux problems. Ann Surg. 1987;206:473.
LWBK1254-ch05_p51-64.indd 63 19/02/14 10:00 AM

LWBK1254-ch05_p51-64.indd 64 19/02/14 10:00 AM
6 Laparoscopic Collis
Gastroplasty
Mara B. Antonoff, Rafael S. Andrade, and Michael A. Maddaus
Introduction
The Collis gastroplasty is a procedure designed to elongate the pathologically foreshort-
ened esophagus, in the setting of long-standing gastroesophageal reflux disease (GERD)
by creating a tubular extension of the proximal stomach beyond the anatomic gastro-
esophageal junction (GEJ). The laparoscopic Collis gastroplasty employs the same original
principles described by Collis in 1957.1 The “neoesophagus” provides an adequate length
of intra-abdominal esophagus to be influenced by the positive pressure environment of
the abdomen facilitating the competency of any antireflux mechanism constructed (e.g.,
fundoplication). The most common circumstances where this esophageal-lengthening
procedure may be required are peptic strictures of the esophagus, long-segment Barrett’s,
recurrent herniation after fundoplication, and repair of a large hiatal hernia, particularly
type III paraesophageal hernias. Selective use of this esophageal-lengthening procedure
may be critical for the successful laparoscopic repair of these pathologic conditions.
Indications
A short esophagus may be suspected by a preoperative barium esophagram or endo-
scopic measurement of the distance from the upper esophageal sphincter to the lower
esophageal sphincter, but is always confirmed intraoperatively. This shortening of the
esophagus is thought to be the result of longitudinal esophageal muscular wall scarring
secondary to severe chronic GERD.2,3 The prevalence of short esophagus is controversial
but has been estimated to be present in 1.5% to 19% of patients who undergo surgery
for GERD.4–14 Esophageal shortening can be defined as an intra-abdominal esophageal
length less than 2.5 cm even after extensive mediastinal mobilization. If one encounters
a shortened esophagus, the first step is to attempt further esophageal mobilization.
However, if after all efforts, the intra-abdominal length of esophagus does not appear
adequate for a tension-free, intra-abdominal wrap, then consideration for the Collis
gastroplasty esophageal-lengthening procedure should be made.15,16
Horvath et al.3 defined three types of esophageal shortening: (1) apparent short
esophagus; (2) true, reducible short esophagus; and (3) true, nonreducible short esophagus.
65
LWBK1254-ch06_p65-74.indd 65 19/02/14 10:01 AM

Figure 6.1 Laparoscopic view of

mediastinal esophageal mobilization.
Both inferior pulmonary veins are
visible, the esophagus (E) has been
dissected free while preserving the
vagus nerve (V). RIPV, right inferior
pulmonary vein; LIPV, left inferior
pulmonary vein.
Apparent short esophagus is the result of longitudinal compression of the esophagus

in the mediastinum, but the esophagus is of normal length. A true, reducible short
esophagus is defined as an esophagus that is indeed shortened, but with proper medi-
astinal mobilization up to and potentially beyond the level of the inferior pulmonary
veins (Fig. 6.1), one is able to gain an intra-abdominal length of at least 2.5 cm. A true,
nonreducible short esophagus does not allow for an intra-abdominal length of ≥2.5 cm,
despite all efforts at esophageal mobilization and mediastinal dissection (Fig. 6.2), and
requires a Collis gastroplasty.16 An esophageal intra-abdominal length of ≥2.5 cm is
critical to avoid cephalad traction on the completed antireflux wrap and potential
wrap herniation.3 As with any other hernia repair, recurrence is more common when
the repair is done under tension. The successful surgical management of hiatal her-
niation may be enhanced when this esophageal-lengthening procedure is included
with the standard operative repair in the setting of true, nonreducible esophageal
shortening.
Contraindications
As long as a patient is considered an appropriate candidate for laparoscopic repair of a
hiatal hernia, there are no absolute contraindications to performing a laparoscopic Collis
gastroplasty. However, there are number of clinical situations where a Collis gastroplasty
may be of concern. For example, in the setting of severe esophageal dysmotility with or
Figure 6.2 Short esophagus. After

mediastinal mobilization and GEJ fat
pad dissection, it is evident that there
is only about 1 cm of esophagus in
the abdominal cavity. The dashed line
indicates the approximate location of
the GEJ, the arrow shows the intra-
abdominal length of esophagus. V,
vagus nerve and mobilized fat pad.
LWBK1254-ch06_p65-74.indd 66 19/02/14 10:01 AM

Chapter 6 Laparoscopic Collis Gastroplasty 67
without stricturing, one would hope to avoid adding a Collis gastroplasty as the dysmotile

segment of neoesophagus and a wrap would contribute to postoperative dysphagia. In
other cases, where the integrity of the esophagus may be of concern, for example, in

difficult hiatal dissections, redo cases, or a difficult giant hernia, significant esophageal
trauma may occur with potential myotomies and the safety of adding a Collis staple line
may be questionable. Other cases that may be of concern include gastroplasty in com-
promised, elderly patients with poor tissue integrity or those on steroids where a staple
line would preferably be avoided. In any event, we consider the Collis gastroplasty to
be a compromise, but one that is necessary if you must do an antireflux procedure and
you cannot gain tension-free, intra-abdominal esophagus. These important points empha-
size that a Collis gastroplasty should never be used as a substitute to extensive medias-
tinal mobilization of the esophagus. That is, if you can avoid gastroplasty with good
mobilization, then of course do this first. In some patients with a true short esophagus,
one may choose to avoid the Collis gastroplasty and the antireflux wrap altogether and
perform an esophageal resection with gastric pull-up or a Roux-en-Y esophagojejunal
reconstruction as the preferred surgical option. In addition, a surgeon who is not prop-
erly trained or sufficiently experienced to technically handle a short esophagus should
not perform this operation, and referral to clinical centers handling complex esophageal
problems on a regular basis should be considered.
The surgeon must consider the possible need for esophageal-lengthening procedure in
patients with a large hiatal hernia (>5 cm), a peptic stricture, long-segment Barrett’s
esophagus (>3 cm), or a previous failed repair of a hiatal hernia. Because obesity
increases intra-abdominal stress on any hernia repair, an esophageal-lengthening pro-
cedure should also be considered in obese patients undergoing hiatal hernia surgery.5,13,14
The clinical work-up of a patient being considered for hiatal hernia repair and
antireflux surgery should include the following.
n A barium esophagram to assess the size of the hernia and the presence of axial or
longitudinal rotation and strictures.
n An upper endoscopy to measure the distance from the GEJ to the crural impression
(i.e., hernia size) and to thoroughly examine the mucosa. Any mucosal abnormalities
should be biopsied.
n Esophageal manometry to assess motility. In the setting of severe motor dysfunction,
we prefer to avoid a Collis if at all possible. This may lead to a decision to perform
a partial wrap or in severe cases an esophagectomy or Roux-en-Y.
n 24 hour (or longer) pH study.
n Gastric emptying studies if clinically indicated, for example, redo cases or patients
with diabetes.
n A computerized tomography scan can occasionally be helpful but is not routinely
required prior to hiatal hernia surgery.
With the clinical information provided by the barium esophagram and endoscopy,
the esophageal surgeon should be able to identify those patients at greatest risk for
esophageal shortening and, accordingly, be prepared to perform esophageal-lengthening
Collis gastroplasty if true esophageal shortening is present.
Surgery
Positioning
The patient should be in a supine position, on a table capable of steep reverse Trende-
lenburg, with arms abducted.
LWBK1254-ch06_p65-74.indd 67 19/02/14 10:01 AM

A B
Figure 6.3 Collis gastroplasty using an EEA (A) and linear stapler (B) as originally described by Steichen and Champion.
Technique
Our initial surgical technique for laparoscopic gastroplasty, as part of a hiatal hernia
repair, was based on the original procedure used by Felix Steichen for open gastroplast-
ies.17 This was later described laparoscopically by Champion and others for laparo-
scopic vertical banded gastroplasty.4 In that procedure, a large esophageal bougie is
placed into the upper stomach alongside the lesser curvature, and an EEA stapler is
used to create a “doughnut hole” in the upper stomach alongside the margin of the
lesser curvature. After successful creation of the “doughnut hole,” a linear endostapler
is positioned within the hole, next to the lesser curvature gastric margin and against
the intraesophageal bougie. The stapler is fired in a cephalad direction to create the
neoesophagus from the lesser curvature stomach tube (Fig. 6.3).18
More recently, we have adopted the “wedge” gastroplasty approach (Fig. 6.4) which
was used by Champion and described by Hunter and colleagues.19 This approach is
easier to master and in most hands reduces the likelihood of staple-line leakage.
Operative steps for hiatal hernia repair and Collis gastroplasty using the wedge
approach include the following.
n Hernia sac reduction and excision.
n Extensive mediastinal esophageal dissection with vagal nerve preservation (Fig. 6.1).
n GEJ fat pad dissection and evaluation of intra-abdominal esophageal length (Fig. 6.2).
Intraoperative endoscopy can be of help to define the exact location of the GEJ. The
anterior vagus nerve is dissected off the GEJ and proximal stomach. The intra-abdominal
esophageal length is best determined after partial closure of the hiatus.
n Placement of a 48-French esophageal dilator along the lesser curvature.
n The tip of the fundus is retracted inferiorly to expose the greater curvature for stapler
application (Fig. 6.5).
n The endoscopic GIA stapler is introduced through a left upper quadrant port (Fig.
6.6). The first staple line determines the appropriate level of transection of the greater
curvature (Fig. 6.4, panel A and Fig. 6.7). A second and sometimes third staple line
is applied to end snuggly at the edge of the dilator (Fig. 6.8).
n The wedge is excised with a final staple line from a right upper quadrant port (Fig. 6.4,
panel B and Fig. 6.9). This is easier to do with the hiatus partially closed, because
it allows the tip of the stapler to enter the mediastinum.
n The Collis segment (neoesophagus) is approximately 2.5 cm in length (Fig. 6.4, panel
C and Fig. 6.10).
LWBK1254-ch06_p65-74.indd 68 19/02/14 10:02 AM

Figure 6.4 Collis wedge

gastroplasty.

A
n The crural reapproximation can now be completed.

n Nissen fundoplication over a 52- to 54-French dilator. This dilator is placed after
removal of the 48-French dilator used earlier in the procedure. The uppermost stitch
of the fundoplication should catch the wall of the distal true esophagus, so that the
neoesophagus is entirely wrapped within the Nissen fundoplication (Fig. 6.10).
n At the end of the procedure, the dilator is removed and a nasogastric tube is placed
under direct vision.
Figure 6.5 Initial set-up for Collis

gastroplasty. The arrow indicates the
general direction of the 48-French
dilator (along lesser curvature), the
dashed line shows the greater curva-
ture as it is being retracted inferiorly
to allow for stapling. V, vagus nerve.
LWBK1254-ch06_p65-74.indd 69 19/02/14 10:02 AM

Figure 6.6 Stapler introduced through

the left subcostal port. The arrow
indicates the general direction of the
48-French dilator (along lesser curva-
ture), the dashed line shows the
greater curvature.
Figure 6.7 First staple line. The arrow

indicates the general direction of the
48-French dilator (along lesser curva-
ture), the dashed line shows the
greater curvature.
Figure 6.8 Second staple line. The tip

of the stapler is in close apposition to
the dilator.
LWBK1254-ch06_p65-74.indd 70 19/02/14 10:02 AM

Figure 6.9 Final staple line. The

stapler is introduced through a right-
sided port to complete the resection

of a wedge of stomach.
In the immediate postoperative period, gastric decompression with a nasogastric tube
should be continued until the first postoperative day. On the first postoperative day, it
is prudent to obtain an esophagram to evaluate the integrity of the gastroplasty staple
line. Any sign of patient toxicity or staple-line disruption on routine radiographic eval-
uation (i.e., pneumoperitoneum or pneumothorax) should signal the need for urgent
consideration for laparoscopic or open surgical exploration.
Most patients can take sips of clear liquids on the first postoperative day and
advance gradually to post-Nissen fundoplication dietary guidelines. Elderly patients
with very large hiatal hernia and diabetic patients may develop gastric distension and
should be carefully monitored for signs of gastric ileus through serial physical examina-
tions and upright chest x-rays.
No uniform guidelines exist for outpatient follow-up of patients after the repair of a
hiatal hernia with or without the use of an esophageal-lengthening procedure. However,
it is clear that postoperative symptoms correlate poorly with objective abnormalities,
A B
Figure 6.10 A: Final view of the neoesophagus. The arrow shows the intra-abdominal length of neoesophagus; the first stitch
(uppermost) of the fundoplication should catch the distal wall of the true esophagus (X), so that the neoesophagus is entirely
wrapped within the Nissen fundoplication. B: Nissen fundoplication constructed over the Collis gastroplasty.
LWBK1254-ch06_p65-74.indd 71 19/02/14 10:02 AM

that recurrences tend to occur within the first 2 years after surgery (but may occur
several years after the repair), and mucosal abnormalities such as Barrett’s metaplasia
may resolve, persist, or progress on endoscopic and histologic examination.2,6,7,9,12,13
In view of these facts, patients should be followed routinely after the surgical repair
of a hiatal hernia; suggested follow-up protocol includes the following.
n Validated symptom review every year for 5 years
n Anatomic evaluation (radiographic or endoscopic) every year for 5 years
n Patients with preoperative esophagitis, stricture, or Barrett’s esophagus should be
endoscopically evaluated within a year of surgery
n Persistent or progressive esophageal mucosal abnormalities without anatomic recur-
rence should be evaluated with a pH study
It is not clear whether every patient with preoperative Barrett’s mucosal changes
and a Collis gastroplasty should be treated postoperatively with proton pump inhibitors
(PPIs).6 Generally, we follow these patients clinically and assess GERD symptoms or
dyspepsia and liberally consider the use of a PPI since the gastric mucosa of the
neoesophagus has acid secretory potential and the associated lack of motility within
this gastric tube may affect refluxed acid clearance from the esophagus. Certainly, any
patient with a normal postoperative anatomic evaluation and an abnormal postoperative
pH study who is symptomatic or has documented Barrett’s esophageal mucosal changes
should be treated with PPIs and followed serially. Radiofrequency ablation of metaplas-
tic/dysplastic Barrett’s mucosa is another consideration when this situation exists.26
Complications
The most important complication related to the Collis gastroplasty procedure with a
Nissen fundoplication is a gastroplasty staple-line leak. In a large series of laparoscopic
hiatal hernia repairs, 88% of all leaks occurred in patients who had undergone Collis
gastroplasty as part of their operative procedure (3.4% in patients with Collis vs. 0.84%
in patients without Collis).8 In addition, dilation of the neoesophageal segment and
pseudodiverticula of this adynamic gastric tube have been observed over time in a
minority of patients. Placing the uppermost stitch of the fundoplication above the
neoesophageal staple line so that it catches the wall of the distal true esophagus may
prevent this complication, because the neoesophagus is completely wrapped in the
fundoplication (Fig. 6.11).19 However, because one has little control over the final length
A B C D
Figure 6.11 Correct positioning of a Nissen fundoplication around the neoesophagus. A: Appearance of the gastric fundus after
wedge gastroplasty. B: Placement of fundoplication too low on the neoesophagus. C: Improper placement with a portion of the
neoesophagus above the fundoplication permits progressive dilation of the neoesophagus over time creating the appearance of a
“slipped” Nissen fundoplication. D: Correct position of the fundoplication with complete coverage of the gastric staple lines. The
superior aspect of the fundoplication is at or above the neoesophagus when placed properly. (From: Van Hove CE, Hunter J, Perry
K. Laparoscopic antireflux surgery: Esophageal lengthening procedures. In: Soper NJ, Swanström LL, Eubanks WS, eds. Mastery of
endoscopic and laparoscopic surgery, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2009.)
LWBK1254-ch06_p65-74.indd 72 19/02/14 10:02 AM


T abl e 6 . 1
Results of Laparoscopic Repair of Large Hiatal Hernia with Collis Gastroplastya

Swanstrom Pierre
(1996)20 Johnson (1998)21 Jobe (1998)6 Awad (2000)22 (2002)23 Whitson (2006)13 Luketich (2010)8
Technique Right VATS Collis–Nissen Collis–Nissen Left VATS Nissen, Collis–Nissen Laparoscopic
assisted assisted Collis– floppy Nissen or
Collis–Nissen Collis–Nissen Nissen partial wrap,
or Toupet Collis in 63%
Patients 3 9 15 8 202 61 662
OR time, minutes 257b 297b 252b – 200c 274c –
LOS, days 2b 3b 2b 3b 3c 4c 3c
Morbidity, % 0 22 15 50 (minor) 28 8 19
Mortality, % 0 0 0 0 0.5 1.7 1.7
Follow-up, 8b – 14b 20b 18c 8c 30c
months
Follow-up Endoscopy, pH Endoscopy, Endoscopy, pH Symptoms Symptoms, Esophagram, Symptoms,
method study, symptoms study, GERD- symptoms esophagram
manometry, manometry, HRQoL24 GERD-HRQoL,24
symptoms biopsy, SF-3625
symptoms
Anatomic 0 11 0 13 2.5 2 15.7
recurrence, %
Patient 100 89 100 88 92 98 89
satisfaction, %
a
GERD-HRQoL, gastroesophageal reflux disease health-related quality of life questionnaire LOS indicates length of stay; OR,
operating room VATS, video-assisted thoracoscopic surgery.
b
Mean value.
c
Median value.
of the Collis segment, this may or may not be possible. But, again, it highlights the need
to perform a complete esophageal mobilization to gain as much tension-free esophageal
length as possible to minimize the length of the Collis segment or ideally to avoid a
Collis gastroplasty altogether. Following all patients after antireflux surgery is impor-
tant, but those with a Collis segment are particularly concerning because of the poten-
tial for ongoing acid exposure to the distal esophagus from the acid-secreting mucosa
of the gastric tube.6,10
Results
Results of laparoscopic repair of hiatal hernia with Collis gastroplasty are summarized
in Table 6.1. Note that in many earlier series of laparoscopic Collis operations, the EEA
approach for creating the Collis gastroplasty was used.4,8,18 The wedge gastroplasty
approach has gained popularity and was the primary approach used in the report by
Whitson et al.13 The overall incidence of recurrent hiatal hernia following a laparoscopic
Collis gastroplasty ranges between 0% and 16%; in our experience, it is about 5% at
2 years. The variation in hernia recurrence between series largely has to do with how
closely these patients are followed, the definition of a recurrence and the actual need
for reoperation. In comparison, recurrence rates for transthoracic open repair of hiatal
hernia with Collis gastroplasty range between 2% and 10%.10,11
Conclusions
Recognition of patients at risk for short esophagus is important for the surgeon consider-
ing hiatal hernia repair and fundoplication, particularly in patients with large hiatal
hernias, reoperative antireflux surgery, Barrett’s esophagus, or peptic strictures. The
important risk factors and preoperative work-up that aid in the identification of these
patients have been discussed. The first key step when considering a Collis gastroplasty
LWBK1254-ch06_p65-74.indd 73 19/02/14 10:02 AM

is careful dissection of the GEJ fat pad to identify the exact location of the GEJ. Objective
estimation of the intra-abdominal esophageal length following mediastinal dissection of
the esophagus is the next important maneuver. If a foreshortened esophagus is identified,
creation of a wedge-type Collis gastroplasty over a 48-French esophageal dilator appears
to be a safe, expedient, and effective approach. A fundoplication that covers the Collis
staple line and neoesophagus should be performed. Laparoscopic repair of hiatal hernia
with Collis gastroplasty can lead to a low-recurrence rate of hiatal hernia and reduce
symptomatic GERD. Patient satisfaction with the Collis gastroplasty and fundoplication
can be excellent in patients appropriately selected for this procedure.
Recommended References and Readings 14. Awais O, Luketich JD, Schuchert MJ, et al. Reoperative antire-
flux surgery for failed fundoplication: An analysis of outcomes
1. Collis JL. An operation for hiatus hernia with short esophagus. in 275 patients. Ann Thorac Surg. 2011;92(3):1083–1089; dis-
J Thorac Surg. 1957;34(6):768–773; discussion 774–778. cussion 1089–1090.
2. Skinner DB, Belsey RH. Surgical management of esophageal 15. Huang CD, Koh PS, Maddaus MA. Short esophagus and esopha-
reflux and hiatus hernia. Long-term results with 1,030 patients. geal stricture. Surg Clin North Am. 2005;85(3):433–451.
J Thorac Cardiovasc Surg. 1967;53(1):33–54. 16. D’Cunha J, Andrade RS, Maddaus MA. Surgical management of
3. Horvath KD, Swanstrom LL, Jobe BA. The short esophagus: gastroesophageal reflux disease/Barrett esophagus. Minerva
Pathophysiology, incidence, presentation, and treatment in the Chir. 2011;66(1):7–19.
era of laparoscopic antireflux surgery. Ann Surg. 2000;232(5):630– 17. Steichen FM. Abdominal approach to the Collis gastroplasty and
640. Nissen fundoplication. Surg Gynecol Obstet. 1986;162(3):272–
4. Champion JK. Laparoscopic vertical banded gastroplasty with 274.
wedge resection of gastric fundus. Obes Surg. 2003;13(3):465; 18. Luketich JD, Grondin SC, Pearson FG. Minimally invasive
author reply. approaches to acquired shortening of the esophagus: Laparoscopic
5. Gastal OL, Hagen JA, Peters JH, et al. Short esophagus: Analysis Collis-Nissen gastroplasty. Semin Thorac Cardiovasc Surg.
of predictors and clinical implications. Arch Surg. 1999; 2000;12(3):173–178.
134(6):633–636; discussion 637–638. 19. Terry ML, Vernon A, Hunter JG. Stapled-wedge Collis gastro-
6. Jobe BA, Horvath KD, Swanstrom LL. Postoperative function fol- plasty for the shortened esophagus. Am J Surg. 2004;188(2):
lowing laparoscopic collis gastroplasty for shortened esophagus. 195–199.
Arch Surg. 1998;133(8):867–874. 20. Swanstrom LL, Marcus DR, Galloway GQ. Laparoscopic Collis
7. Lin E, Swafford V, Chadalavada R, et al. Disparity between gastroplasty is the treatment of choice for the shortened esopha-
symptomatic and physiologic outcomes following esophageal gus. Am J Surg. 1996;171(5):477–481.
lengthening procedures for antireflux surgery. J Gastrointest 21. Johnson AB, Oddsdottir M, Hunter JG. Laparoscopic Collis gas-
Surg. 2004;8(1):31–39; discussion 38–39. troplasty and Nissen fundoplication. A new technique for the
8. Luketich JD, Nason KS, Christie NA, et al. Outcomes after a management of esophageal foreshortening. Surg Endosc. 1998;
decade of laparoscopic giant paraesophageal hernia repair. 12(8):1055–1060.
J Thorac Cardiovasc Surg. 2010;139(2):395–404. 22. Awad ZT, Filipi CJ, Mittal SK, et al. Left side thoracoscopically
9. Mattar SG, Bowers SP, Galloway KD, et al. Long-term outcome assisted gastroplasty: A new technique for managing the short-
of laparoscopic repair of paraesophageal hernia. Surg Endosc. ened esophagus. Surg Endosc. 2000;14(5):508–512.
2002;16(5):745–749. 23. Pierre AF, Luketich JD, Fernando HC, et al. Results of laparo-
10. Maziak DE, Todd TR, Pearson FG. Massive hiatus hernia: Evalu- scopic repair of giant paraesophageal hernias: 200 consecutive
ation and surgical management. J Thorac Cardiovasc Surg. patients. Ann Thorac Surg. 2002;74(6):1909–1915; discussion
1998;115(1):53–60; discussion 61–62. 1915–1916.
11. Patel HJ, Tan BB, Yee J, et al. A 25-year experience with open 24. Velanovich V. The development of the GERD-HRQL symptom
primary transthoracic repair of paraesophageal hiatal hernia. severity instrument. Dis Esophagus. 2007;20(2):130–134.
J Thorac Cardiovasc Surg. 2004;127(3):843–849. 25. McHorney CA, Ware JE Jr. Construction and validation of an alter-
12. Smith CD, McClusky DA, Rajad MA, et al. When fundoplication nate form general mental health scale for the Medical Outcomes
fails: Redo? Ann Surg. 2005;241(6):861–869; discussion 869–871. Study Short-Form 36-Item Health Survey. Med Care. 1995;33(1):
13. Whitson BA, Hoang CD, Boettcher AK, et al. Wedge gastroplasty 15–28.
and reinforced crural repair: Important components of laparo- 26. Velanovich V. Endoscopic endoluminal radiofrequency ablation of
scopic giant or recurrent hiatal hernia repair. J Thorac Cardio- Barrett esophagus: Initial results and lessons learned. Surg Endosc.
vasc Surg. 2006;132(5):1196–1202. 2009;23(10):2175–2180.
LWBK1254-ch06_p65-74.indd 74 19/02/14 10:02 AM

7 Open Collis Gastroplasty
Ankit Bharat and Bryan F. Meyers
Introduction
Postoperative hiatal herniation of a fundoplication performed to control medically
recalcitrant gastroesophageal reflux disease (GERD) is a common cause of surgical
failure and recurrent symptoms following antireflux surgery.1 It has been recom-
mended that at least 2 to 3 cm of tension-free intra-abdominal esophageal length be
obtained during repair of the hiatal hernia. This allows the fundoplication to be per-
formed on tension-free intra-abdominal esophagus and reduce the chances of transdi-
aphragmatic wrap herniation after antireflux surgery.2–5 In most patients, extended
mediastinal esophageal mobilization will enable an adequate length of intra-abdominal
esophagus to be achieved. However, up to 10% of patients who undergo routine
antireflux surgery may not have adequate intra-abdominal esophageal length, despite
maximal mediastinal mobilization maneuvers, to create a tension-free intra-abdominal
fundoplication.
A solution to this problem of a shortened esophagus was introduced by Leigh Collis
in 1957. He described a gastroplasty technique that could lengthen the esophagus
by creating a neoesophageal gastric tube.6 As was the general consensus of that era,
Collis’s primary approach to hiatal hernias was limited to reducing the stomach into
the abdomen and restoring a normal esophageal hiatal aperture. In the case of true
short esophagus, this was not possible, so Collis created the gastroplasty to make a
connecting tube that remained in the chest between the intrathoracic gastroesophageal
mucosal junction and the body of the stomach, which could now be reduced into the
abdomen before repair of the hiatal hernia (Fig. 7.1). A fundoplication was not per-
formed and the esophageal pathology was approached through a left thoracoabdominal
exposure.
Although hiatal hernia control was acceptable, medically recalcitrant GERD plagued
many of the patients who underwent Collis’s original procedure. Subsequent surgeons
reported their experience with the combination of Collis’s esophageal-lengthening pro-
cedure and fundoplication that resulted in both acceptable hiatal hernia management
and control of GERD.7–11 These procedures were primarily performed through a thora-
coabdominal or lateral thoracotomy approach. Today, the open approach to Collis gas-
troplasty can be performed through thoracotomy access or primary abdominal access
using the technique for banded gastroplasty with cutting of the vertical staple line and
by use of the wedge gastroplasty approach.3,12,13
75
LWBK1254-ch07_p75-84.indd 75 19/02/14 7:04 AM

Figure 7.1 Original Collis illustrations from

Short esophagus 1957. (From: Collis JL. An operation for
hiatus hernia with short esophagus. Thorax.
Cardia 1957;12(3):181–188, with permission).
Hiatus hernia
Broad neck through

diaphragmatic hiatus
After division
and suture
Position for Lower part

clamps returned to
abdomen
The absolute indication for performing a Collis gastroplasty is the presence of obvious
esophageal shortening that prohibits reduction of the gastroesophageal junction into the
abdomen without tension. This esophageal shortening is usually the result of transmu-
ral fibrosis and esophageal stricture related to chronic GERD injury. It is appreciated
that at least 2 to 3 cm of distal esophagus within the abdominal cavity below the repair
of a hiatal hernia is required to re-establish the normal intra-abdominal esophageal
length estimated by radiographic studies and esophageal manometric analysis of normal
subjects. Of course, this restoration of normal intra-abdominal length must be accom-
plished without tension to avoid recurrence of the hiatal hernia. The diaphragm con-
tracts 30,000 times each day for respiration and the esophagus contracts 1,000 times a
day for swallowing. Therefore, tension on the repair can lead to wrap herniation or
disruption over time, and more importantly, any retching or sudden increase in intra-
abdominal pressure can also increase the likelihood of hiatal hernia recurrence.
Standard antireflux procedures in cases of shortened esophagus are unlikely to
achieve a sufficient tension-free length of intra-abdominal esophagus and consequently
the likelihood of hiatal hernia recurrence, as with any other hernia, is increased.7,8 The
primary issue is defining the true short esophagus. While some authors recommend the
use of a Collis gastroplasty in all cases of reflux stricture due to the inherent tendency
for esophageal shortening (Fig. 7.2),9,10 others have shown that good results can be
obtained with dilation and standard antireflux procedures if the above criteria of 2 to
3 cm of tension-free intra-abdominal esophagus can be achieved.14–16 As described by
Collis and others,6,17 many patients have only moderate esophageal shortening that can
be treated by an extended mediastinal dissection and esophageal mobilization. O’Rourke
et al. defined an esophageal mediastinal dissection less than 5 cm as type I and an
esophageal mediastinal dissection greater than or equal to 5 cm as type II. While such
nomenclature might help analyze surgical decision making and guide this discussion,
LWBK1254-ch07_p75-84.indd 76 19/02/14 7:04 AM

Chapter 7 Open Collis Gastroplasty 77
Figure 7.2 Hiatal hernia with stricture and shortened

esophagus. Morse C, Pennathur A, and Luketich
JD. Laparoscopic techniques in reoperation for failed

antireflux repairs. In: Pearson FG, Patterson GA, eds.
Pearson’s thoracic & esophageal surgery. 3rd ed.
Philadelphia: Churchill Livingstone/Elsevier; 2008:
367–375 (Used with permission).
such terminology has not been commonly adopted and is rarely reported in typical
operative notes. On average, a type II dissection was carried up between 7 and 10 cm
into the mediastinum. In cases reported by O’Rourke in which type II dissection failed
to release an adequate segment of tension-free intra-abdominal esophagus, a Collis gas-
troplasty was recommended.17
Relative indications for performing a Collis gastroplasty include situations associ-
ated with increased risk of recurrence following antireflux surgery, for example, a large
hiatal hernia, a failed prior antireflux procedure, or morbid obesity, which is associated
with increased intra-abdominal pressure after hiatal hernia repair.18–20 Collis gastro-
plasty should be avoided in patients with severe inflammatory conditions of the stom-
ach that increase the risk of staple-line failure and leak.
Preoperative assessment of esophageal shortening can be challenging. Conditions in
which esophageal shortening is likely to occur include fibrotic strictures, ulceration
with dense periesophageal fibrosis, large or fixed hiatal hernias with dense adhesions
around the sac and following failed prior antireflux procedures, particularly where
there is proximal migration of the gastroesophageal junction into the chest. The pres-
ence of a large paraesophageal hiatal hernia is also considered by some to be highly
predictive of the presence of short esophagus.20–22 Urbach et al. reported a 4.5-fold
increased use of gastroplasty in their experience when the surgery was performed for
paraesophageal hernia, 4.3-fold increase in the setting of Barrett’s esophagus, and 11.6-
fold likelihood of gastroplasty during “redo” surgery.20 Of course, this is not necessarily
the experience of other skilled esophageal surgeons. However, Urbach’s work does give
us some direction as to which patients may have anatomic changes suggestive of
esophageal shortening where gastroplasty may be considered. It is also important to
realize that no preoperative assessment can provide information about the degree of
elasticity or fibrosis of the esophagus. Therefore, the decision to perform a gastroplasty
is an intraoperative decision based on all the factors mentioned above and ultimately,
LWBK1254-ch07_p75-84.indd 77 19/02/14 7:04 AM

the intraoperative estimate of an adequate length of intra-abdominal distal esophagus

for tension-free hiatal hernia repair and fundoplication.23
The preoperative modalities available to assess the likelihood that esophageal short-
ening will require a Collis gastroplasty include barium contrast studies, endoscopy,
manometry, and cross-sectional radiographic imaging. The following findings have been
associated with the presence of short esophagus.
n Larger (>5 cm) nonreducing hiatal hernia indicates long-standing disease with asso-
ciated mediastinal scarring and shortened esophagus. This can be assessed on con-
trast swallow or cross-sectional radiographic imaging.
n Esophageal stricture that suggests transmural inflammation and mediastinal scarring.
Strictures can be diagnosed on contrast swallow as well as upper endoscopy.
n Barrett’s esophagus is most commonly associated with a hiatal hernia and is a marker
of long-standing GERD. Although this is not an independent factor associated with
esophageal shortening, the presence of Barrett’s esophagus is commonly seen in the
large hiatal hernia (>5 cm length) and peptic stricture setting.
n Lower esophageal sphincter (LES) at 35 cm or less from the incisors as assessed using
upper endoscopy or manometry in an adult male of average height. The normal
esophageal (LES) location is around 40 cm from the upper incisors.
n The LES is normally seen within the positive pressure swings with respiration seen
with an intra-abdominal location of the LES. If the LES is noted in a negative pres-
sure swing environment of the thoracic cavity on manometric evaluation, this sug-
gests that the LES is in a shortened circumstance. Of course, these manometric
findings must be correlated with barium esophagram and endoscopic findings sug-
gestive of hiatal hernia.
Surgery
Transabdominal Collis Gastroplasty

Collis gastroplasty is performed as one component of the primary procedure used to
correct a hiatal hernia and control of gastroesophageal reflux. Occasionally, an open
gastroplasty via an abdominal approach is required. This is relatively rare and is done
when the primary esophageal procedure is being approached through laparotomy, for
example, in patients who have had multiple prior laparotomies, multiple prior antire-
flux procedures, or who are undergoing another unrelated open abdominal procedure.
Intraoperative endoscopy following esophageal mobilization is strongly advised for
the assessment of shortened esophagus.5,24 After completing the hiatal and mediastinal
dissections, we routinely perform endoscopy to assess adequate intra-abdominal length
of the esophagus. The gastric folds provide a good anatomic landmark of the GE junc-
tion as they are normally located at or a few millimeters below the Z-line.24 After the
endoscope is passed into the gastric fundus, the point of passage between the tubular
esophagus and the stomach is recognized by means of transillumination or by palpating
the tip of the scope. The distance between the hiatus and GE junction is estimated. A
stitch is placed on the GE junction to mark it and to facilitate subsequent Collis gastro-
plasty and antireflux wrap calibrations.
If a diagnosis of shortened esophagus is made after adequate transhiatal mediastinal
mobilization, we will make the decision to perform the Collis gastroplasty. The orogastric
tube is removed, and a 48- to 52-French bougie is advanced down the esophagus into the
stomach carefully with manual assistance by the surgeon. We always perform the gastro-
plasty after placing a bougie to avoid esophageal narrowing. Open gastroplasty can be
performed using the technique of EEA circular stapler or wedge gastroplasty, although we
prefer to use wedge gastroplasty due to the complications associated with the EEA technique.
To accomplish the wedge gastroplasty, an angulating linear stapler with a thick tissue
load is introduced. The assistant retracts the fundus of the stomach inferiorly and slightly
LWBK1254-ch07_p75-84.indd 78 19/02/14 7:04 AM


B
B
A B
Figure 7.3 Wedge Gastroplasty A: Surgeon’s left hand lifts the gastric cardia with a grasper and the assistant grasps the greater
curvature and gives a downward and lateral traction. A linear stapler is placed so that it approximates the bougie in the esopha-
gus. B: After the initial firing of the stapler, the wedge gastroplasty is completed by one or two additional firings parallel to the
bougie. B indicates location of the bougie in the esophagus. (A laparoscopic Collis gastroplasty is depicted; the same principles
apply when performing open transabdominal Collis gastroplasty).
to the patient’s left, thereby pulling the lesser curve against the bougie. The stapler is directed
perpendicular to the long axis of the planned neoesophageal segment, aiming the tip of
the stapler to the planned distal end of the gastroplasty (Fig. 7.3). The assistant retracting
the stomach should manipulate the top edge of the greater curve into the stapler jaw,
and then retract the stomach inferiorly thereby withdrawing as much of the greater curve
out of the stapler to avoid excessive resection of the fundus. It is important that the greater
curvature be the portion of the stomach most deeply into the jaws of the stapler. It is easy
to create an oblique bite of the stomach if careful attention is not paid to this point. The
tip of the stapler is carefully advanced to fit snugly against the intraluminal bougie and
fired to create a transverse stapled resection line. It is important that the bougie is reached
with the final firing, and this is assured when the dilator is pushed away when closing
the stapler. The second staple line is completed longitudinally with the stapler aimed
toward the mediastinum while applied firmly against the bougie. It is crucial that the
assistant place gentle lateral traction on the wedge of stomach to be removed during the
second staple-line firing. The stapler is fired once or twice to produce a stapled wedge
of stomach. The two stapled resection lines result in a small triangular wedge resection
of the stomach at the angle of His, effectively lengthening the intra-abdominal esophagus
by length of the upward directed staple line. Since the neoesophagus is aperistaltic, it is
advisable to limit this length as much as possible. The bougie is then removed and an
orogastric tube can be passed back so that the tip is in the proximal stomach.
Some authors have suggested that the distal esophagus and proximal stomach can
be filled with 250 mL dilute methylene blue to test the staple line and establish that
there is no leak. We skip this step and have not regretted doing so. The senior author
of this chapter is aware of two leaks after Collis gastroplasty procedures in 15 years:
Both were associated with necrosis of the Collis segment and neither would have likely
demonstrated any leakage immediately after their creation.
As previously mentioned, gastroplasty using the circular stapler has fallen out of use
completely at our center as well as most other centers. We only use the wedge gastro-
plasty technique to perform esophageal lengthening due to the reasons described before.
After the Collis gastroplasty, we complete the operation by reconstructing the esophageal
hiatus and creating the antireflux wrap. The details of the subsequent crural closure and
antireflux wrap are covered by other authors in this text.
Transthoracic Collis Gastroplasty

The transthoracic approach to Collis gastroplasty was commonly performed until the
advent of laparoscopic fundoplication. There are still several circumstances when an open
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thoracotomy approach for hernia repair, Collis gastroplasty, and fundoplication is a

reasonable surgical option. For example, after a prior transabdominal antireflux surgery,
the herniated portion of stomach may not be accessible via an abdominal approach due
to adhesions. In other patients, the transthoracic approach may be preferred for improved
visualization of the esophageal pathology due to excessive obesity. Similarly, some
esophageal surgeons prefer the transthoracic approach for the correction of large
paraesophageal hernias. In any case, the transthoracic approach to Collis gastroplasty
can be more straightforward than the transabdominal and laparoscopic approaches for
the procedure.
n The thoracotomy incision is usually at the seventh interspace with the eighth rib
shingled posteriorly to increase the rib mobility during retraction to achieve intratho-
racic exposure of the esophageal pathology.
n The inferior pulmonary ligament is incised which allows visualization of the hiatal
hernia contents and distal esophagus in the posterior mediastinum.
n The hernia sac is opened and the stomach and esophagus mobilized to identify the
shortened GE junction. The gastroesophageal fat pad is dissected off the stomach
with care taken to preserve the vagus nerves.
n A 48- to 54-French bougie is passed through the esophagus, the GE junction and
verified manually within the intra-abdominal esophagus (Fig. 7.4A).
n With the bougie in place, a linear stapler is placed adjacent to the bougie while the
bougie is firmly pressed against the lesser curvature of the stomach (Fig. 7.4B). The
stapler is fired, typically creating a staple line of 3 to 5 cm in length. No resection
of tissue is required as the wedge gastroplasty described in the abdominal procedure
is merely a method to allow the gastroplasty to be created toward the angle of His
as opposed to away from it.
n Once the staple line is completed, an antireflux wrap is formed and the chest closed.
Some authors advocate oversewing the staple line with absorbable suture (Fig. 7.4C)
but we have not had problems with staple-line leaks and do not perform this step
routinely.
Type of Fundoplication Performed with the Collis Gastroplasty

The Collis gastroplasty has been combined with many fundoplication procedures. Typ-
ically a standard 360-degree, Nissen fundoplication or a 270-degree, partial, Toupet
fundoplication is constructed when the procedure is approached through the abdomen,
as described in Chapter 3. The Belsey partial fundoplication (described in Chapter 5)
or the standard Nissen fundoplication (described in Chapter 4) is constructed when
using a thoracotomy approach (Fig. 7.5). One controversial point is that a complete
360-degree Nissen wrap over the aperistaltic neoesophagus may be prone to cause post-
operative dysphagia, especially since many of these patients may already have had
esophageal dysmotility disorders. The partial, 270-degree, Toupet wrap, on the other
hand, may be less effective in controlling reflux symptoms. There are no good clinical
trials comparing complete and partial wraps after Collis gastroplasty.
The immediate postoperative management is influenced by the surgical approach,
namely, abdominal or chest. We obtain a contrast swallow on the first postoperative day
and then feed a full liquid diet if the study is normal. The information that we seek
from the swallow evaluation includes the integrity of the wrap, whether there is edema
leading to contrast retention in the esophagus, gastric transit time that might be delayed
in case of vagus nerve injury and any evidence of leak. The patients are typically dis-
charged on a full liquid diet for 3 to 4 weeks, after which we expect the swelling at the
wrap site to have resolved and the patients to better tolerate solid food.
If the hiatal dissection was tedious or if there was some other reason for not feeding
LWBK1254-ch07_p75-84.indd 80 19/02/14 7:04 AM


A B
Figure 7.4 Transthoracic Collis Gastroplasty. A: The esophagus is encircled and a bougie inserted. The gastric fundus is retracted
superiorly using atraumatic clamps. B: Neoesophagus is created using a stapler, making sure that the stapler is parallel to the
bougie. C: The suture can be oversewn using absorbable suture material.
Figure 7.5 The combined Collis-

Nissen as described by Orringer.
Placement of the gastric fundus
around the gastroplasty tube and
construction of the fundoplication.
Inset A shows the 3-cm long
fundoplication. Inset B shows the
fundoplication reduced beneath
the diaphragm. (From: Stirling MC,
Orringer MB. The combined
Collis–Nissen operation for
esophageal reflux strictures. Ann
Thorac Surg 1988:45(2):148–157,
with permission).
LWBK1254-ch07_p75-84.indd 81 19/02/14 7:04 AM

the patient, for example, tenuous respiratory status, we occasionally delay the swallow
evaluation until the patient is deemed ready for oral feeding.
Complications
Collis gastroplasty allows a more durable hiatal hernia repair and antireflux procedure
by eliminating tension in the setting of short esophagus and also allows for the perform-
ance of the fundoplication around a healthy segment of neoesophagus that accepts
fundoplication sutures more readily than an inflamed or a fibrosed esophagus. However,
the more liberal extension of Collis gastroplasty to patients with less complicated forms
of GERD needs to be considered very cautiously, weighing the potential complications
of the procedure.25,26 Complications include the suture-line leaks, suture-line fistula,
and consequences associated with the gastric mucosa of the neoesophagus. The con-
struction of the neoesophagus leads to a relatively adynamic distal segment that may
result in dysphagia. This can be more profound in patients with considerable esopha-
geal dysmotility, those with a longer than average gastroplasty and those given a full
Nissen wrap. Second, because the neoesophagus contains gastric mucosa, in effect it
produces an iatrogenic Barrett’s columnar-lined esophagus that may result in acid pro-
duction inside the esophagus. This may be relevant to the incidence of postoperative
esophageal inflammation. Lin et al. reported that recurrent erosive esophagitis due to
pathologic acid exposure was found in over 80% of patients who underwent Collis
gastroplasty. Nevertheless, 65% of patients with recurrent hiatal hernias reported sig-
nificant symptomatic improvement after Collis gastroplasty and repair of the hernia. It
is therefore advised that patients undergo subsequent follow-up with objective testing
and be placed on proton pump inhibitors if there is an abnormal acid exposure. For
these reasons, some experts advocate the use of a Collis gastroplasty only when abso-
lutely indicated for significant esophageal shortening consequent to severe forms of
reflux stricture or ulceration with peri-esophageal fibrosis.
Results
Large original series of Collis gastroplasty with antireflux procedures have been pub-
lished by Pearson and Henderson,19 Stirling and Orringer,18 and Henderson.27 The series
published by Pearson included 430 patients who underwent Collis gastroplasty in con-
junction with a Belsey antireflux wrap. In this series about 50% of the patients had
dilatable stricture treated surgically. The remaining subjects included patients with
severe ulcerative esophagitis, failed prior antireflux procedures, large, fixed hiatal her-
nias and patients with severe esophageal dysmotility. Overall, satisfactory results were
obtained in over 80% of the patients. Patients with a stricture but with neither a motil-
ity disorder nor previous surgery did better than those who had either or both of these
complicating conditions. Five patients developed adenocarcinoma up to 7 years after
surgery. Stirling and Orringer,18 and Henderson,27 both reported a high recurrent reflux
rate of 30% following the Collis–Belsey procedure and advocated the use of Nissen
fundoplication in combination with Collis gastroplasty. In the series of 353 Collis–Nissen
procedures reported by Stirling and Orringer,18 patients with reflux strictures comprised
20% of the patients, and a majority of the patients were believed to be at high risk for
recurrence due to the presence of a hiatal hernia, dysmotility, marked obesity, or having
undergone a previous unsuccessful hiatal hernia repair. This series demonstrated good
symptomatic and objective improvement in 90% of cases. In this series, 10% of patients
required revisional surgery for recurrent reflux and 17% required dilation for dysphagia.
The Henderson series included 601 Collis–Nissen procedures, 250 of which were
performed transabdominally in patients who had not undergone previous surgery.27
Patients with reflux strictures comprised 10% of the series and half of these patients
had esophageal shortening. Overall, good symptomatic results were shown in 93%
LWBK1254-ch07_p75-84.indd 82 19/02/14 7:04 AM

of patients while 88% of patients with strictures had good results. Avoidance of

post-thoracotomy pain proved to be an advantage of performing the procedures transab-
dominally.

Conclusions
Collis gastroplasty remains a useful technique augmenting hiatal hernia repair
and antireflux surgery in patients with shortened esophagus. The addition of the
esophageal-lengthening Collis gastroplasty may improve the durability of the repair
by reducing tension in the surgical repair and fundoplication. Several modifications
have been proposed following the original description and presently the technique of
stapled wedge gastroplasty through the laparoscopic approach has become the most
popular. Collis gastroplasty is not without long-term sequelae and therefore it should
be carefully selected on a case by case basis and careful attention should be paid to the
technical details of this procedure.
Recommended References and Readings 15. Hill LD, Gelfand M, Bauermeister D. Simplified management of
reflux esophagitis with stricture. Ann Surg. 1970;172(4):638–651.
1. Smith CD, McClusky DA, Rajad MA, et al. When fundoplication 16. Watson A. The role of antireflux surgery combined with fiberop-
fails: Redo? Ann Surg. 2005;241(6):861–869; discussion 869– tic endoscopic dilatation in peptic esophageal stricture. Am
871. J Surg. 1984;148(3):346–349.
2. Swanstrom LL, Marcus DR, Galloway GQ. Laparoscopic Collis 17. O’Rourke RW, Khajanchee YS, Urbach DR, et al. Extended trans-
gastroplasty is the treatment of choice for the shortened esopha- mediastinal dissection: An alternative to gastroplasty for short
gus. Am J Surg. 1996;171(5):477–481. esophagus. Arch Surg. 2003;138(7):735–740.
3. Luketich JD, Grondin SC, Pearson FG. Minimally invasive 18. Stirling MC, Orringer MB. Continued assessment of the com-
approaches to acquired shortening of the esophagus: Laparo- bined Collis-Nissen operation. Ann Thorac Surg. 1989;47(2):224–
scopic Collis-Nissen gastroplasty. Semin Thorac Cardiovasc 230.
Surg. 2000;12(3):173–178. 19. Pearson FG, Henderson RD. Long-term follow-up of peptic stric-
4. Richardson JD, Richardson RL. Collis-Nissen gastroplasty for tures managed by dilatation, modified Collis gastroplasty, and
shortened esophagus: Long-term evaluation. Ann Surg. 1998; Belsey hiatus hernia repair. Surgery. 1976;80(3):396–404.
227(5):735–740; discussion 740–742. 20. Urbach DR, Khajanchee YS, Glasgow RE, et al. Preoperative
5. Mittal SK, Awad ZT, Tasset M, et al. The preoperative predict- determinants of an esophageal lengthening procedure in laparo-
ability of the short esophagus in patients with stricture or scopic antireflux surgery. Surg Endosc. 2001;15(12):1408–1412.
paraesophageal hernia. Surg Endosc. 2000;14(5):464–468. 21. Low DE. The short esophagus-recognition and management.
6. Collis JL. An operation for hiatus hernia with short esophagus. J Gastrointest Surg. 2001;5(5):458–461.
J Thorac Surg. 1957;34(6):768–773; discussion 774–778. 22. Maziak DE, Todd TR, Pearson FG. Massive hiatus hernia: Evalu-
7. Orringer MB, Skinner DB, Belsey RH. Long-term results of the ation and surgical management. J Thorac Cardiovasc Surg. 1998;
Mark IV operation for hiatal hernia and analyses of recurrences 115(1):53–60; discussion 61–62.
and their treatment. J Thorac Cardiovasc Surg. 1972;63(1):25–33. 23. Awad ZT, Mittal SK, Roth TA, et al. Esophageal shortening dur-
8. Bonavina L, Fontebasso V, Bardini R, et al. Surgical treatment of ing the era of laparoscopic surgery. World J Surg. 2001;25(5):558–
reflux stricture of the oesophagus. Br J Surg. 1993;80(3):317–320. 561.
9. Pearson FG, Cooper JD, Patterson GA, et al. Gastroplasty and 24. Mattioli S, Lugaresi ML, Di Simone MP, et al. The surgical treat-
fundoplication for complex reflux problems. Long-term results. ment of the intrathoracic migration of the gastro-oesophageal
Ann Surg. 1987;206(4):473–481. junction and of short oesophagus in gastro-oesophageal reflux
10. Stirling MC, Orringer MB. The combined Collis-Nissen opera- disease. Eur J Cardiothorac Surg. 2004;25(6):1079–1088.
tion for esophageal reflux strictures. Ann Thorac Surg. 1988; 25. Jobe BA, Horvath KD, Swanstrom LL. Postoperative function fol-
45(2):148–157. lowing laparoscopic collis gastroplasty for shortened esophagus.
11. Henderson RD, Marryatt GV. Total fundoplication gastroplasty Arch Surg. 1998;133(8):867–874.
(Nissen gastroplasty): Five-year review. Ann Thorac Surg. 1985; 26. Lin E, Swafford V, Chadalavada R, et al. Disparity between
39(1):74–79. symptomatic and physiologic outcomes following esophageal
12. Champion JK. Laparoscopic vertical banded gastroplasty with wedge lengthening procedures for antireflux surgery. J Gastrointest
resection of gastric fundus. Obes Surg. 2003;13(3):465; author reply. Surg. 2004;8:31–39; discussion 38–39.
13. Terry ML, Vernon A, Hunter JG. Stapled-wedge Collis gastroplasty 27. Henderson RD. The advantage of Collis-Nissen procedure via an
for the shortened esophagus. Am J Surg. 2004;188(2):195–199. abdominal or thoracic approach. In: Giuli R, McCallum RW, eds.
14. Mercer CD, Hill LD. Surgical management of peptic esophageal Benign Lesions of the Esophagus and Cancer. Heidelberg:
stricture. Twenty-year experience. J Thorac Cardiovasc Surg. Springer-Verlag; 1989:471–474.
1986;91(3):371–378.
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8 Reoperative Antireflux
Surgery
Omar Awais, Arjun Pennathur, and James D. Luketich
Introduction
The majority of patients with gastroesophageal reflux disease (GERD) are managed
medically; however, in a subset of patients, antireflux surgery is necessary for intrac-
table GERD. Since the first laparoscopic Nissen fundoplication was performed in
1991, minimally invasive antireflux surgery has been widely accepted as the “gold
standard” operation for intractable GERD. Prior to laparoscopic operations, open
operations were the standard for these patients and the reported failure rates for open
fundoplication ranged from 9% to 30%.1–3 Laparoscopic failure rates have been sim-
ilar and range from 2% to 17%.4,5 Although some patients with recurrent symptoms
after antireflux surgery can be managed medically, it is estimated that 3% to 6% of
post-Nissen patients will require reoperative antireflux surgery.6 In experienced cent-
ers, many claim that first-time antireflux surgery is successful in over 90% of patients.7
While the exact success rate varies from center to center and surgeon to surgeon, all
agree that the success rates for reoperative antireflux surgery performed either open
or laparoscopically do not measure up to that of the first-time operation. Historically,
with open antireflux surgery, satisfactory results have been reported in 84% of patients
who have undergone reoperative antireflux surgery and in only 42% of patients who
have undergone three or more antireflux operations.1 It is clear that in some patients,
especially those that have undergone multiple redo operations on the esophagus and
remain markedly symptomatic, an esophagectomy may be the only viable option;
however, in the majority of patients with benign esophageal disease, the first goal is
esophageal preservation. There are several options for the patient who remains symp-
tomatic after antireflux surgery including redo fundoplication (partial or complete),
the addition of a Collis gastroplasty, Roux-en-Y (RNY) near esophagojejunostomy,
which is particularly applicable in obese patients, jejunal or colon interposition, and
finally esophagectomy. After seeing many different approaches to redo antireflux sur-
gery, it is clear to us that the redo procedure is unlikely to be a simple operation that
can be successful by removing one or two sutures, or simply “tightening up the
wrap.”
85
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Reoperative antireflux surgery is a complex operation, and the success of the operation
is strongly correlated with the surgeon’s experience, the patient’s symptom complex,
and the findings of detailed objective tests. Performance of the surgery by an inexperi-
enced surgeon will increase the chances of a suboptimal result and the best shot at
successful redo antireflux surgery is a first redo in experienced hands. Another impor-
tant consideration is poor correlation between objective tests and clinical symptoms,
which should raise concern when considering redo surgery. For example, if the original
indications for surgery were unclear, such as a cough in the setting of a normal pH
study and no evidence of a hiatal hernia, additional workup may be needed before
considering a redo operation. However, obvious symptoms, such as dysphagia, dumping
syndrome, excessive nausea, and chest pain, that were not present prior to the original
antireflux operation and are now recalcitrant to medical therapy will frequently need
reoperation, depending on the severity.
Failure of antireflux surgery can have numerous etiologies including misdiagnosis
prior to the initial operation. Thus, one of the first steps when evaluating these patients
is a thorough review of the history and testing performed prior to the original operation.
If these considerations are in order, a failure of the original antireflux operation can be
due to technical problems during the first operation, or later breakdown of the wrap. A
hiatal hernia after antireflux surgery may be due to poor hiatal closure, delayed reherni-
ation, or placement of the wrap on the tubularized cardia due to an unrecognized short
esophagus. The cause of symptoms such as recurrent heartburn, regurgitation, and dys-
phagia should be thoroughly investigated with a barium esophagogram and esophageal
physiology testing. Factors such as the type of symptoms (heartburn vs. dysphagia), the
status of esophageal motor function, the number of prior antireflux operations, and the
patient’s body mass index (BMI) should be strongly considered when counseling
patients regarding the options when symptomatic after initial antireflux surgery.
For example, a patient with recurrent or persistent heartburn who has failed opti-
mal medical therapy and with a positive DeMeester score, a barium swallow that dem-
onstrates a recurrent or persistent hiatal hernia, reasonable peristalsis, a normal-range
BMI, and a single prior antireflux operation should be considered an ideal patient for
a redo fundoplication by an experienced esophageal surgeon. In our experience, many
of these redo fundoplications can be performed laparoscopically. Again, it is important
to stress that these cases should be performed by an experienced esophageal surgeon
who is comfortable with advanced minimally invasive procedures.
Reoperation may be more complex in patients with some of the following charac-
teristics.
n Morbid obesity
n Esophageal dysmotility
n Multiple prior antireflux procedures
In the setting of morbid obesity and the comorbidities of obesity, a patient with a
failed antireflux surgery may be the ideal patient for an RNY.8 If an RNY is determined
to be a reasonable option, then a full workup for bariatric surgery should be pursued.
This might include nutritional counseling, psychiatric evaluation, attendance at a sup-
port group meeting, and review of all the implications regarding quality of life (QOL)
and the range of potential complications. If the RNY is decided upon, the surgeon
should be experienced in both advanced laparoscopic antireflux surgery and gastric
bypass techniques. In some cases, this might be best accomplished by consultation with
an established esophageal surgeon working with an experienced bariatric surgeon to
deliver the best care for these complicated patients. Sound judgment is needed for all
patients who undergo reoperative antireflux surgery and the more complex the case,
the more experience is needed. In patients with a severely diseased esophagus, such as
severe dysmotility, nondilatable strictures, multiple prior operations, and significant
gastroparesis, an esophagectomy may be the best option.
LWBK1254-ch08_p85-96.indd 86 20/02/14 10:31 PM

Chapter 8 Reoperative Antireflux Surgery 87
In summary, the following two general groups of patients should be considered for

reoperative antireflux surgery.

1. Those with intractable recurrent or persistent GERD symptoms after prior antireflux
surgery.
2. Those with intractable symptoms (e.g., dysphagia, nausea, gas bloat, or pain) that began after
the initial antireflux operation, persisted, and did not respond to conservative measures.
The workup of a patient who presents with recurrent symptoms after a prior antireflux
surgery is initiated with a detailed history of the evolution of symptoms. It is important
to evaluate the original symptoms prior to the first operation, the response to medical
therapy, and the findings of prior testing. This may identify an esophageal motility dis-
order that may have been missed or an incorrect indication for the original operation.
You may also identify a number of potential warning signs that may have been overlooked
and present serious obstacles to successful antireflux surgery including the following.
n The presence of severe constipation that has not been resolved
n Chronic opiate usage, medically controlled or otherwise
n Atypical GERD symptoms with poor correlation with objective tests, such as a chronic
cough with a normal DeMeester study
n Poor esophageal motility
n Morbid obesity with comorbidities
n Irritable bowel syndromes
The presence of any one of these clinical entities may limit the success of what
appears to be a technically sound antireflux operation. Of course, failure can occur in
any setting if the technical approach was initially poor, or has changed in an unfavo-
rable way since the initial operation, due to reherniation, crural breakdown, etc.
A detailed review of the original operative report focusing on esophageal mobiliza-
tion, vagal preservation, division of the short gastric vessels, and crural repair (prima-
rily or with mesh) should give further insight into the technical causes of failure of the
prior antireflux operation. Symptomatic improvement or lack of relief after the original
repair should be carefully assessed. In addition, it is important to determine if there
was a change in the patient’s symptoms (e.g., heartburn before the operation but dys-
phagia afterward) and the exact timing of the return of symptoms.
During the assessment, it is essential to consider the patient’s BMI and any related
comorbidities. There is a strong association between obesity and GERD, and RNY may
be an attractive surgical option in severely obese patients with a failed fundoplication.9,10
In addition to a detailed history, a detailed physical examination, and a careful
review of the prior operative notes, it is essential to obtain a barium esophagogram as
one of the first steps in the workup of the symptomatic patient after antireflux surgery.
This simple and inexpensive test is universally available and is extremely useful in
defining the anatomy, and identifying the presence of a persistent or recurrent hiatal
hernia, a paraesophageal hernia, a tight or twisted wrap with or without herniation, or
a specific pattern of failure of the prior fundoplication. In some cases, the barium swal-
low may be all you need prior to reoperative surgery. In some cases, the esophagogas-
troduodenoscopy (EGD) may allow the surgeon to define one of the classic patterns of
failure. There are many ways that a prior antireflux operation can fail; these have been
summarized previously and include crural disruption, transdiaphragmatic herniation
of the fundoplication, breakdown of the fundoplication, slipped or misplaced Nissen,
misdiagnosis of achalasia, loose fundoplication, or tight fundoplication.5,11–13
Upper endoscopy permits direct visualization of the mucosa with complete evalu-
ation of the esophagus, stomach, duodenum, and the fundoplication. The finding of
esophagitis or esophageal stricture may contribute to the evaluation. Biopsies can be
performed to evaluate for cancer and/or Barrett’s esophagus. Detailed evaluation of the
LWBK1254-ch08_p85-96.indd 87 20/02/14 10:31 PM

fundoplication and hiatal anatomy will further give insight into the likely cause of
failure. Frequently, one can identify subtle recurrent hiatal hernias, failure of the clas-
sic “stack of coins” on retroflex view, or a wrap that is simply too tight or too loose.
Repeat pH monitoring is helpful when primary symptoms are heartburn-related; how-
ever, it is clear that some patients may have a normal pH study and still have marked
symptoms from a twisted wrap, too tight of a wrap, or a completely herniated and par-
tially obstructing wrap. A repeat manometry is important in the workup of the patient
with a failed Nissen, even if the prior manometry was normal, but is especially helpful
in patients with predominant symptoms of dysphagia. Intractable bloating or gastropare-
sis may indicate vagal nerve compromise and gastric emptying studies may help in plan-
ning the best approach. All of these studies are very valuable in identifying the cause of
the patient’s symptoms and help the surgeon tailor the best redo operation for the
patient.11,14,15 After completion of all comprehensive testing, the surgeon and the patient
discuss the findings and determine the best course of action, which may include con-
tinuation of medical therapy, redo fundoplication, conversion to an RNY, or esophagec-
tomy or colon interposition. Factors to consider in determining the best course of action
will depend on the dominant clinical symptoms (i.e., heartburn or dysphagia), baseline
esophageal function on physiology testing, number and success of the prior antireflux
operations, evidence of gastroparesis, and the patient’s BMI. A number of warning signs
were listed earlier and must be considered prior to reoperation.
One example of a warning sign that may have been overlooked and may present seri-
ous obstacles to successful antireflux surgery is chronic constipation due to bowel abnor-
malities or simply due to chronic opiate usage. In this setting, one can anticipate extremes
of gas bloating and recurrent GERD due to extremely poor downstream peristalsis. In some
cases, simply resolving the chronic constipation can go a long way to improving symptoms
of bloat, gas, and in some cases even typical GERD symptoms. Thus, in all patients with
constipation, we first work on a bowel regimen that normalizes bowel movements. Con-
sultation with an experienced gastroenterologist is essential to resolve these issues prior
to surgery. We consider chronic opiate usage a very serious warning sign that a simple
Nissen may be technically adequate but postoperatively, the patient may be troubled by
excessive gas, bloat, abdominal cramps, nausea, and failure to reach a satisfactory resolu-
tion of GERD symptoms. In this setting, we give strong consideration to the possibility of
first working on a satisfactory bowel regimen, then reassessing the patient to see if indeed
some of the GERD symptoms have resolved. We have seen many cases where a patient
troubled by GERD and on chronic opiates with severe constipation is managed with a
successful bowel regimen, and the GERD symptoms markedly improve. This is becoming
an increasingly familiar clinical problem, and the Drug Enforcement Agency (DEA) has
noted a clear epidemic of the legal use and abuse of prescription narcotics and has esti-
mated that the prescribing of narcotics in the United States has increased over 600% in
the past decade.16 In some of these patients, aggressive proton pump inhibitor (PPI) use,
bowel regimens to control constipation, or working with the patient and the pain clinic
to lower or completely eliminate the opiate, if possible, may resolve the GERD symptoms.
In summary, assessment of patients with failed fundoplication contains the follow-
ing steps.
n A detailed history and physical examination with review of all prior testing and
records.
n A comprehensive evaluation that includes an endoscopy and a barium esophago-
gram, and frequently manometry, pH testing, and gastric emptying studies.
n Establishing a correlation between clinical symptoms and objective testing to tailor
an appropriate redo operation.
Surgery
Esophageal-preserving surgical options for redo antireflux surgery include redo fundopli-
cation (partial or complete) and RNY. To provide the best outcome, an individualized
approach based on the cause of fundoplication failure, the overall esophageal motility, and
LWBK1254-ch08_p85-96.indd 88 20/02/14 10:31 PM

the patient’s BMI is necessary. As a last resort, an esophagectomy or a colon interposition

may be the only viable option. Operative technique for redo fundoplication and RNY
will be discussed.

Key factors to consider when selecting the type of operative approach include the
following.
n Redo fundoplication is ideal for a first-time redo in patients who have preserved
esophageal function, an obvious anatomic wrap failure, objective evidence of recur-
rent reflux, and who are not obese.
n RNY should be considered in obese patients with recurrent symptoms and multiple
comorbidities.
n For very complex settings, such as patients with multiple failed redo operations,
poor esophageal motility, and associated gastroparesis, going straight to minimally
invasive esophagectomy with a high intrathoracic anastomosis and narrow gastric
tube may be considered.
Positioning
Once the patient is under general anesthesia, an arterial line, a Foley catheter, and
adequate intravenous access are placed. The patient is placed supine in reverse
Trendelenburg position with his or her arms out. In anticipation for a long operative
case, all pressure points need to be padded.
Operative Technique for Redo Fundoplication

The principles of reoperative antireflux surgery, whether minimally invasive or open,
are the same. The focus should be on first carefully assessing the existing anatomy,
reestablishing the normal anatomy (step by step), preserving vagal integrity, preserving
crural integrity if possible, looking for and recognizing a short esophagus and perform-
ing an esophageal-lengthening procedure when necessary, identifying the need for
crural reinforcement, and properly constructing the fundoplication. The operation
should be performed at a center with extensive experience in reoperative esophageal
surgery.
n On-table endoscopy is performed to evaluate the esophagus, the stomach, and the
fundoplication. An assessment of the mucosa is essential to rule out the presence of
Barrett’s esophagus or neoplasm that might change the operative plan.
n The abdomen is prepped and draped, and the initial port is placed away from prior
incisions via a cut-down technique to allow safe entry into the abdomen. In most
cases, we are able to perform laparoscopic lysis of adhesions to allow the remaining
ports to be placed under direct visualization. However, the surgeon should not hes-
itate to open the abdomen, if needed, at any time.
n The upper abdomen is explored and additional lysis of adhesions is performed to
free the liver from the prior fundoplication. The caudate lobe of the liver is identi-
fied, which will allow the surgeon to recognize the right crus. Right and left crural
mobilization is performed from the liver and the spleen, respectively, paying par-
ticular attention to preserving the integrity of the crus.
n Frequently, it is necessary to go from side to side, moving from areas of recognizable
anatomy, and into more difficult areas carefully. We frequently first work a little
lower on the crus muscle and identify normal planes and carefully move up the crus.
n Once the crura have been identified, we attempt to remove crural sutures and open
the posterior mediastinum.
n Next, we carefully work along the crural planes laterally into the mediastinum,
attempting to avoid injury to the vagus nerves, and avoid entering the pleura. Early
entry into the pleura may necessitate placing a pigtail catheter into the respective
pleural space. As we move into the mediastinum, we can frequently see the esopha-
gus and vagus nerves proximally. We carefully continue this plane of dissection and
then begin to move anteriorly.
LWBK1254-ch08_p85-96.indd 89 20/02/14 10:31 PM

n As one moves either anteriorly or posteriorly, care must be taken to preserve vagal
integrity. We avoid going directly between the two limbs of the wrap in the initial
phases of the reoperation as the vagus nerves are particularly at risk early in the
reoperation before the anatomy is identified.
n Sharp dissection with the ultrasonic shears or other device will provide a relatively
bloodless field allowing safe recognition of important structures.
n At any point in the operation, where progress is not safe, we will move to another
area and reassess there. For example, assessing slightly lower on the greater curva-
ture of the stomach and taking down the short gastric vessels and dissecting up
toward the left crus from below can be a rewarding plane in some cases.
n As we work on the right or left crus, knowledge of the operative steps during the
initial operation(s) is essential. Knowing if the vagal nerves were left inside the wrap
(as in most cases) or outside the wrap or if mentioned at all can be helpful.
n If the wrap was tacked to the right and left crus, it is very easy to inadvertently enter
the stomach. Again, we frequently go back and forth from the right crus to the left,
looking for areas of safe progress. Once we have some identification of the stomach
and wrap limbs, we generally start on the left limb of the wrap and gently work
inside of this, sweeping any fat or tissue centrally, assuming the anterior vagus is
between the suture limbs of the wrap. As this is done, removal of fundoplication
sutures can safely be done from just on the undersurface of the wrap on the left,
thereby preserving the anterior vagal trunk. Once this is done, one can frequently
pick up the right limb of the wrap, sweep inside of this, and gently clear the esopha-
geal side of the wrap until both limbs of the gastric wrap are mobilized.
n Once both limbs are mobilized completely, the wrap is freed completely from the
right and posterior crus and tucked back under the esophagus into its normal ana-
tomic location.
n If we can pick up the fundic tip and it lifts easily and completely, then we consider that
near-normal anatomy is reestablished. At this point, we completely remove the fat pad,
starting from the angle of His and moving from the left crus side toward the right. We
avoid the anterior vagus and identify the true esophageal wall as it meets the stomach.
n Next, we completely mobilize the esophagus into the mediastinum and assess the
esophageal length to determine if it is adequate. Ideally, 2.5 to 3 cm of tension-free
intra-abdominal esophageal length should be established. If we do not have this
length, we first attempt to mobilize the esophagus more proximally to gain additional
length. If the esophagus is still short, a Collis gastroplasty should be strongly con-
sidered. Collis gastroplasty can be performed with a bougie in the esophagus, using
a circular end-to-end anastomotic (EEA) technique (Fig. 8.1), but is more commonly
performed with a wedge gastroplasty (Fig. 8.2).
n An on-table endoscopy is again performed to evaluate any inadvertent esophageal or
gastric perforations. It is very easy to miss a small gastric enterotomy, and these injuries
should be repaired before performing a fundoplication. If there is extensive damage to
the gastroesophageal junction or the fundus, such that repair or a safe fundoplication
cannot be constructed, a different surgical option, such as RNY or esophagectomy,
should be considered. We always discuss these extreme situations with the redo patient
before operation and the consent indicates these other options as “possible.”
n If performing a complete wrap, we do a floppy, two-stitch fundoplication on the
esophagus over a 52 to 56 F bougie or on the neoesophagus if a Collis gastroplasty
was performed. (Fig. 8.3). It is essential to deliver the fundus with proper orientation
in an untwisted, nonspiraled fashion, as assessed by the “shoe-shine” maneuver.
n For patients with severe dysmotility or significant dysphagia, a partial wrap (Dor or
Toupet) may be considered. In rare circumstances, in the setting of a very tight wrap
that led to long-standing dysphagia, manometry testing may suggest pseudoachalasia.
In these unusual cases, a distal myotomy may be needed in addition to converting
the wrap to a partial fundoplication.
n The crural repair completes the operation. The crura are approximated posteriorly
with permanent suture. It is important to completely mobilize the right and left crus
of the liver and the splenic attachments to allow tension-free primary closure. If the
LWBK1254-ch08_p85-96.indd 90 20/02/14 10:31 PM


5 cm
2 cm
B C
D
Figure 8.1 Collis gastroplasty performed with a transgastric EEA followed by a linear stapler. A–C: Anvil
positioning of the EEA stapler. D: Creation of the neoesophagus with an Endo GIA stapler.
LWBK1254-ch08_p85-96.indd 91 20/02/14 10:32 PM

Figure 8.2 Collis wedge gastro-

plasty.
integrity of the crura is compromised or a tension-free closure cannot be achieved

despite all efforts (e.g., inducing a left-side pneumothorax or lowering intra-abdominal
pressure during laparoscopy), a biologic mesh should be used to reinforce the crural
repair. Nonabsorbable mesh should be avoided at all costs due to the concern of
delayed erosion into the esophagus.
n The operation is concluded with the placement of nasogastric tube and closure of all
incisions.
Figure 8.3 Completed Nissen fundop-

lication. The wrap is tension-free
and subdiaphragmatic with proper
orientation.
LWBK1254-ch08_p85-96.indd 92 20/02/14 10:32 PM

Operative Technique for Roux-en-Y Near Esophagojejunostomy

n RNY can be performed either laparoscopically 10 or via an open technique. For

laparoscopic RNY, the initial port placement, lysis of adhesions and dissection to
establish normal anatomy is the identical to that described above for redo fundop-
lication.
n Once normal anatomy has been established, a small gastric pouch is constructed with
linear stapling devices from the cardia just beyond the GE junction.
n We have used two options for laparoscopic gastrojejunostomy. One is to perform an
end-of-stomach pouch to the side of the jejunum anastomosis. To accomplish this,
we insert a 25- or 28-mm anvil into the pouch of stomach and secure with a purse-
string stitch.
n Next, the crus is approximated posteriorly, as noted above, to close the diaphragmatic
hiatus.
n Attention is directed toward the ligament of Treitz and we divide the jejunum approx-
imately 40 cm from the ligament of Treitz, using care to first ensure that we have
chosen a relatively mobile area of the jejunal mesentery. We then measure down 75 to
100 cm on the distal side of the divided jejunum to create a Roux limb. This limb is
delivered in a retrocolic and retrogastric manner and an end-to-side gastrojejunostomy
is performed with the EEA.
n Alternatively, one may use a side-to-side stapled gastrojejunostomy. We use an endo-
GIA to perform this and then close the opening with an inverting Connell stitch. An
on-table endoscopy is performed to test for a leak.
n Intestinal continuity is reestablished by constructing a jejunojejunostomy between
the proximal ends of the divided jejunum at the 40-cm mark from the ligament
of Treitz and performing a side-to-side jejunostomy between the proximal jeju-
num and 75 to 100 cm down the Roux limb using a 60-mm linear stapler.
Again, we close the enterostomy with a running Connell stitch. This is followed
by closure of all potential mesenteric defects created to prevent internal herniation
(Fig. 8.4).
Figure 8.4 A Roux-en-Y near

esophagojejunostomy. This is typically
performed with a laparoscopic
approach in a retrocolic and retrogas-
tric fashion. A gastrostomy tube is
placed to drain the remaining stomach.
Inset shows esophagojejunal anasto-
mosis performed with an EEA stapler.
LWBK1254-ch08_p85-96.indd 93 20/02/14 10:33 PM

n A 10 F flat Jackson-Pratt (JP) drain is routinely placed behind the proximal anasto-
mosis. This allows for control of an anastomotic leak if a leak was to develop in the
postoperative period.
n A feeding gastrostomy is placed in the partitioned gastric remnant in select patients.
In general, the more trauma and gastric serosal tears present, the more likely we will
choose to add a decompressing gastrostomy.
n All incisions are approximated.
The care of the patients in the immediate postoperative period is similar for patients
who have undergone a redo fundoplication and patients who have undergone an RNY.
All patients are extubated in the operating room and, after a short period in the recov-
ery room, are transferred to a monitored bed. Nutritional and respiratory services are
consulted to help with dietary education and pulmonary toilet, respectively. Patients
are started on patient-controlled analgesia until they can start oral intake. Early ambu-
lation is encouraged.
In our experience, the median length of stay after redo fundoplication is 2 to 3
days.12 A barium contrast study is performed, usually on postoperative day 2, and if
there is no leak and gastric emptying is acceptable, patients are started on a post-Nissen
diet and transitioned to oral medications. During the first postoperative office visit,
patients are transitioned to a regular diet. Long-term follow-up depends on the symp-
toms and individual case, but in general we follow with an annual clinic visit and
barium contrast imaging.
In patients who underwent conversion to RNY, the barium contrast study is delayed
to postoperative day 3 if the patient’s clinical status permits. The drainage character
and output from the JP drain are evaluated on a daily basis to identify a leak. After the
barium contrast study is performed and looks good, patients are started on a phase 1
diet (clear liquids limited to a few ounces at a time). Patients are started on oral medi-
cation and are discharged when tolerating adequate oral diet usually by postoperative
day 3 or 4. Prior to discharge, the JP drain is advanced slightly and resutured. During
the patient’s first follow-up visit, 10 to 14 days after discharge, if the JP drainage has
appropriate character and the drain has appropriate output, it is removed and patients
are transitioned to a pureed diet. If there is any question of a subclinical leak or if the
drainage from the JP drain has changed, we obtain another contrast study. Over the next
3 to 4 weeks, the patient is advanced to a regular diet. Lifelong daily multivitamins and
monthly B12 shots are required. We also recommend a dose of a PPI or H2 blocker at
bedtime. The patient’s weight and clinical symptoms are followed very closely every 3
months for the first year then annually, thereafter.
Complications
In a literature review of 81 studies examining reoperation for failed antireflux surgery
by Furnée et al., the overall mortality was 0.9%. The authors concluded that the mor-
bidity and mortality was higher with reoperative surgery than after primary antireflux
surgery.17 In our recently published analysis of outcomes of over 270 patients who
underwent reoperative antireflux surgery, overall perioperative morbidity (pneumonia,
pulmonary embolism, leaks, etc.) was 10%, and there was no mortality. The most
significant complication, a postoperative gastroesophageal leak, after a redo fundopli-
cation was noted in 3% of patients in our experience.12 Similarly, the reported leak
rate after conversion of a prior failed Nissen to an RNY ranges from 0% to 8%; the
reported morbidity ranges from 0% to 32%, and the mortality is less than 1% in most
series.10,18,19
LWBK1254-ch08_p85-96.indd 94 20/02/14 10:33 PM


Results

First-time antireflux operations have reliably demonstrated successfully outcomes in
terms of symptomatic control in over 90% of patients.7 In contrast, the successful out-
comes drop to ∼80% or less after reoperative antireflux surgery.17 In our recent analysis
of outcomes in 275 patients with reoperative antireflux surgery using specific, estab-
lished tools to measure QOL (GERD-Health related QOL; SF-36 physical and mental
scores), excellent to satisfactory outcomes were noted in over 80% of patients.12 These
findings are seen when reoperative antireflux surgery is performed at high-volume cent-
ers of excellence.13 The improvement of GERD symptoms after conversion to RNY
ranges from 78% to 90% with the added benefit of weight loss.10,18,19,20
The need for surgical intervention after a primary antireflux procedure is reported
to be 3% to 6%.6 In carefully selected patients with a failed initial antireflux surgery,
the success rate in terms of improvement in GERD symptoms and overall satisfaction
scores approached 90% after reoperation in our experience.12 One can conclude that
not only is the morbidity and mortality higher after redo antireflux surgery compared
with the primary operation, but also there is a greater likelihood of recurrent GERD
symptoms or symptoms due to the repeated surgeries, such as dumping and dysphagia,
and the need for possible additional surgical intervention.
Conclusions
n Redo antireflux surgery is a complex operation and should be performed at centers
with extensive experience.
n A detailed history and physical examination are necessary to document the evolution
of the patient’s symptoms. The clinical symptoms should be verified with thorough
comprehensive testing that includes upper endoscopy, barium esophagogram, pH
testing, manometry, and gastric emptying studies.
n Patients with recurrent intractable symptoms that correlate with the findings of
objective tests should be considered for reoperative antireflux surgery.
n Surgical options that allow esophageal preservation include a redo fundoplication
(complete or partial) and RNY near esophagojejunostomy.
n Important steps of a redo fundoplication include complete takedown of the fundop-
lication and esophageal mobilization to restore normal anatomy, vagal and crural
preservation, identification of a short esophagus, esophageal lengthening when indi-
cated, careful crural closure with consideration of crural reinforcement when the
crural integrity is destroyed or when tension-free repair cannot be achieved, and
construction of a “floppy” wrap.
n If during the performance of a complex reoperation, the normal anatomy cannot be
reestablished and it appears likely that the antireflux procedure will fail sympto-
matically or will leak, the surgeon should consider esophagectomy, using a mini-
mally invasive approach if possible.
n RNY is an attractive option in obese patients who require redo antireflux surgery. A
small gastric pouch constructed of gastric cardia and a roux limb of 75 to 100 cm
are necessary to divert the acid and bile from the esophagus.
n A postoperative barium contrast study is necessary to rule out leak before starting
oral intake.
n Redo antireflux surgery has a higher morbidity and mortality and a greater need for
surgical reintervention than primary antireflux surgery.
n Successful outcomes in terms of reflux control can be achieved in over 80% of
patients who undergo reoperative antireflux surgery at centers of excellence.
LWBK1254-ch08_p85-96.indd 95 20/02/14 10:33 PM

Recommended References and Readings 11. Hinder RA, Klingler PJ, Perdikis G, et al. Management of the failed
antireflux operation. Surg Clin North Am. 1997;77:1083–1098.
1. Little AG, Ferguson MK, Skinner DB. Reoperation for failed 12. Awais O, Luketich JD, Schuchert MJ, et al. Reoperative antire-
antireflux operations. J Thorac Cardiovasc Surg. 1986;91: flux surgery for failed fundoplication: An analysis of outcomes
511–517. in 275 patients. Ann Thorac Surg. 2011;92(3):1083–1089.
2. DeMeester TR, Bonavina L, Albertucci M. Nissen fundoplication 13. Smith CD, McClusky DA, Rajad MA, et al. When fundoplication
for gastroesophageal reflux disease: Evaluation of primary repair fails: redo? Ann Surg. 2005;241:861–869; discussion 9–71.
in 100 consecutive patients. Ann Surg. 1986;204:9–20. 14. DeMeester TR, Wang CI, Wernly JA, et al. Technique, indica-
3. Hiebert CA, O’Mara CS. The Belsey operation for hiatal hernia: tions, and clinical use of 24-hour esophageal pH monitoring.
A twenty-year experience. Am J Surg. 1979;137:532–535. J Thorac Cardiovasc Surg. 1980;79:656–670.
4. Peters JH, DeMeester TR. Indications, benefits and outcomes 15. Pellegrini CA, DeMeester TR, Wernly JA, et al. Alkaline gastro-
of laparoscopic Nissen fundoplication. Dig Dis. 1996;14:169– esophageal reflux. Am J Surg. 1978;135:177–184.
179. 16. Gupta S. Let’s end the prescription drug death epidemic. http://
5. Hunter JG, Trus TL, Branum GD, et al. A physiologic approach www.cnn.com/2012/11/14/health/gupta-accidental-overdose.
to laparoscopic fundoplication for gastroesophageal reflux dis- Published November 19, 2012. Accessed April 26, 2013.
ease. Ann Surg. 1996;223:673–687. 17. Furnée EJ, Draaisma WA, Broeders IA, et al. Surgical reinterven-
6. Collard JM, Verstraete L, Otte JB, et al. Clinical, radiological, and tion after failed antireflux surgery: A systematic review of the
functional results of remedial antireflux operations. Int Surg. literature. J Gastrointest Surg. 2009;13:1539–1549.
1993;78:298–306. 18. Kellogg TA, Andrade R, Maddaus M, et al. Anatomic findings
7. Pessaux P, Arnaud JP, Delattre JF, et al. Laparoscopic antireflux and outcomes after antireflux procedures in morbidly obese
surgery: Five-year results and beyond in 1340 patients. Arch patients undergoing laparoscopic conversion to Roux-en-Y gas-
Surg. 2005;140(10):946–951. tric bypass. Surg Obes Relat Dis. 2007;3(1):52–57.
8. Awais O, Luketich JD, Reddy N, et al. Roux-en-Y near esophago- 19. Houghton SG, Nelson LG, Swain JM, et al. Is Roux-en-Y gastric
jejunostomy for failed anti-reflux surgery: An analysis of outcomes bypass safe after previous antireflux surgery? Technical feasibil-
in over 100 patients. Presented at the Society of Thoracic Surgeons ity and postoperative symptom assessment. Surg Obes Relat Dis.
49th Annual Meeting. Los Angeles, CA January 29, 2013. 2005;1(5):475–480.
9. Fisher BL, Pennathur A, Mutnick JL, et al. Obesity correlates 20. Awais O, Luketich JD, Reddy N, Levy RM, Schuchert MJ, Gooding
with gastroesophageal reflux. Dig Dis Sci. 1999;44(11):2290– WE, Crist L, Landreneau RJ. Pennathur A. Roux-en-Y near
2294. esophagojejunostomy for failed anti-reflux surgery. An analysis
10. Awais O, Luketich JD, Tam J, et al. Roux en Y near esophagoje- of outcomes in over 100 patients. Oral presentation at the Soci-
junostomy for intractable gastroesophageal reflux after antireflux ety of Thoracic Surgeons 49th Annual Meeting. Los Angelos CA
surgery. Ann Thorac Surg. 2008;85:1954–1961. Jan 29, 2013.
LWBK1254-ch08_p85-96.indd 96 20/02/14 10:33 PM

9 Gastric Bypass
Brian R. Smith and Ninh T. Nguyen
Introduction
Over the past 40 years, use of the Roux-en-Y gastric bypass has increased to become
the most commonly performed bariatric operation for the treatment of morbid obesity.
It has also undergone evolution from an open operation to a predominately laparoscopic
one. Multiple benefits of the laparoscopic approach have been observed. These benefits
include decreased risk for incisional hernia, decreased rate of wound infection, shorter
length of hospital stay, faster recovery, and shorter convalescence. Furthermore, the
field of bariatric surgery has emerged with an understanding of the metabolic benefits
that accompany surgical weight loss, which now carries importance equal to that of
actual weight loss. This chapter discusses the indications, technique, and outcomes of
laparoscopic gastric bypass in the modern era.
In 1991, the National Institutes of Health Consensus Development Conference estab-
lished the current indications for bariatric surgery, which have remained in effect since
that time. These guidelines recommend bariatric surgery for patients
n with acceptable operative risks
n who are well informed and motivated
n evaluated by a multidisciplinary team
n with failure of established weight control programs
n with body mass index (BMI) ≥40, or ≥35 with at least one high risk, obesity-related
comorbid condition
The prominent obesity-related comorbid conditions include hypertension, type
2 diabetes, dyslipidemia, obstructive sleep apnea, cardiomyopathy, and pseudotumor
cerebri.1,2 Other common obesity-related comorbidities include gastroesophageal reflux,
osteoarthritis, infertility, cholelithiasis, venous stasis, and urinary stress incontinence.3
With a large body of evidence supporting the efficacy of bariatric surgery in ameliorat-
ing the above comorbidities, debate over the role of bariatric surgery specifically to treat
these conditions, more than the obesity, has begun.4,5
Relative contraindications to bariatric surgery include the following.
97
LWBK1254-ch09_p97-108.indd 97 20/02/14 1:36 PM

n Alcohol or drug dependence

n Ongoing smoking
n Uncontrolled psychiatric disorders such as depression or schizophrenia
n Inability to comprehend the requirements for postoperative nutritional and behavio-
ral changes
n Unacceptable cardiorespiratory risk (American Society of Anesthesiologists [ASA] class IV)
n End-stage hepatic disease
Patients preparing for gastric bypass require both preoperative medical evaluation and
optimization of medical comorbidities prior to surgery. Medical clearance requires a
comprehensive and thorough review of the patient’s medical history, specifically looking
for factors which can predict an adverse outcome. Independent predictors of surgical
morbidity and mortality include age ≥45 years, male gender, BMI ≥50 kg/m2, risk for
pulmonary embolism, and hypertension.6,7 Collectively, these clinical findings can be
used to calculate an Obesity Surgery Mortality Risk Score (OS-MRS), which has been
validated at multiple institutions. Patients with 0 or 1 comorbidity are considered low
risk or class A with a 0.2% risk of mortality. Those in class B have 2 or 3 comorbidities
and are at intermediate risk of 1.2%. Class C patients are highest risk and have 4 or 5
comorbidities with a corresponding mortality of 2.4%.6 BMI ≥50 kg/m2 and cigarette
smoking have also been shown to be associated with higher postoperative surgical
morbidities.8,9 Preoperative workup should include the following:
n Comprehensive history and physical examination
n 12-lead EKG
n Basic blood chemistries, lipid profile, and nutritional panel
n Chest radiograph
The choice of operation for a particular patient must take into account several
issues including the surgeon’s expertise and the patient’s preference, BMI, metabolic
conditions, and other associated comorbidities. While gastric bypass is largely consid-
ered the most effective procedure in achieving long-term weight loss, it is also the most
effective in reducing the metabolic derangements of obesity, including diabetes, hyper-
tension, and dyslipidemia. However, these benefits come with a slightly higher overall
mortality rate. For gastric bypass, an average 30-day mortality is 0.16% compared with
that of laparoscopic adjustable gastric band placement at 0.06%.10 For this reason, high-
risk patients may at times be counseled away from the more definitive gastric bypass
and toward the safer, albeit less effective, laparoscopic gastric banding.
The benefit of preoperative weight loss prior to gastric bypass has been debated. A
recent randomized trial demonstrated that patients who achieve ≥5% excess body
weight loss prior to surgery had significantly lower weight and BMI and a higher excess
body weight loss 1 year after surgery.11 The success of this and other trials is felt to
predict those patients with the discipline and willingness to follow healthy lifestyles
that will ultimately translate to successful and sustained long-term weight loss.12 As a
result, many surgeons will place patients on one of many available forms of preopera-
tive weight loss diet for 2 to 4 weeks prior to surgery, with a goal of 10% excess body
weight loss. Many forms of commercial dietary programs are available for these pur-
poses, often consisting of a high-protein, low-fat, low-carbohydrate, predominately liq-
uid diet. An additional benefit of this preoperative liquid diet is decreased liver size
and density that makes manipulation of the left lobe of the liver easier during surgery.
SURGERY
All patients should receive routine deep venous thrombosis (DVT) chemoprophylaxis
immediately prior to arrival in the operating room, as initial development of DVT is
felt to occur intraoperatively in this high-risk population. In addition, routine preoperative
LWBK1254-ch09_p97-108.indd 98 20/02/14 1:37 PM

Chapter 9 Gastric Bypass 99
antibiotic prophylaxis is also indicated. A second generation cephalosporin is adequate,

but typically requires increased dosing in morbidly obese patients.

Patient Positioning
Patient positioning is often dictated by the surgeon’s preference. Some surgeons prefer
the French or lithotomy position. The main advantage of this position is access in
between the patient’s legs and the inline trajectory of one’s laparoscopic instruments.
This centers the surgeon over the operative field and improves the posture while min-
imizing shoulder fatigue. However, this position can be difficult and time consuming
and places patients at risk for nerve injury if not positioned properly. Most surgeons
have evolved their procedure to a completely supine position with arms outstretched
on and secured to arm boards. A footboard is recommended to minimize patient slip-
page inferiorly during reverse Trendelenburg positioning, as is an upper thigh strap to
minimize lateral slippage during rotation of the patient. All bolsters placed behind the
patient’s neck and/or shoulders during anesthesia to facilitate endotracheal intubation
should be removed prior to initiation of surgery. A Foley catheter is optional. Routine
cardiac noninvasive monitoring is essential. Invasive monitoring, including arterial and
central venous catheters, is not routinely indicated and is only utilized in selected cases
where such additional monitoring is necessary.
Technique
Standard technique includes a 5-trocar configuration (Fig. 9.1). Initial cannulation of
the abdominal cavity with a Veress needle is typically through the camera port, located
in the left supraumbilical region. Upon insufflation to 15 mm Hg, the Veress needle is
removed and a 12-mm trocar is inserted followed by camera confirmation of no visceral
injury from entry. Subsequent 5-mm trocars are placed in the far left and right subcos-
tal margins just above the viscera, along with a right epigastric (12-mm) and right upper
quadrant (5-mm) trocars. The far right subcostal trocar secures a serpentine liver retrac-
tor for anterior retraction of the left lobe of the liver. Alternatively, the subxiphoid 5-mm
trocar site can be used to accommodate a Nathanson liver retractor. The operating sur-
geon utilizes the epigastric and right upper quadrant trocars while the assistant utilizes
the left subcostal trocar and the laparoscope.
Creation of the gastric pouch and gastrojejunostomy begins with division of the gas-
trohepatic ligament (Fig. 9.2). The vasculature of the lesser curve of the stomach should
be divided with a vascular stapler. Creation of the gastric pouch then proceeds with trans-
verse division of the proximal stomach approximately 4 cm distal to the gastroesophageal
Figure 9.1 Trocar configuration for standard 5-port

technique.
5 mm
5 mm
5 mm
12 mm 10 mm
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Figure 9.2 Construction of lesser

curve-based gastric pouch. The
staple line should start horizon-
tally and then turn perpendicu-
larly, directly up toward the angle
of His in an effort to create a
rectangular pouch.
junction. The transection is made approximately 3 cm wide and then proceeds superiorly
toward the lateral aspect of the angle of His. Once the pouch is constructed, the gastroje-
junostomy can be formed. The small bowel and its mesentery are divided approximately
30 cm distal to the ligament of Treitz, and the distal (Roux) limb is brought up to the
gastric pouch (Fig. 9.3). Great care must be taken to divide the mesentery carefully so as
to avoid significant devascularization of the Roux limb. The greater omentum can be
divided in the middle to permit easier approximation of and less tension on an antecolic
gastrojejunostomy.
Figure 9.3 Division of jejunum and

its mesentery 30 cm distal to the
ligament of Treitz.
LWBK1254-ch09_p97-108.indd 100 20/02/14 1:37 PM

Figure 9.4 Preparation for the

jejunojejunostomy. Alignment of
the biliopancreatic limb and the

jejunal Roux limb occur in prepa-
ration for a side-to-side linear
anastomosis using a 60-mm white
vascular stapler cartridge.
The jejunojejunostomy, while the lower risk of the two anastomoses, is often the
most technically challenging. The biliopancreatic limb should line up against the left
side of the Roux limb approximately 150 cm distal to the proximal end (Fig. 9.4). A
stay suture is placed between the two limbs and an enterotomy is created in each limb.
A single, linear, 60-mm gastrointestinal anastomosis (GIA) stapler with 2.5-mm staples
(white load) is introduced and the anastomosis is constructed (Fig. 9.5). The common
enterotomy is then closed in either a handsewn fashion or with a linear stapler, taking
great care to ensure the lumen is not narrowed and that the completed anastomosis lies
comfortably without kinking or twisting. An antiobstruction suture is placed to discour-
age kinking of the common channel. The mesenteric defect between the two limbs is
then closed with several interrupted sutures.
The gastrojejunal anastomosis can be created in one of several ways, including
circular stapled, linear stapled, or handsewn. For circular stapled, the stapler anvil can
be placed within the pouch either transorally on a preloaded orogastric tube or by cre-
ating a small gastrotomy on the pouch, placing the anvil through the anterior or poste-
rior wall and then closing the gastrotomy with a linear stapler. The stapler is then
inserted into the open end of the Roux limb and coupled to the anvil through the
antimesenteric border of the Roux limb. The open end of the Roux limb (sometimes
referred to as the “candy cane”) is then closed with a linear stapler. For a linear stapled
anastomosis, an enterotomy is created in the Roux limb and a gastrotomy in the gastric
LWBK1254-ch09_p97-108.indd 101 20/02/14 1:37 PM

Figure 9.5 Completed construction

of a stapled side-to-side jejunoje-
junostomy with handsewn closure
of the common enterotomy and
mesenteric defect.
pouch, and one jaw of the laparoscopic linear stapler is inserted into each segment of
the bowel and fired to create an anastomosis (Fig. 9.6). The common enterotomy is then
closed in a handsewn fashion. For an entirely handsewn anastomosis, posterior stay
sutures are placed between the pouch and Roux limb, followed by the creation of an
enterotomy and gastrotomy. A running absorbable suture then approximates the anas-
tomosis. A final anterior layer is placed to reinforce the anastomosis. Several stay
sutures can be placed between the pouch and Roux limb at the discretion of the sur-
geon, depending on the perceived tension on the anastomosis (Fig. 9.7). Although some
surgeons utilize drains around the proximal anastomosis, especially in the setting of
gastric bypass or a redo esophageal procedure,13 we do not routinely use drains at any
anastomosis for gastric bypass surgery.
A leak test at the completion of the final anastomosis is routinely performed by
most surgeons. This test can be carried out in one of three ways. The first is instilla-
tion of methylene blue down a nasogastric tube into the gastric pouch, with laparo-
scopic observation for leak of dye. The second option is placement of a nasogastric
or Ewald tube by the anesthesiologist, with air instillation while the anastomosis is
submerged, looking for bubbles from the anastomosis. The final option is intraopera-
tive endoscopy, where the gastrojejunostomy is visualized with an endoscope and
intraluminal insufflation while the anastomosis is submerged under peritoneal irriga-
tion, again looking for bubbling of air from the anastomosis. This technique has been
shown to decrease both the incidence and the seriousness of anastomotic leaks post-
operatively.14
LWBK1254-ch09_p97-108.indd 102 20/02/14 1:37 PM

Figure 9.6 Laparoscopic construc-

tion of the gastrojejunostomy using
a linear 45-mm stapler. A posterior

layer of running suture secures the
Roux limb to the gastric pouch,
followed by a stapled end-to-side
anastomosis and suture closure of
the enterotomy.
Routine patients without significant cardiac issues can be transferred to a ward bed.
Cases where continuous monitoring may be indicated postoperatively include a sig-
nificant cardiac history, any intraoperative cardiorespiratory issue, or severe obstructive
sleep apnea. Nasogastric tube decompression is not indicated and there is risk for pouch
perforation if not inserted by experienced personnel. A postoperative upper gastroin-
testinal study on the first postoperative day should be performed, particularly during
the surgeon’s learning curve. Patients begin a diet of sugar-free clear liquids on the first
postoperative morning and are continued on DVT chemoprophylaxis until discharge.
Ambulation can begin as early as the evening of surgery and is essential by the first
postoperative day. Medication adjustments are vital, particularly in diabetic patients,
and must take place immediately postoperatively. While each patient must be consid-
ered individually, often utilizing half of the patient’s preoperative dose of diabetic
medications serves as an appropriate starting point after surgery.
Diet may be advanced to sugar-free full liquids on the second postoperative day
and most patients will be ready for discharge by this time. Full liquids, including
protein shake supplements, continue until 2 weeks postoperatively. Patients are then
LWBK1254-ch09_p97-108.indd 103 20/02/14 1:37 PM

Figure 9.7 Completed laparo-

scopic Roux-en-Y gastric bypass
with antecolic Roux limb.
transitioned to a pureed diet, soft foods, and finally a modified regular diet over the
ensuing 6 weeks. Postoperatively, patients are counseled regarding appropriate behav-
ioral and dietary changes. Overall dietary guidelines include routine low-calorie, low-
fat, and low-sugar food intake. Patients are encouraged to take in three small meals
per day with healthy snacks in between and to eat slowly, stopping at the first sign
of feeling full. Specific efforts at protein intake during each meal are encouraged.
Patients are counseled to take eight 8-ounce cups of water daily and should avoid
taking beverages concurrently with meals. Carbonated beverages result in gas expan-
sion of the small gastric pouch, which leads to significant discomfort, and hence
should be avoided. Vitamin and mineral supplementation is essential to avoid defi-
ciencies in vitamins A, D, B1, B6, B12, calcium, and folate.15 Alcoholic beverages
undergo rapid absorption through the small intestine, resulting in accelerated intoxi-
cation. Patients must be counseled regarding these changes in their intestinal absorp-
tion. Routine daily physical activity is encouraged and participation in monthly
bariatric support groups has been shown to result in significantly improved and sus-
tained weight loss.16,17 Postoperative follow-up typically occurs 1 week, 1, 3, 6, 9, and
12 months postoperatively, and then every 4 months thereafter. Evaluation for late
complications, behavioral counseling, and monitoring for nutritional deficiencies are
the main goals of these routine visits.
LWBK1254-ch09_p97-108.indd 104 20/02/14 1:37 PM


Complications

Significant effort has been put forth to improve the safety of gastric bypass since the
inception of the laparoscopic approach in the late 1990s. Complications can be classi-
fied as those occurring early (<30 days) and those occurring beyond this perioperative
period (Table 9.1).
Of the early complications, pulmonary embolus remains the most common cause
of mortality in bariatric patients, with an overall incidence of 0.1% to 2%.10 Anasto-
motic leak occurs most commonly at the gastrojejunostomy, followed in decreasing
frequency by the gastric remnant, the jejunojejunostomy, the gastric pouch, and the
stapled end of the Roux limb.18 The overall incidence of all leaks after laparoscopic
gastric bypass ranges from 1% to 5.6%. Prompt identification of the source of the leak
and control of peritoneal contamination are crucial in minimizing sepsis. In addition,
the presentation of anastomotic leak is highly heterogeneous and as a result, early
operative intervention as a diagnostic and therapeutic tool is highly encouraged.18 Of
the clinical symptoms that are suggestive of leak, tachycardia, fever, and abdominal
pain are the most common. Early postoperative gastrointestinal hemorrhage typically
occurs along the gastrointestinal staple line and can occur intraluminally or intraperi-
toneally.19
Small bowel obstruction is the most frequent late complication following laparo-
scopic gastric bypass. Early small bowel obstruction (first few months postoperatively)
is more common in laparoscopic gastric bypass than open gastric bypass, as are internal
hernias.20 The most common causes of small bowel obstruction after laparoscopic gas-
tric bypass include internal hernia, jejunojejunostomy complications, adhesions, and
port-site herniation.21 Internal hernias can occur through either small bowel mesenteric
defects or more commonly through Petersen’s space (beneath the Roux limb). Findings
of a mesenteric “swirl” sign on the computed tomography scan are the single best pre-
dictor of internal herniation and should prompt urgent surgical intervention.22 Leaks
predispose patients to anastomotic strictures, as do ischemia, tension, technical errors,
and marginal ulceration. Strictures often require endoscopic balloon dilation to main-
tain an anastomotic diameter greater than 10 mm.23 Rates of marginal ulceration vary
widely from 1% to 16%, depending on the study. Gallstone formation is a common
occurrence after significant weight loss, with a frequency up to 30% following gastric
bypass.24
T able 9 . 1 Early (<30 days) and Late (>30 days) Complications After Laparoscopic
Gastric Bypass
Complications Rate of Occurrence
Overall 7%
Early
Hemorrhage 2–3.5%
Wound Infection 1.8%
Bowel Obstruction 1.7%
Anastomotic Leak 1–5.6%
Venous Thromboembolism (VTE) 0.1–2%
Late
Symptomatic Gallstones 22–71%
Gastrogastric Fistula 3%
Marginal Ulceration 1–16%
Anastomotic Stricture 1–9%
Small Bowel Obstruction 3.2%
Nutrient Deficiency (Unmonitored) 1% (30%)
LWBK1254-ch09_p97-108.indd 105 20/02/14 1:37 PM

RESULTS
Bariatric surgery has been shown repeatedly to be the most definitive and successful
treatment for severe obesity, compared with conventional medical therapy.4,5 Nearly 80%
of patients who undergo gastric bypass experience an excess body weight loss of 60%
to 80%.23 Lifetime risk of death from extreme obesity is decreased by 35% in individu-
als who undergo bariatric surgery, compared with control individuals.25 However, the
safety of bariatric surgery has come under increasing scrutiny since the early part of this
century. Bariatric Centers of Excellence were developed by the American College of
Surgeons and the American Society of Metabolic and Bariatric Surgery and many insur-
ance carriers have followed by only covering bariatric surgery performed at these centers.
The Leapfrog Group has added bariatric surgery to the growing list of procedures with
improved mortality when performed at high-volume centers (>125 annual cases).26
The most comprehensive meta-analysis to date evaluated more than 85,000 patients
and found the overall mortality for laparoscopic gastric bypass to be 0.16%.10 Outcomes
of gastric bypass on metabolic derangements are equally impressive. Pories et al. were the
first to describe long-term glucose control in 83% of noninsulin-dependent diabetics and
99% of patients with glucose impairment.27 Since that time, numerous studies have vali-
dated gastric bypass as the most effective operation for the treatment of type 2 diabetes,
both as early as 1 week postoperatively and with sustained results at 2 years.28,29 Metabolic
syndrome is composed of the triad of diabetes, dyslipidemia, and hypertension. Collec-
tively, this triad increases the risk of coronary artery disease. Metabolic syndrome is cured
in 96% of patients who undergo bariatric surgery and no other medical treatment has come
close to the success rates of bariatric surgery.30 More recently, similar results have also
been shown in diabetic patients with lower BMI (30 to 35), who do not meet traditional
bariatric surgical criteria.31,32 Finally, adverse maternal and neonatal outcomes are lower
in patients who become pregnant after undergoing bariatric surgery for morbid obesity.33
Conclusions
Gastric bypass remains the gold standard operation for significant, sustained weight loss
in morbidly obese patients. It is also the most effective means of treating metabolic syn-
drome, type 2 diabetes, and other obesity-related medical comorbidities, such as uncon-
trolled GERD or the need for a redo antireflux operation.13 Significant progress has been
made in the overall safety of gastric bypass and it is considered as safe as other com-
monly performed general surgical operations such as laparoscopic cholecystectomy.
Patients must be monitored for long-term complications, including vitamin and nutrient
deficiencies, small bowel obstruction, anastomotic stricture, and marginal ulceration.
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21. Koppman JS, Li C, Gandsas A. Small bowel obstruction after ation and use of gastrointestinal surgery to treat type 2 diabetes
laparoscopic Roux-en-Y gastric bypass: A review of 9,527 mellitus. Ann Surg. 2010;251:399–405.
patients. J Am Coll Surg. 2008;206:571–584. 33. Maggard MA, Yermilov I, Li Z, et al. Pregnancy and fertility fol-
22. Lockhart ME, Tessler FN, Canon CL, et al. Internal hernia after lowing bariatric surgery: A systematic review. JAMA. 2008;300:
gastric bypass: Sensitivity and specificity of seven CT signs with 2286–2296.
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LWBK1254-ch09_p97-108.indd 108 20/02/14 1:37 PM
10 Endoscopic Antireflux
Repair—EsophyX
Kyle A. Perry and W. Scott Melvin
Introduction
Gastroesophageal reflux disease (GERD) represents a serious health concern in Western
countries with nearly half of Americans reporting symptoms at least monthly, and up
to 10% experiencing daily reflux symptoms. Proton pump inhibitors (PPI) provide effec-
tive symptom control for many GERD patients, but this approach requires lifelong med-
ical treatment, and up to 20% of patients experience breakthrough heartburn and
regurgitation. Laparoscopic antireflux surgery provides excellent reflux control and high
patient satisfaction rates; however, the invasiveness, high costs and risks associated
with surgery are significant factors that deter some potential patients.
These hurdles have led physicians to pursue minimally invasive, effective and
durable treatment alternatives that directly address the pathophysiologic mechanisms
of reflux. Over the past two decades, several endoluminal approaches to GERD manage-
ment have been developed as an intermediate between medical management and inva-
sive surgical fundoplication. Transoral incisionless fundoplication (TIF) using the
EsophyX device (Endogastric Solutions Inc., Redmond, WA) allows creation of a robust
gastroesophageal plication via the transoral route and is detailed in this chapter.
Another intermediate between medical management and surgical fundoplication is
the LINX system (Torax Medical, St Paul, MN), which augments lower esophageal
sphincter function using a ring of magnetic beads placed laparoscopically at the gastro-
esophageal junction. For reflux to occur, the intragastric pressure must overcome both
the patient’s native lower esophageal sphincter pressure and the force of the magnetic
beads; however, the magnetic beads separate sufficiently to allow passage of a food bolus,
belching, or vomiting. Initial clinical trials of the LINX system indicate that it is effective
at decreasing esophageal acid exposure, reducing GERD symptoms, reducing PPI depend-
ence, and improving the patient’s quality of life, and that it can be removed without
damaging the esophagus. An update on this new technology will be forthcoming.
109
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As with other endoscopic reflux therapies, the ideal patients for TIF are those with
minimal anatomic change at the gastroesophageal junction (GEJ) and moderate-to-severe
GERD symptoms that are responsive to PPI therapy. TIF should not be performed in
patients with significant hiatal hernias, severe esophagitis, esophageal dysmotility, or
in the setting of esophageal varices. Also, TIF is not recommended for acid control in
patients with Barrett’s esophagus because normalization of esophageal pH has not been
consistently demonstrated.
Indications
n PPI-dependent patients with objective evidence of GERD
n Good response to PPI therapy
n Medically fit for general anesthesia
Contraindications
n Age <18 years
n BMI >35 kg/m2
n Hiatal hernia >2 cm
n Esophageal varices
n Barrett’s esophagus
n Severe esophagitis (LA class C or greater)
n Severe esophageal dysmotility
Patients with GERD may present with typical or atypical symptoms. Most often, GERD
presents with heartburn and regurgitation and may progress to dysphagia and chest
pain. Less commonly, patients may present with supraesophageal symptoms including
chronic nausea, aspiration, asthma exacerbation, cough, hoarseness, and globus sensa-
tion, with or without typical GERD symptoms. Patients who have undergone a period
of medical treatment with improvement of their symptoms with acid suppression may
be candidates for TIF; however, further objective evaluation is required.
The preoperative evaluation prior to TIF centers on establishing objective evidence
of acid reflux and assessing patient suitability for the procedure. At a minimum, patients
should undergo an upper endoscopy to assess for the presence of hiatal hernia and
esophagitis, and esophageal manometry should be performed to demonstrate adequate
peristalsis. Ambulatory pH testing is useful for establishing the diagnosis of GERD in
patients who do not have erosive esophagitis and those with atypical symptoms. Con-
trast radiography can assess the presence and size of hiatal hernia and a video esopha-
gram can be used in lieu of manometry to establish evidence of normal esophageal
motility.
Routine preoperative upper endoscopy with a rigorous assessment of the GEJ anat-
omy performed by the operating surgeon can improve patient selection for TIF. This
allows for identification of reflux-related complications including severe esophagitis,
strictures, and Barrett’s esophagus that may exclude TIF as a treatment option. Also, a
detailed examination of the GEJ in the retroflexed view should be performed with the
stomach sufficiently distended to produce effacement of the rugal folds. In this view,
the crura can be seen impinging on the GEJ, and the transverse dimensions of the
hiatus should be evaluated (Fig. 10.1). TIF should only be considered for patients in
whom this measurement is less than twice the diameter of the endoscope because when
the transverse hiatal diameter exceeds this threshold, the plication may fail due to a
tendency to herniate into the thorax.
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Chapter 10 Endoscopic Antireflux Repair—EsophyX 111
Figure 10.1 Retroflexion view of the

gastroesophageal junction used to
assess transverse hiatal diameter.

Surgery
Device
The EsophyX device (Endogastric solutions, Inc., Redmond, WA) is a gastroesophageal
plicating device that is introduced into the stomach transorally over a standard endo-
scope (Fig. 10.2). This enables approximation of gastric and esophageal tissue in the
region of the GEJ, and plicates these tissues together using placement of H-shaped full-
thickness polypropylene fasteners.
The device consists of a handle (Fig. 10.3) where the device controls are located, a
shaft that is 18 mm in diameter, and an articulating arm (the tissue mold) that approxi-
mates tissue and deploys tissue fasteners. When the tissue mold is placed in the retroflex-
ion position, a tissue retractor with a helical screw at the tip can be advanced to engage
and manipulate the mucosa at the GEJ (Fig. 10.4). A deployable stylet is located on either
side of the helical retractor, and these serve to guide the deployment of the tissue fasten-
ers (Fig. 10.5). The stylets are deployed through the esophageal and gastric walls and the
H fasteners are deployed over the stylet so that the leading leg of the fastener engages in
the gastric lumen, while the trailing leg remains within the esophageal lumen (Fig. 10.6).
Pertinent Anatomy
When describing the location of the fastener placements, it is useful to orient the ret-
roflexion view of the GEJ as a clock face. The 12-o’clock position is defined as the
location of the lesser curvature, with the 3-o’clock position on the anterior surface of
the stomach and the 9-o’clock position on the posterior gastric wall. Six o’clock refers
to the valve position that faces the greater curvature of the stomach (Fig. 10.7).
Figure 10.2 EsophyX device consisting

of the handle, shaft, and articulating
tissue mold. (© 2014 EndoGastric
Solutions, Inc.)
LWBK1254-ch10_p109-120.indd 111 19/02/14 5:49 PM

Figure 10.3 EsophyX device handle.

(© 2014 EndoGastric Solutions, Inc.)
Figure 10.4 Partially closed tissue

mold with deployed helical retractor.
(© 2014 EndoGastric Solutions, Inc.)
Figure 10.5 Fully closed tissue mold

with deployed stylet and polypropylene
H fastener. (© 2014 EndoGastric Solu-
tions, Inc.)
Figure 10.6 Schematic representation of tissue apposition and fastener deployment during TIF. Left: the helical retractor engages
the mucosa at the level of the gastroesophageal junction. Middle: The tissue mold is closed to appose the esophagus and stomach
while transmural fasteners are placed to recreate the angle of His. Right: Proper fastener position with leading and trailing limbs
positioned within the stomach and esophagus, respectively.
LWBK1254-ch10_p109-120.indd 112 19/02/14 5:50 PM

Figure 10.7 Preprocedure endoscopy

shows a clear retroflexed view of the
Lesser Curve gastroesophageal junction demon-

strating no evidence of hiatal hernia.
12
11
1
10
2
9
3
8 4
7 5
6
Greater Curve
Technical Evolution
TIF is an endoscopic procedure that aims to create a gastroesophageal reflux valve
through the creation of a full-thickness gastroesophageal plication. The technique used to
create the plication has evolved since the introduction of the EsophyX device in 2007.
The initial TIF-1 technique aimed to create the plication at the level of the GEJ, creating
a partially circumferential gastrogastric fundoplication. The second iteration (TIF-2)
involved creating a more robust gastroesophageal fundoplication by adding rotary and
longitudinal elements and deploying fasteners 3 to 4 cm above the GEJ. This approach
has proven capable of producing a 270-degree plication over a length of 3 to 4 cm. The
most recent evolution of the TIF-2 procedure described here emphasizes the rotational
elements of the gastroesophageal plication and achieving a valve of adequate length
without including crural tissue in the plication.
Patient Positioning and Preparation

The patient is nasotracheally intubated and placed under general anesthesia. Nasotra-
cheal intubation minimizes the space occupied within the oropharynx and facilitates
passage of the EsophyX device into the esophagus. Sequential compression devices are
placed, and preoperative antibiotics are administered due to the full thickness, trans-
luminal application of the polypropylene fasteners. The patient is then placed in a
semi-recumbent position with the left side elevated approximately 45 degrees. A pre-
procedure endoscopy is then performed to evaluate the GEJ anatomy and identify ana-
tomical landmarks. Following this endoscopy, the hypopharynx and esophagus are
dilated via placement of a 56-French Maloney dilator. Early in our experience, we did
not use bougie dilation, but have since found that this greatly reduces the difficulties
encountered with device insertion.
Technique
The device is generously lubricated and placed over a standard endoscope, and a bite
block is placed over the device and between the patient’s teeth. The endoscope-device
LWBK1254-ch10_p109-120.indd 113 19/02/14 5:50 PM

A B
Figure 10.8 A: Retroflexed view of the device with the articulating arm completely advanced into the gastric lumen.
B: Antegrade view from within the device of the articulating arm within the gastric lumen.
complex is inserted into the stomach transorally. A jaw-lift maneuver often facilitates
easy passage of the device through the hypopharynx. Care must be taken during device
insertion as hypopharyngeal perforations were reported during the early experience
with this procedure. The endoscope is advanced into the stomach, a retroflexed view
of the GEJ is obtained, and the stomach is insufflated with carbon dioxide to a pressure
of 15 mm Hg using a standard high-flow laparoscopic insufflator. The device is advanced
until the entire articulating arm is visualized within the gastric lumen (Fig. 10.8A). The
endoscope is then backed up into the device (Fig. 10.8B) and the tissue mold is placed
into the retroflexion position. Following this, the endoscope is advanced into the gastric
lumen and retroflexed to view the GEJ and tissue mold (Fig. 10.9).
The gastroesophageal plication is created by placing pairs of full-thickness fasteners at
strategic locations. The initial steps create the rotary portion of the plication, whereas the
final steps increase its length. The steps involved in creating the valve include the following.
n Placement of fasteners in the anterior corner of the plication
n Fastener placement in the posterior corner
n Deep plication along the greater curvature
Figure 10.9 Retroflexed view of the

device with the articulating arm
flexed and in position to begin the
TIF procedure.
LWBK1254-ch10_p109-120.indd 114 19/02/14 5:50 PM

Figure 10.10 The helical retractor

engaging the mucosa at the gastro-
esophageal junction along the lesser

curvature (12-o’clock position).
Placement of Anterior Plication Sets

The closed tissue mold is rotated to the 12-o’clock position, and the helical retractor
engages the mucosa at the GEJ (Fig. 10.10). The tissue mold is opened and rotated back to
the 6-o’clock position to prepare for performing the initial anterior plication. While traction
is placed on the helical retractor, the tissue mold is partially closed and rotated anteriorly
toward the 1-o’clock position (Fig. 10.11). Simultaneously, the stomach is desufflated to
allow maximal rotation into the anterior corner and the device is closed against the tissue,
apposing the gastric and esophageal walls. Once this is achieved, the suction is applied
and the stomach is insufflated to visualize the articulating arm of the device and permit
the safe engagement of the stylets and deployment of a pair of fasteners (Fig. 10.12). This
process is repeated twice at slightly different depths relative to the GEJ so that six fasten-
ers have been deployed to create the anterior corner of the gastroesophageal plication.
Placement of Posterior Plication Sets

While maintaining the helical retractor at the 12-o’clock position on the lesser curve, the
tissue mold is opened and rotated through the lesser curve in the counterclockwise
direction and returned to the 6-o’clock position. Traction is placed on the helical retractor
while the stomach is desufflated. The tissue mold is partially closed and rotated in the
clockwise direction into the posterior corner toward the 11-o’clock position (Fig. 10.13).
Figure 10.11 Anterior rotation of the

device toward the 1-o’clock position
to appose tissue for the anterior
corner plication.
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Figure 10.12 Engaged stylet for

deployment of tissue fastener in the
anterior corner.
When maximal rotation is achieved, the tissue mold is closed and the suction applied.
The stomach is then insufflated to allow visualization of the back of the tissue mold.
The device is gradually rotated back out of the corner to allow safe deployment of the
stylets and fasteners. Two more fastener sets are deployed in the posterior corner at
different depths to complete this portion of the plication.
Greater Curve Longitudinal Plication

When the anterior and posterior corners of the plication are complete, attention is turned
to the placement of deep plicating fasteners closer to the greater curvature of the stomach
to increase the valve length. The helical retractor is disengaged from the mucosa at the
12-o’clock position, and may be replaced at the 6-o’clock position (Fig. 10.14). These fas-
teners may also be placed without using the helical retractor. The tissue mold is opened
slightly and positioned at the 5-o’clock position. The device is withdrawn slightly from the
mouth and the tissue mold is closed to create a gastroesophageal plication 2 to 4 cm above
the GEJ (Fig. 10.15). Care should be taken not to close the device over the crus, incorporat-
ing diaphragmatic tissue into the plication, as the fasteners are not designed to traverse this
thick tissue. Including excess tissue in the plication may cause the fasteners to pull through
and lead to areas of esophageal perforation. Two fastener sets are deployed at different
depths at the 5-o’clock and 7-o’clock positions to complete the esophageal plication.
Figure 10.13 Posterior rotation of the

device toward the 11-o’clock position
to appose tissue for the posterior
corner plication.
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Figure 10.14 Engaged helical retrac-

tor at the 6-o’clock position applies
traction during longitudinal plication

at the greater curve positions.
Device Removal
When the plication is complete, the device is advanced until the hinge can be clearly
visualized within the stomach. The helical retractor is disengaged and the endoscope
is withdrawn into the shaft of the device. The tissue mold is straightened and with-
drawn under direct vision. Care must be taken during device removal to avoid esopha-
geal mucosal lacerations. If this occurs, the mucosal injury may be closed with endoclips.
Completion Endoscopy
Immediately after the procedure, endoscopy is performed to assess the esophageal
mucosa, completeness of the fundoplication, and adequacy of hemostasis. When visual-
ized in the retroflexed view, the TIF valve exhibits the classic omega-shaped appearance
associated with Nissen fundoplication (Fig. 10.16).
Following completion endoscopy, patients are given intravenous ondansetron to pre-
vent retching, which may disrupt the T fasteners and lead to early procedure failure.
Figure 10.15 The tissue mold is

closed at the 5-o’clock position to
create a longitudinal gastroesopha-
geal plication above the GEJ.
LWBK1254-ch10_p109-120.indd 117 19/02/14 5:50 PM

Figure 10.16 Postprocedure endos-

copy demonstrating the retroflexed
view of a completed TIF valve that
resembles the classic omega-shaped
appearance associated with Nissen
fundoplication.
Patients are admitted for overnight observation and receive scheduled intravenous
antiemetic medications during their hospital stay. Patients often experience sore
throat and chest or shoulder pain during the first 3 to 4 days and may require nar-
cotic pain medication. We do not routinely employ contrast swallow evaluation fol-
lowing TIF, but pain that is persistent or out of proportion with expectations should
raise concern for complications including esophageal perforation or mediastinal
abscess.
Patients are permitted sips of clear liquids following the procedure, and in the
absence of dysphagia, diet is advanced to thick liquids prior to hospital discharge on
postoperative day 1. A full liquid diet is maintained for 5 days and then advanced to
a soft food diet for the next 2 to 4 weeks. Liberal use of oral antiemetics and consump-
tion of small frequent meals are encouraged to limit retching and gastric distension
during the early postoperative period.
Complications
Although rare, complications of cervical esophageal perforation, postoperative hem-
orrhage, mediastinal abscess, and early procedure failure have been reported. In an
early multicenter European trial, two patients suffered cervical esophageal injuries
during TIF. As with any over-the-scope device, care must be exercised during the
insertion of the EsophyX. Insertion of these large devices in patients with limited
working space due to body habitus or limited neck mobility is particularly difficult,
and care must be taken when selecting patients for these procedures. Along with
careful patient selection and adequate lubrication of the device, predilation of the
esophagus with a 56- to 60-French bougie may facilitate the delivery of this system
and reduce complications.
Postprocedure hemorrhage requiring blood transfusion or endoscopic intervention
has been reported in several series. This may occur at the site of helical retractor place-
ment or if fasteners are deployed too close to the lesser curvature of the stomach. In
our experience, two patients have required blood transfusions following TIF. Repeat
LWBK1254-ch10_p109-120.indd 118 19/02/14 5:50 PM

endoscopy did not reveal an active site of bleeding in either case. Careful placement

and removal of the helical retractor, awareness of the lesser curve location, and exami-
nation of all surgical sites during completion endoscopy may help reduce the incidence

of postprocedure bleeding.
Finally, gastric leak, mediastinal abscess, and early procedure failure have been
reported following TIF. Each of these complications likely relate to fasteners pulling
through the gastric or esophageal wall during the early postoperative period. During
TIF, care should be taken to ensure that the diaphragmatic crura are not included
in the plication, as the fasteners are not designed to pass through and plicate that much
tissue. Postoperatively, aggressive use of antiemetic medications should be employed
to prevent retching, and small meals should be encouraged to reduce the amount of
gastric distension during the early postoperative period.
Results
Early cohort studies examining the clinical efficacy of TIF have been promising.
Cadiere et al. reported an initial experience of 86 patients with 6-month follow-up
in 81 patients. GERD Health-Related Quality of Life (GERD-HRQL) scores improved
in 80% of patients and PPI use was eliminated in 81%. Postoperative pH studies
demonstrated normal esophageal acid exposure in 40%. We reported the initial US
experience in a relatively unselected population referred for surgical GERD treat-
ment. After 10 months, 53% of patients showed reduced medication usage and symp-
tom improvement. Bell demonstrated significant symptom improvement in patients
with both typical (70%) and atypical (64%) GERD symptoms with no reported dys-
phagia, bloating, or flatulence after TIF. Several other small cohort series have dem-
onstrated similar improvements in heartburn scores, PPI use, and esophageal acid
exposure; however, controlled trials and long-term follow-up studies are lacking.
Further studies are required to identify the subset of GERD patients most likely to
benefit from TIF.
In addition, some centers have abandoned this procedure despite early enthusi-
asm due to recurrence of GERD symptoms and generally dissatisfaction with the
overall results. For example, Hoppo et al. reported the outcomes of 19 patients who
underwent the EsophyX procedure at three institutions over a 16-month period. Dur-
ing a short follow-up (median 10.8 months), most patients experienced symptom
recurrence (13/19, 68%) and over half (10/19, 53%) required surgical reintervention.
In Furnee’s series of 88 patients who underwent an EsophyX antireflux procedure,
11 patients (12.5%) required laparoscopic Nissen fundoplication as a redo surgery
for recurrent symptoms. Median time between procedures was 8.1 months. Similarly,
Romario et al. reported outcomes in nine patients who underwent laparoscopic Nis-
sen fundoplication a median of 13.3 months after the EsophyX procedure. Both sur-
geons noted an increased risk of dysphagia after fundoplication performed as a redo
surgery for a failed EsophyX procedure, as dysphagia occurred in 22% to 27% of
patients who underwent a revisional fundoplication. While Romario et al. reported
no intraoperative complications during laparoscopic Nissen fundoplication as a
result of the EsophyX procedure, Furnee reported intraoperative gastric perforation
in two patients and a postoperative subphrenic abscess in one. The risk of gastric
damage caused by the EsophyX fasteners (27% of patients in Furnee’s series) was
higher than that typically seen during primary or redo antireflux surgery. Other sur-
geons have also noted significant difficulty in removing the H fasteners and restoring
normal anatomy. The H fasteners tend to produce minute fistulous tracts that are
noted following laparoscopic removal, and leaks may be evident during endoscopic
insufflation during the redo procedure (J. Luketich, personal communications). Thus,
it is imperative that surgeons performing redo antireflux surgery on patients who
have had an EsophyX antireflux procedure be aware of these issues and prepared to
deal with these technical problems.
LWBK1254-ch10_p109-120.indd 119 19/02/14 5:50 PM

Conclusions
The EsophyX device and TIF technique have improved over time, and show potential
for the treatment of patients with GERD. Multiple studies have demonstrated that TIF
can be accomplished in most patients with a low risk of complications. Following TIF,
symptoms and quality-of-life scores are significantly improved, as is esophageal acid
exposure. However, a high failure rate and significant complications during subsequent
antireflux surgeries have been seen in other studies. Prospective controlled trials and
long-term registry studies are currently underway and will continue to define the role
for TIF in the management of GERD.
Recommended References and Readings 8. Demyttenaere SV, Bergman S, Pham T, et al. Transoral incision-
less fundoplication for gastroesophageal reflux disease in an
1. Bell RC, Cadière GB. Transoral rotational esophagogastric fun- unselected patient population. Surg Endosc. 2010;24:854–858.
doplication: Technical, anatomical, and safety considerations. 9. Ganz R, Peters J, Horgan S, Bemelman W, Dunst C, Edmundow-
Surg Endosc. 2011;25:2387–2399. icz S, et al. Esophageal sphincter device for gastroesophageal
2. Bell RC, Freeman KD. Clinical and pH-metric outcomes of reflux disease. N Engl J Med. 2013;368:719–727.
transoral esophagogastric fundoplication for the treatment 10. Hoppo T, Immanuel A, Schuchert M, et al. Transoral incision-
of gastroesophageal reflux disease. Surg Endosc. 2011;25:1975– less fundoplication 2.0 procedure using EsophyX for gastro-
1984. esophageal reflux disease. J Gastrointest Surg. 2010;14(12):
3. Bergman S, Mikami DJ, Hazey JW, et al. Endolumenal fundopli- 1895–1901.
cation with EsophyX: The initial North American experience. 11. Fumagalli Romario U, Barbera R, Repici A, et al. Nissen fundop-
Surg Innov. 2008;15:166–170. lication after failure of endoluminal fundoplication: Short-term
4. Bonavina L, DeMeester T, Fockens P, Dunn D, Saino G, Bona D, results. J Gastrointest Surg. 2011;15(3):439–443.
et al. Laparoscopic sphincter augmentation device eliminates 12. Furnee EJ, Broeders JA, Draaisma WA, et al. Laparoscopic Nis-
reflux symptoms and normalizes esophageal acid exposure: one- sen fundoplication after failed EsophyX fundoplication. Br J
and 2-year results of a feasibility trial. Ann Surg. 2010;252:857– Surg. 2010;97(7):1051–1055.
862. 13. Testoni PA, Corsetti M, Di Pietro S, et al. Effect of transoral
5. Cadière GB, Rajan A, Germay O, et al. Endoluminal fundoplica- incisionless fundoplication on symptoms, PPI use, and ph-
tion by a transoral device for the treatment of GERD: A feasibil- impedance refluxes of GERD patients. World J Surg. 2010;34:
ity study. Surg Endosc. 2008;22:333–342. 750–757.
6. Cadière GB, Buset M, Muls V, et al. Antireflux transoral incision- 14. Trad KS, Turgeon DG, Deljkich E. Long-term outcomes after tran-
less fundoplication using EsophyX: 12-month results of a pro- soral incisionless fundoplication in patients with GERD and
spective multicenter study. World J Surg. 2008;32:1676–1688. LPR symptoms. Surg Endosc. 2012;26:650–660.
7. Cadière GB, Van Sante N, Graves JE, et al. Two-year results of a 15. Velanovich V. Endoscopic, endoluminal fundoplication for gas-
feasibility study on antireflux transoral incisionless fundoplica- troesophageal reflux disease: Initial experience and lessons
tion using EsophyX. Surg Endosc. 2009;23:957–964. learned. Surgery. 2010;148:646–651.
LWBK1254-ch10_p109-120.indd 120 19/02/14 5:50 PM

11 Laparoscopic Paraesophageal
Hernia Repair
Katie S. Nason and James D. Luketich
Introduction
Hiatal hernias are generally classified into four types (Fig. 11.1) with Type I being a
sliding hiatal hernia, with a simple sliding of the gastroesophageal junction into the
chest (Fig. 11.1A). Paraesophageal hernia (PEH) occurs when part or all of the stomach
translocates from the abdomen through the esophageal hiatus and into the posterior medi-
astinum. When the gastroesophageal junction remains in the normal intra-abdominal
position, the PEH is a “true” PEH as the fundus of the stomach herniates through an
anterolateral weakening of the phrenoesophageal ligament and lies next to the esophagus
in the mediastinum. This type of PEH is known as a Type II PEH, which we and others
have found to be rare (Fig. 11.1B). More commonly, the gastroesophageal junction
has migrated cephalad, likely as a result of long-standing gastroesophageal reflux and
fibrotic changes to the esophagus causing foreshortening of the esophageal longitudinal
muscles and, subsequently, the esophagus itself. Over time, this foreshortening pulls the
gastroesophageal junction into the posterior mediastinum, along with the proximal stom-
ach, lengthens the phrenoesophageal ligament and widening the crural aperture. Eventu-
ally, the gastroesophageal junction becomes fixed within the posterior mediastinum with
varying degrees of gastric herniation and is known as a Type III PEH (Fig. 11.1C). Patients
with large, symptomatic PEH usually present with symptoms suggestive of obstruction,
including chest pain, postprandial bloating, or dysphagia. Anemia and shortness of
breath are also common symptoms that are often attributed to other causes. Type III PEH
account for approximately 5% to 10% of all hiatal hernias. When other abdominal
organs follow the stomach into the chest, such as omentum, colon, spleen and or por-
tions of the pancreas, they are referred to as Type IV PEH (Fig. 11.1D).
Over the past decade, the laparoscopic approach for PEH repair has become a stand-
ard approach, enabling PEH to be repaired with less pain, faster recovery, and reduced
morbidity particularly when performed by experienced surgeons with significant open
and minimally invasive esophageal surgery experience.1–3 When performed in centers
of excellence, the outcomes of laparoscopic repair compare favorably with the outcomes
of open repair.4,5 To optimize repair durability and to ensure long-term symptom reso-
lution, PEH repair requires strict attention to several key elements: (1) Complete dis-
section and tension-free reduction of the hernia sac, stomach, and any other contents
121
LWBK1254-ch11_p121-136.indd 121 20/02/14 10:34 PM

Figure 11.1 Types of hiatal her-

nia. The various types of hiatal A B
hernia (Types I to IV) are
depicted. (A) Sliding hiatal her-
nia. (B) True paraesophageal
hernia with herniation of only
a portion of the fundus of the
stomach. (C) Paraesophageal
hernia with herniation of the
gastroesophageal junction and
a portion of the fundus of the
stomach. (D) Paraesophageal
hernia with herniation of the
gastroesophageal junction, fun-
dus of the stomach, and portions
of one or more other abdominal
organs. (From: Sun R. Imaging for
Surgical Disease. Philadelphia, Type I Type II
PA: Lippincott Williams & Wilkins,
2014.)
C D
Type III Type IV
from the mediastinum back into the abdomen; (2) complete mobilization of the thoracic
esophagus and when present, recognition and management of a shortened esophagus;
and (3) closure of the hiatal defect without tension, and (4) addition of a fundoplication,
full or partial or in some cases, after the first three steps, gastropexy alone.
Repair is recommended for all symptomatic patients. The management of asympto-
matic hernia remains the subject of debate, however, and warrants further discussion.
The incidence of a truly asymptomatic giant PEH is uncommon in our experience,
and more commonly, significant symptoms exist, but they have occurred so insidi-
ously and have been present so long, that patients have learned to live with these
significantly troublesome symptoms. Some studies have estimated that the risk of life-
threatening complications from a PEH is lower than the risk of undergoing repair.6,7
When analyzing the findings of these studies, however, it is important to make note
of the definition of minimally symptomatic or asymptomatic used; in the paper by
Stylopoulos, minimal symptoms were defined as “heartburn that did not affect patient
quality of life.” In our experience, the vast majority of patients with radiographic
findings of large PEH will have obstructive symptoms, including dysphagia, postpran-
dial bloating, and chest pain. On occasion, elderly patients in our clinics may deny
difficulty swallowing and other symptoms, but will report significant and uninten-
tional weight loss over the previous 5 to 10 years and, when questioned further, report
substantial changes to their diet to avoid hard, and sometimes even soft solids, because
the “food would not go down.”
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Chapter 11 Laparoscopic Paraesophageal Hernia Repair 123
When these hernias progress to requiring semi-urgent, nonelective repair, we and

other surgeons have found that they are associated with a significantly increased risk of
perioperative morbidity and mortality. In our series of 662 patients who underwent

laparoscopic repair of giant PEH, patients admitted electively for laparoscopic repair had
a postoperative mortality rate of 0.5% compared with 7.5% for patients who underwent
urgent repair.5 This can be markedly higher when patients present with gastric necrosis,
massive hemorrhage or severe aspiration pneumonia, albeit these more life threatening
situations are less common. Thus, when evaluating patients who may be minimally
symptomatic it is important to keep this data in mind. The risk of perioperative mortal-
ity and/or morbidity with elective and nonelective operation can be estimated to some
degree by the size of the PEH, the patient’s functional status, the presence of comorbid
conditions, and the patient’s symptom complex. We have recently shown that in patients
with age-adjusted Charlson Comorbidity Index (CCI) scores of 5 or less, perioperative
morbidity and mortality with elective laparoscopic repair is low and increases dramati-
cally when performed urgently. We also showed that patients with very large PEH were
much more likely to have obstructive symptoms, and to present urgently when com-
pared with patients with smaller (<75% gastric herniation) PEH.8 Many of these urgent
presentations occurred in patients who were over 80 years of age and in whom the pres-
ence of the PEH was known at an earlier age, even decades earlier, and not repaired. As
such, we recommend elective surgical repair for most patients who have minimal symp-
toms and very large PEH because of the higher risk of mortality or complications after
emergency surgery.
Relative contraindications to laparoscopic PEH repair include conditions that might
preclude or increase the risk of all laparoscopic surgery, such as portal hypertension,
dense abdominal adhesions preventing progress in the case, and significant hematologic
clotting disorders, and contraindications to any surgery, such as inadequate cardiovascu-
lar function or the inability to tolerate general anesthesia. Age greater than 80 years is not
a contraindication for laparoscopic PEH repair if these relative contraindications are man-
ageable. Obesity is not a contraindication, but in the appropriate patient, a hernia repair
along with a Roux-en-Y near-esophagojejunostomy may be a better option, especially in
patients with comorbidities of obesity and a very high body mass index (BMI).9 It has
also been noted that the risk for recurrent herniation with PEH repair in the morbidly
obese patient may be increased5 and might be lowered by combining a hernia repair with
a Roux-en-Y.
Careful preoperative evaluation is essential. Careful symptom history includes: assess-
ment of typical symptoms of gastroesophageal reflux disease (GERD) (heartburn, regur-
gitation), obstructive symptoms (dysphagia), chest or epigastric pain, postprandial pain,
postprandial vomiting, and atypical symptoms (recurrent aspiration with or without
associated pneumonia, cough, shortness of breath, and dyspnea on exertion). In patients
with gastric volvulus in association with a PEH, which may be exacerbated in patients
with a narrow crural opening, overt or occult bleeding can occur due to compromised
blood supply to the herniated portion of the stomach. Even when overt strangulation
or volvulus is not apparent, some patients with large PEH will experience varying
degrees of gastritis. In some cases, ulceration and bleeding, occurs and patients present
with hematemesis or melena but more often the presentation of bleeding is with a
chronic anemia. In our experience, iron-deficiency anemia was diagnosed in a number
of patients prior to surgical referral, but the relationship to the PEH went unrecognized;
this association, when overlooked, can result in multiple blood transfusions, often over
many years, before the patient is finally referred for surgical PEH repair. Following
repair, the anemia resolves in the majority of patients.10,11 As such, assessment in
patients with radiographic findings of PEH must include assessment for bleeding or
chronic iron-deficiency anemia.
LWBK1254-ch11_p121-136.indd 123 20/02/14 10:34 PM

Additional preoperative evaluation includes the following.

n Blood work. Hemoglobin to assess anemia; serum albumin to evaluate nutritional status.
n Radiographic evaluation. Prior to operative intervention, all patients have radio-
graphic evaluation of the PEH. The most common study is a barium esophagram, and
this is currently standard for all of our elective cases unless the patient is unable to
participate in the study. Computed tomography provides complementary information
to the barium esophagram, such as identification of Type IV PEH, and can be used
as a substitute for barium esophagram in urgent situations or for those patients
unable to tolerate the barium esophagram. The barium esophagram and computed
tomography scan provide an assessment of the location of the gastroesophageal junc-
tion, esophageal length, the amount of stomach herniated into the chest, if other organs
may also be herniated, and whether a volvulus of the stomach is present. The barium
esophagram may suggest that esophageal shortening is present, although, the absolute
finding of a shortened esophagus can only be made at the time of surgery when the
gastroesophageal junction cannot be delivered tension free into a subdiaphragmatic
location. In addition, the barium esophagram can provide information about abnor-
mal esophageal motility and associated abnormalities such as esophageal lesions,
strictures or diverticula. A preoperative chest radiograph is obtained in all patients
as well to identify other pulmonary pathology that might be present and assess for
signs of either chronic lung injury or acute pneumonia secondary to aspiration.
n Flexible endoscopy. Preoperative or intraoperative endoscopy is always performed
by the operating surgeon to evaluate gastric and esophageal viability, identify associ-
ated abnormalities, such as Barrett’s esophagus or esophageal malignancy, identify the
location of the gastroesophageal junction, and assess and estimate esophageal length,
which may have been difficult to evaluate due to the anatomic distortion created by
the PEH. It is critical for the surgeon to perform their own endoscopy and not rely
on the findings on endoscopy reported by others as the anatomy of the esophagus
and stomach are often distorted and can be difficult to evaluate when unaccustomed
to evaluation of PEH.
n Pulmonary function testing. We do not routinely obtain pulmonary function testing
(PFT) for elective repair of a large PEH; however, when shortness of breath or dyspnea
on exertion is present, PFTs may offer important information and risk assessment.
This can be due to the space-occupying effects of the gastric herniation into the
posterior mediastinum, with local effects on both the heart and the adjacent lung,
but may also be due to chronic aspiration and in some cases repeated pneumonias.
In cases of complete intrathoracic stomach, the herniation may occupy as much as
40% to 50% of the volume of the right or left hemithorax. In these extremes, PFTs
may be useful for assessing the degree of pulmonary impairment but it may be diffi-
cult to determine how much of this is due to the hernia versus coexisting lung disease.
n Esophageal physiology testing. For large PEH, particularly in patients with primarily
obstructive symptoms, pH studies are not routinely performed because the primary
indication for repair is related to the mechanical obstruction of the esophagus and
stomach rather than sphincter incompetence and reflux disease. A negative pH study
would not change the need for operative repair. Manometry can be useful in some
patients in whom an esophageal motility disorder is suspected, but should be under-
taken with caution as the placement of the catheter can result in perforation of the
esophagus or stomach when the anatomic derangements due to the herniation are
not recognized. However, if simple manometric assessment of the esophageal body
and motor function are being performed, this is generally well tolerated and may
help in determining the type of fundoplication used during repair of the PEH.
Surgery
It is important that in the preoperative setting a thorough discussion of the risks and
benefits of the operation, including the risk for perioperative death or other adverse
LWBK1254-ch11_p121-136.indd 124 20/02/14 10:34 PM

outcomes, recurrent hernia, and potential need for reoperation is undertaken. After

repair, patients are followed in our clinics long term to monitor for recurrent symptoms
or hernia. This close attention to long-term outcomes facilitates early recognition of

recurrent symptoms, including dysphagia, and appropriate interventions to assist with
patient comfort and satisfaction with quality of life. It is important for the surgeon to
remain engaged in this process as the patient’s primary care physicians and even their
gastroenterologists may incorrectly attribute symptoms to the PEH repair or fail to rec-
ognize correctible problems that are related to the PEH repair.
Once the patient agrees to proceed, final preparations for surgery are made. All
patients have a preoperative electrocardiogram, chest radiograph, type and screen and
received modified bowel prep with 1 L of polyethylene glycol electrolyte solution. We
have found this to be helpful, especially in elderly patients or in patients prone to con-
stipation. Any patients with risk factors for coronary heart disease, including age, hyper-
tension, history of smoking or prior history of coronary disease also undergo cardiac
evaluation with a minimum of an exercise or persantine-thallium stress test to determine
whether significant coronary disease is present. If the stress test is positive, cardiology
consultation is obtained prior to operative intervention, except in emergency cases.
On the day of surgery, patients receive 5,000 units of heparin subcutaneously prior
to induction of anesthesia, preferably in the preoperative holding area.12 In the operat-
ing room, general endotracheal anesthesia is induced and flexible endoscopy performed
by the surgeon. Care is taken to minimize air insufflation during the endoscopic evalu-
ation. The esophagus is inspected and the stomach is decompressed as much as pos-
sible, given the anatomy of the patient. The patient is then positioned for laparoscopy.
Our preferred approach for positioning of the patient is supine with the surgeon on the
patient’s right side and the assistant on the left. A subhepatic liver retractor is used, so
the patient is placed to the far right of the operating room table. A foot stop is placed
to facilitate reverse Trendelenburg positioning. Sequential compression devices are
placed on the legs bilaterally. A Foley catheter is placed. The patient’s arms are rotated
away from the patient, secured to an arm board at a 45-degree angle from the bed and
carefully padded. This angle provides adequate access to the operating table and mini-
mizes the risk of stretch injury to the brachial plexus. The abdomen is then prepped
and draped and intravenous antibiotics administered for wound infection prophylaxis.
Proper port placement is the key to successful execution of the operation. Because
of the extensive mediastinal dissection required to reduce the hernia sac and to fully
mobilize the esophagus, placement of the ports in the upper aspect of the abdomen is
critical. To accomplish this, we identify the midline from the xiphoid to the umbilicus
Figure 11.2 Surgeon and port position.

Port placement and instrument posi-
tions are shown. In a nonobese
patient, the ports are positioned one-
third of the distance from the xiphoid
to the umbilicus. In obese patients,
this measure is often inaccurate
because of the increased abdominal
circumference. In this situation, the
patient’s bony anatomy can be used to
determine appropriate placement with
an imaginary line across the abdomen
Surgeon’s
at top of the anterior superior iliac
grasper
spines serving as a marker for the
Surgeon’s normal distance to the umbilicus.
dissector
Assistant’s
Liver retractor grasper
Camera port
LWBK1254-ch11_p121-136.indd 125 20/02/14 10:34 PM

and use a skin marker to divide the distance into thirds (Fig. 11.2). In morbidly obese
patients, attention to the distance from the costal margins to the pelvis using the bony
anatomy will assist with gauging proper port placement. In the majority of patients, five
ports are used. Using the open, blunt port cut down technique, a 10-mm Hassan port,13
is placed in the right paramedian line approximately one-third of the way from the
xiphoid to the umbilicus, taking care to avoid dissection into the falciform ligament.
Insufflation pressures are set at between 12 and 15 mm Hg, depending on the patient’s
hemodynamics and intraoperative visibility. In compromised patients with poor cardio
pulmonary risk, we have found that many can be repaired with insufflation pressure
ranging from 8 to 10 mm Hg routinely. Once we have confirmed proper positioning of
the Hassan port within the peritoneal cavity, full insufflation is achieved. Port place-
ment then proceeds under direct vision. The assistant’s ports are positioned to the left
of the midline. The assistant’s left hand holds the camera, which is passed via a 5- or
10-mm port in the left paramedian line at approximately the same level or slightly lower
than the Hassan port in the right paramedian line. The assistant’s right hand is directly
below the costal margin in the midclavicular line and is used for retraction. The sur-
geon’s ports include the Hassan port, through which an energy device is passed for use
in sharp dissection. A 5-mm port for the surgeon’s left hand is placed in the right mid-
clavicular line directly below the costal margin. It is critical that the subcostal ports on
either side be at least a hands breath (9 to 10 cm) from the paramedian ports as closer
positioning creates the potential for interference between the instruments during the
procedure. Liver retraction can be accomplished either using a subxiphoid position or
through a 5-mm port in the far right lateral subcostal position, depending upon the type
of liver retractor to be used.
Reducing the Hernia Sac

Following port placement and liver retraction, the operating room table is placed in
steep reverse Trendelenburg to facilitate visualization of the hiatus. Because the patient
may be dehydrated due to having nothing by mouth for at least 8 hours, we often begin
slowly and incrementally increasing the angle as soon as the operation begins, which
allows time for the anesthesiologist to respond to hemodynamic changes and volume
requirements. Steep reverse Trendelenburg is helpful to fully expose the hiatus and
shift the upper abdominal contents toward the patient’s pelvis and away from the hia-
tus. Reduction of herniated contents, such as omentum and bowel, is performed upon
initial assessment of the hiatus. We do not, however, place traction on the stomach
itself, as this causes unnecessary trauma. Rather than placing retraction on the stomach,
the surgeon focuses on dissection and reduction of the sac back into the abdomen,
which will, by default, also reduce the stomach because the hernia sac also includes
the peritoneal lining of the cardia of the stomach. To accomplish sac reduction, the
surgeon and assistant grasp the hernia sac just inside the hiatus at or near the 12-o’clock
position using the surgeon’s left hand and the assistant’s right hand (Fig. 11.3). By
everting this sac, the surgeon can then use hemostatic energy devices such as the har-
monic scalpel (Ethicon, Cincinnati, OH) or the ultrasonic shears (US Surgical/Covidien,
Mansfield, MA) to proceed. The sac is opened at the junction between the attenuated
phrenoesophageal ligament and the peritoneal reflection. The posterior mediastinum is
entered through this anterior opening in the hernia sac, exposing the areolar attach-
ments of the hernia sac to the mediastinal structures. To minimize even modest bleed-
ing, the areolar attachments are divided using the energy source, rather than with blunt
dissection.
During dissection of the sac, the pleural reflection is identified early in the proce-
dure to minimize risk of intraoperative pneumothorax. Injury to the pleura allows the
insufflated CO2 to enter the hemithorax and can result in hemodynamic instability or
ventilation difficulties related to a pneumothorax. The pleural reflection, particularly
on the left, can often be identified crossing the midline over the esophagus and can be
easily injured during the dissection if intentional and early identification is not rou-
tinely performed. Mediastinal dissection is continued until the entire hernia sac is
LWBK1254-ch11_p121-136.indd 126 20/02/14 10:34 PM

Figure 11.3 Reduction of the

Vagal sparing hernia sac without retraction on
the stomach. The operation begins

with the surgeon and the assistant
everting the hernia sac just inside
the hiatus. The sac is incised,
allowing entry into the mediasti-
num. Dissection proceeds using
an energy device and coagulation
of the fine areolar attachments of
the hernia sac to the surrounding
mediastinal structures (inset).
Crural integrity During this dissection, care is
taken to maintain the integrity of
the crural lining and avoid dam-
age to the crural muscle, vagus
nerves, or pleura. Note, the stom-
ach is not being retracted during
this dissection.
Surgeon’s
grasper Assistant’s grasper
Surgeon’s dissector
dissected and subsequently reduced, taking care to avoid injury to the pleura, and the
anterior and posterior vagus nerves (Fig. 11.4).
After the sac has been reduced from the mediastinum, it is completely separated
from the crura. With the sac fully reduced back into the abdomen, the stomach will be
noted to lie within the subdiaphragmatic location and frequently completely returned to
its anatomic position without the potential for injury that can be caused by retraction on
the stomach itself when using the hand-over-hand technique. When separating the sac
from the crura, great care is taken to avoid injury to the peritoneal lining covering the
crura so to preserve the integrity of the crura and this is a key component to a successful
Careful preservation Figure 11.4 Establishment of an intraperito-

of crural muscle neal stomach after complete reduction of the
and peritoneal lining hernia sac. Complete reduction of the sac
and esophageal mobilization may require 1 to
2 hours of dissection within the mediastinum,
but is critical for the long-term success of
the operation.
Reduced hernia sac
LWBK1254-ch11_p121-136.indd 127 20/02/14 10:34 PM

Figure 11.5 Mobilization of the esopha-

Location of geal fat pad and identification of the
gastroesophageal GEJ. To facilitate precise identification
junction is unclear of the GEJ and prevent inadvertent
placement of the fundoplication
around tubularized proximal stomach,
the esophageal fat pad is carefully
dissected from the anterior surface of
the stomach, taking care to preserve
the integrity of the anterior and poste-
rior vagal nerves. This dissection is
carried posteriorly, staying close to the
esophagus, to create a retroesopha-
geal window.
Mobilization of
fat pad with
anterior vagus
primary closure (Fig. 11.5). If the crural integrity is not preserved, the integrity is mark-
edly compromised and will not hold sutures securely to prevent dehiscence of the
crural repair. If the integrity of the crural lining is maintained and the attachments
between the diaphragm and the stomach, spleen, and other retroperitoneal structures
are completely divided, a tension-free closure of the crura can be achieved in more than
85% of patients without requiring mesh cruroplasty. We have found that if crural ten-
sion is still present after complete mobilization of the hernia and sac, inducing a left-
sided pneumothorax may indeed yield a “floppy diaphragm sign,” making tension-free
primary repair much easier. Subsequently, the surgeon can then place a small pigtail
catheter and eliminate the pneumothorax. This catheter can be removed very early in
the postoperative course. It is important to communicate with the anesthesiologist when
inducing a pneumothorax.
Re-establishing Adequate Intra-abdominal Esophageal Length

The next step in the PEH repair is to re-establish adequate intra-abdominal esophageal
length. If this is not achieved, the esophagus and stomach continue to exert axial forces
on the crural closure and a recurrence is likely to result. Extensive, circumferential
mobilization of the esophagus is performed high into the mediastinum. The dissection
can be carried as high as the inferior pulmonary veins without difficulty. In extreme
cases, the dissection can be carried significantly higher, if needed, to gain additional
esophageal length. In order to accurately assess the location of the true gastroesophageal
junction, we routinely mobilize the gastric fat pad off the stomach and the distal esopha-
gus, similar to the procedure to expose the gastroesophageal junction for a Heller myo-
tomy. This allows clear visualization of the junction of the longitudinal muscle fibers
of the esophagus and the serosa of the stomach. We continue the fat pad dissection
around the GEJ to create a posterior window between the esophagus and posterior vagus
nerve through which to perform the fundoplication (Fig. 11.6). As with the sac reduc-
tion, awareness of the anterior and posterior vagus nerves is critical to avoid injury to
these vital structures. If there is significant esophageal shortening, which is common
with Type III PEH, extensive esophageal mobilization is required and the surgeon
should be prepared to perform a Collis gastroplasty if necessary to achieve adequate
intra-abdominal esophageal length. We have found over the years, that with more expe-
rience, and better esophageal mobilization, the need for a Collis gastroplasty can be
reduced, and when it is needed, the length of the gastroplasty can be kept to a smaller
distance. We consider adequate esophageal length to be 2 to 3 cm distance from the
crura to the gastroesophageal junction with the stomach in a relaxed position within
LWBK1254-ch11_p121-136.indd 128 20/02/14 10:34 PM

Inadequate length of Figure 11.6 Fully mobilized fat pad provides

intra-abdominal esophagus clear localization of the GEJ and facilitates
assessment of esophageal length. The

presence of a foreshortened esophagus is
determined intraoperatively as described in
the text.
Fat pad reflected away revealing

gastroesophageal junction
the abdomen. If tension on the gastroesophageal junction is needed to create this amount
of intra-abdominal esophagus, further dissection or gastroplasty is required. Currently
our preferred technique for Collis gastroplasty is the wedged technique that we and
others have previously described (Fig. 11.7).14
Re-establishing the Antireflux Barrier

While gastroesophageal reflux is present in only approximately 50% of patients at the
time of PEH repair, the reduction of the mediastinal sac and dissection of the esopha-
gus, by necessity, disrupt the phrenoesophageal ligament and the integrity of the lower
Figure 11.7 Laparoscopic wedge Collis gastroplasty. If additional esophageal length is needed following extensive esophageal
mobilization, the stomach is then grasped at the short gastric vessels and rolled toward the surgeon. The surgeon determines the
length of gastroplasty required to create a neoesophagus that will provide at least 2 cm of tension-free intra-abdominal esophagus.
A 54-French bougie is placed by the surgeon with direct visualization with the laparoscope to ensure safe passage into the stom-
ach. The surgeon then grasps the stomach just proximal to the planned location of the initial staple line. Depending on the thickness
of the stomach, either a 4.8-mm (green load) or 3.5-mm (blue load) cutting endostapler is then applied. Alternatively, a triple-staggered,
height-progressive staple can be used where available. We now routinely use cartridges with triple-staggered staple heights of
3.0 mm, 3.5 mm, and 4 mm, respectively (purple load). Serial fires of the stapler directly perpendicular to the bougie are used to divide
the stomach until the staple line reaches the bougie. The surgeon and assistant provide very gentle counter-traction on the proximal
and distal aspects of the stomach to draw the lesser curve tight against the bougie. This ensures that the neoesophagus is not
patulous. Care must be taken to avoid traction in the cephalad or caudal direction as this can tear the stomach at the edge of the
staple line; this can be difficult to repair and increases the risk of postoperative leak from the Collis gastroplasty. The wedge of
stomach is then removed with serial firings of the endostapler parallel to the bougie.
LWBK1254-ch11_p121-136.indd 129 20/02/14 10:34 PM

C
A
A D
B
B
Neo esophagus
D
Staple line of
Collis gastroplasty
New gastroesophageal junction Anterior aspect of stomach
Figure 11.8 Creation of “floppy, two-stitch” Collis–Nissen fundoplication. Maintenance of a proper orientation of the wrap as
it passes through the retroesophageal space is critically important for the successful creation of a new antireflux barrier. The
Nissen fundoplication is performed after placement of a bougie (usually 54-French) into the esophagus under direct vision.
esophageal antireflux barrier and create the potential for symptomatic reflux disease
postoperatively. As such, we generally perform an antireflux procedure in the majority
of patients. Surgeon preference and preoperative findings on manometry regarding
esophageal motility, may help determine the type of fundoplication to be performed:
a circumferential “floppy” fundoplication (2-stitch Nissen over a 54 or 56 bougie)15
(Fig. 11.8) or a partial fundoplication.16,17 In the past, we routinely performed the
circumferential “floppy” Nissen fundoplication but more recently, have moved on to
a partial fundoplication or “near” Nissen to minimize side effects such as dysphagia,
gas bloat, and flatulence. Before performing the fundoplication, the surgeon passes the
bougie, which we find preferable due to varying experience in doing this by the
anesthesiologist. We then go on to crural closure. In the past, we performed a fundo
plication of some type on the vast majority of patients. However, more recently, we
have noted that some patients clearly do well with this step omitted but only if the
other steps are completely performed, including sac dissection, complete stomach
mobilization, and careful crural closure followed by gastropexy. While you may leave
some patients with reflux, the side effects of a wrap in elderly patients are not incon-
sequential. However, we acknowledge, that most patients will tolerate a partial wrap
or a floppy Nissen.
In rare situations, such as when the surgeon is concerned about patient stability in
the operating room or the viability of the stomach, in very elderly patients (age ≥80
years), in patients with significant multiple comorbidities, or in patients with a signifi-
cant esophageal motility disorder, salvage procedures, such as gastropexy only, have
been recommended. We try to avoid gastropexy only. If pressed for time, we will try to
at least perform the sac mobilization and obtain tension-free intra-abdominal stomach.
It is rare that with we cannot get this done safely and then add the gastropexy. In our
experience, this is much more likely to prevent marked recurrence of the intrathoracic
stomach along with symptoms. If esophageal or gastric necrosis is present, esophagogas-
trectomy may be required. Partial resections and diversion may be necessary in emer-
gency situations with compromised patients, and we would then do a delayed
reconstruction when the patient is more stable. For the occasional patient in whom the
LWBK1254-ch11_p121-136.indd 130 20/02/14 10:34 PM

surgeon decides not to perform fundoplication, the stomach should at least be mobi-

lized, sac dissected and then the stomach secured in an intra-abdominal position using
an extended gastropexy technique. Others have described gastropexy as a single point

of fixation using suture or the placement of a gastrostomy tube. In contrast, we perform
a gastropexy with multiple serial interrupted horizontal mattress heavy sutures (0-gauge)
between the stomach and the diaphragm and along the anterior abdominal wall. Begin-
ning at the gastroesophageal junction with a pexy of the stomach to the left crura,
sutures are placed approximately 2 cm apart over a distance of 10- to 14-cm. Using this
approach, multiple points of fixation are created between the stomach and the dia-
phragm and abdominal wall to minimize the risk of large hernia recurrence.
Repairing the Hiatus

After complete reduction of the hernia sac and extensive esophageal mobilization to
restore adequate intra-abdominal length, the third critical element of PEH repair is
the crural closure. With meticulous attention to preservation of crural integrity and
complete untethering of the crura by dividing the phrenogastric, phrenosplenic and
retrogastric attachments, a tension-free, primary suture closure of the hiatus can be
achieved in the majority of patients (∼85%). To ensure crural integrity, the lining of
the crura is identified and preserved early in the procedure. The fully mobilized crura
are reapproximated, without tension, using heavy suture (0-gauge) (Fig. 11.9). We
prefer to perform crural closure with the bougie removed. After completion of the
fundoplication, the bougie is removed and the hiatal opening is inspected. The clo-
sure is performed with 2 or 3 interrupted sutures placed posteriorly with the esopha-
gus lying in a neutral, tension-free position within the hiatus. We typically do not
place more than 2 stitches posteriorly as additional sutures create an artificial angu-
lation of the esophagus as it passes through the hiatus and may be a source of post-
operative dysphagia. After placing the sutures posteriorly, the hiatus is reevaluated.
If the anterior space continues to be patulous, that is, more than a centimeter of space
between the crura and esophagus with introduction of a grasper through the opening,
additional interrupted horizontal sutures are placed anteriorly, on the upper aspect
of the crura. If tension is present to any degree, at this point, we induce an intentional
pneumothorax to create a “floppy diaphragm sign” which allows the crura to be
repaired with essentially no tension. At the completion of the closure, a grasper
Figure 11.9 Tension-free hiatal

closure. After completion of the
fundoplication wrap, the bougie is
removed and the crura assessed
for tissue integrity and mobility.
The crura are reapproximated
with heavy (0-gauge) braided,
permanent suture. If the hiatus
remains too widely splayed after
placement of a 3rd posterior
suture, we add an anterior suture
to reduce the size of the anterior
opening. The final, tension-free
closure is illustrated in the inset.
LWBK1254-ch11_p121-136.indd 131 20/02/14 10:34 PM

should be easily introduced through the hiatus with approximately 1 cm of space

surrounding the esophagus circumferentially. In those situations where the crural
muscles are attenuated or the overlying peritoneum was denuded during dissection
or the crural muscles remain tethered and unable to be reapproximated without ten-
sion, the induced pneumothorax may allow viable, good integrity diaphragm to be
pulled into place. If this is absolutely not possible, cruroplasty can be performed with
bioprosthetic mesh to reinforce the closure. Cruroplasty with other forms of mesh
have been reported over the years, by others and by us, but all have some propensity
to erode into the esophagus. Thus, we try to avoid synthetic mesh if at all possible
in this location, but there will be times when mesh must be considered to avoid leav-
ing an obvious large defect. While biomesh does appear to nicely buttress a somewhat
weakened primary repair, spanning distances of crura space with biomesh alone, will
likely fail in the long run. A nasogastric (NG) tube is then placed by the anesthesi-
ologist or the surgeon while carefully watching the tube as it is advanced into the
stomach with the laparoscope. It is critical that the surgeon and anesthesiologist
approach this placement with care as the obstruction created by the wrap and the
closure can easily cause resistance to passage of an NG tube and subsequent esopha-
geal perforation during placement if the nasogastric tube is pushed forcefully through
the repair.
The majority of patients are extubated in the operating room, transferred to the recov-
ery room, and then admitted to the hospital ward for postoperative recovery. However,
it is not uncommon to make the decision to admit the patient to the intensive care unit
(ICU) for postoperative observation due to age and comorbidities. This decision takes
into account intraoperative concerns, the length and urgency of the operation (elective
vs. nonelective), and the patient’s underlying comorbid diseases. We also consider ICU
admission for the first postoperative night in patients with marked sleep apnea for
careful observation. In our series of more than 650 patients, we placed 32% of our
patients in the ICU postoperatively for observation. In contrast, ICU admission after
antireflux procedures for small hiatal hernias and GERD is extremely rare. Median ICU
stay for this subset of patients was 2 days (interquartile range 1 to 3 days). We routinely
restrict oral intake to nothing by mouth until after a barium esophagram is performed.
In the majority of patients as determined by clinical condition, the barium study is
performed on postoperative day number 1 (fundoplication or gastropexy alone) or post-
operative day number 2 (Collis gastroplasty plus fundoplication). The barium esopha-
gram in the immediate postoperative setting documents subdiaphragmatic positioning
of the fundoplication wrap and assesses for unrecognized esophageal or gastric injury
or staple-line leak (in patients who received an esophageal lengthening [Collis] proce-
dure). Given the documented reports of a significant incidence of recurrent hiatal her-
nias in this population, we perform this test as our first baseline assessment and it
serves as a comparison for future studies and as a critique of our surgical repair. In rare
patients, the barium esophagram has identified immediate postoperative recurrence
and facilitated reoperation in the same hospital setting. After a barium esophagram
confirms the adequacy of the repair and an intact esophagus and stomach, oral intake
is initiated with clear liquids (∼120 mL/hour). Patients are then discharged to home
after a median hospital length of stay of 3 days (IQR 2 to 5), although, it is clear that
many patients under the age of 80, with minimal comorbidities can be discharged on
postoperative day 1 or 2. At discharge, they are instructed to progress to full liquid
intake after 3 days and then soft solids after another 3 days. Patients are instructed to
eat smaller, frequent meals up to six to eight times daily in small quantities and
to avoid hard solids, such as chicken, steak or doughy breads, for at least 6 weeks to
allow swelling from the procedure to resolve and to minimize the risk of gas bloat, and
dysphagia.
LWBK1254-ch11_p121-136.indd 132 20/02/14 10:34 PM


Complications

Laparoscopic repair by experienced, laparoscopic, esophageal surgeons is associated
with a significant decrease in postoperative morbidity as compared with most series
of open repair (∼25% of patients experience complications after laparoscopic repair
as compared with ∼60% after open repair), although no randomized comparative
studies have been performed.3 In our series of over 650 patients who underwent
laparoscopic giant PEH repair from 1997 to 2006, the largest series to date, major
adverse outcomes included pneumonia (4%), pulmonary embolism (3.4%), conges-
tive heart failure (2.6%), need for reintubation (2.6%), and postoperative leak (2.5%).5
Older patients and patients with significant comorbidities (CCI ≥3) had an increase
in perioperative morbidity. All postoperative deaths occurred in patients who were
older than 70 years, were obese, or had significant comorbid conditions. The major-
ity of postoperative leaks in the series occurred in patients who received Collis
gastroplasty (12/14).18 Obesity was also correlated with the risk of a postoperative
leak. When we examined predictors of adverse outcome in a subsequent analysis of
980 patients, a prediction model incorporating patient age (<80 vs. age 80 years or
more), elective versus nonelective urgency of operation, and two CCI variables (con-
gestive heart failure and pulmonary disease) provided discriminatory accuracy of
88% for postoperative mortality. Similarly, the discriminatory accuracy of a predic-
tion model for major postoperative morbidity that incorporated sex (male vs. female),
age by decade, urgency of operation, the presence of congestive heart failure, and
pulmonary disease was 68% (Table 11.1).8 While further refinement is needed,
patient-specific risk prediction can contribute substantially to decision making
regarding operative intervention in this disease process as it will enable the surgeon
and patient to weigh the benefits of repair against the potential risk of the operation,
taking into account the individual patient’s comorbid conditions along with their
symptoms and the size of the hernia.
T able 1 1 . 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
Variables in Each Model Points Comparison p-value Adjusted ORa 95% CI
Mortality
Congestive heart failureb 5 present vs. absent 0.009 4.740 1.481, 15.172
Pulmonary diseaseb 3 present vs. absent 0.009 3.342 1.345, 8.306
Surgery typec 3 nonelective vs. elective 0.021 3.165 1.193, 8.397
Age ≥80 (years) 9 ≥80 vs. <80 <0.001 8.577 3.043, 24.174
Morbidity
Sex 1 male vs. female 0.122 1.328 0.927, 1.901
Congestive heart failureb 4 present vs. absent <0.001 4.267 2.083, 8.737
Pulmonary diseaseb 2 present vs. absent 0.015 1.515 1.083, 2.121
Surgery typec 2 nonelective vs. elective <0.001 2.142 1.466, 3.128
Age group (years)
1 50–59 vs. <50 0.395 1.487 0.596, 3.712
2 60–69 vs. <50 0.221 1.718 0.722, 4.086
2 70–79 vs. <50 0.128 1.940 0.826, 4.558
3 ≥80 vs. <50 <0.001 2.689 1.123, 6.441
OR, Odds ratio; CI, confidence interval.

a
Adjusted for all other factors in the model.
b
History of each comorbid disease as defined in the CCI.
c
Nonelective surgery includes urgent and emergency surgery as defined by the Society of Thoracic Surgeons.
From reference 8; used with permission.
LWBK1254-ch11_p121-136.indd 133 20/02/14 10:34 PM

Postoperative Follow-Up
Postoperatively, we follow patients according to our clinical pathway at 2 weeks and
then again 1 year after surgery. In the absence of any symptoms, patients are then
followed every 2 years with routine barium esophagram and symptom assessment. We
have found routine barium esophagram to be extremely useful for determining whether
the repair is intact and for understanding the etiology of any symptoms that may
develop over time. For example, approximately 15% of patients in our series had a
radiographic evidence for small recurrent hernia during postoperative assessment. The
majority of these recurrences were associated with minimal symptoms that were
managed nonoperatively. If a patient is known to have a minimally symptomatic small
recurrence but subsequently presents with worsening symptoms, a repeat barium
esophagram can be compared with prior studies when fewer symptoms were present.
If the barium esophagram remains unchanged, operative repair of the recurrence may
not improve the patient’s symptoms. In contrast, a patient who previously had an intact
repair, with worsening or recurrent symptoms associated with a new recurrence would
be a candidate for reoperation after confirmatory testing. Symptom assessment is also
routine and standardized, including the use of validated measures for GERD health-
related quality of life (GERD-HRQL)19 and overall quality of life (SF-36).20 Common
postoperative complaints include dysphagia, heartburn, gas bloat, and diarrhea. When
significant symptoms are identified during routine, pathway-driven clinical follow-up,
appropriate therapy and/or intervention can be performed based on the degree of symp-
toms, including resumption of medical therapy, endoscopy and dilation, or reoperation,
as needed.
Results
In our experience, laparoscopic PEH repair, resulted in good-to-excellent results in up
to 90% of patients in both intermediate (median 30 months) and long-term (median
44 months) follow-up. Small radiographic recurrences identified by barium esophagram
were seen in ∼16%; less than 5% of patients underwent reoperation for recurrent symp-
toms or symptomatic hernia recurrence.4,5 We have also shown that symptomatic out-
comes after laparoscopic fundoplication with Collis gastroplasty are excellent and
comparable with those of fundoplication alone. The use of Collis gastroplasty was asso-
ciated with a higher rate of postoperative leaks (2.7% vs. 0.6%, respectively); however,
patients who required Collis gastroplasty in this series had significantly larger PEHs.18
Conclusions
n There are several key elements to laparoscopic repair of PEH, and these include:
(1) complete reduction of the hernia sac and contents; (2) careful preservation of
the anterior and posterior vagus nerve; (3) mobilization of the gastroesophageal fat
pad and identification of the gastroesophageal junction; (4) recognition and manage-
ment of a shortened esophagus (extensive mediastinal mobilization and perform-
ance of a Collis gastroplasty when necessary); (5) preservation of crural integrity
and closure of the hiatal defect without tension; selective use of mesh reinforce-
ment only when a tension-free repair is not possible; and (6) performance of an
antireflux procedure.
n Laparoscopic repair of PEH provides excellent patient satisfaction and symptom
resolution.
n When performed by surgeons with extensive experience in minimally invasive and
open esophageal surgery, the reoperation rates with a minimally invasive approach
are comparable with the best open series.5,21
LWBK1254-ch11_p121-136.indd 134 20/02/14 10:34 PM

Recommended References and Readings 11. Haurani C, Carlin AM, Hammoud ZT, et al. Prevalence and

resolution of anemia with paraesophageal hernia repair. J Gas-
1. Luketich JD, Raja S, Fernando HC, et al. Laparoscopic repair of trointest Surg. 2012;16(10):1817–1820.

giant paraesophageal hernia: 100 consecutive cases. Ann Surg. 12. Zurawska U, Parasuraman S, Goldhaber SZ. Prevention of pul-
2000;232(4):608–618. monary embolism in general surgery patients. Circulation.
2. Mattar SG, Bowers SP, Galloway KD, et al. Long-term outcome 2007;115(9):e302–e307.
of laparoscopic repair of paraesophageal hernia. Surg Endosc. 13. Zollinger RM Jr, Zollinger RM Sr. Plate 91. Cholecystectomy,
2002;16(5):745–749. Hasson open technique, laparoscopic. In: Zollinger RM Jr,
3. Karmali S, McFadden S, Mitchell P, et al. Primary laparoscopic Zollinger RM Sr, eds. Zollinger’s Atlas of Surgical Operations.
and open repair of paraesophageal hernias: A comparison of 9th ed. New York, NY: McGraw-Hill; 2011.
short-term outcomes. Dis Esophagus. 2008;21(1):63–68. 14. Luketich JD, Maddaus MA. Laparoscopic Collis Gastroplasty. In:
4. Nason KS, Luketich JD, Qureshi I, et al. Laparoscopic repair of Pearson FG, Patterson GA, eds. Pearson’s Thoracic and Esopha-
giant paraesophageal hernia results in long-term patient satisfac- geal Surgery, 3rd ed. Philadelphia, PA: Churchill Livingstone/
tion and a durable repair. J Gastrointest Surg. 2008;12(12):2066– Elsevier; 2008:326–336.
2075; discussion 2075–2077. 15. Davis RE, Awad ZT, Filipi CJ. Technical factors in the creation of
5. Luketich JD, Nason KS, Christie NA, et al. Outcomes after a a “floppy” Nissen fundoplication. Am J Surg. 2004;187(6):724–727.
decade of laparoscopic giant paraesophageal hernia repair. 16. O’Reilly MJ, Mullins SG, Saye WB, et al. Laparoscopic posterior
J Thorac Cardiovasc Surg. 2010;139(2):395–404. partial fundoplication: Analysis of 100 consecutive cases.
6. Allen MS, Trastek VF, Deschamps C, et al. Intrathoracic stom- J Laparoendosc Surg. 1996;6(3):141–150.
ach. Presentation and results of operation. J Thorac Cardiovasc 17. el-Sherif AE, Adusumilli PS, Pettiford BL, et al. Laparoscopic
Surg. 1993;105(2):253–258; discussion 258–259. clam shell partial fundoplication achieves effective reflux con-
7. Stylopoulos N, Gazelle GS, Rattner DW. Paraesophageal hernias: trol with reduced postoperative dysphagia and gas bloating. Ann
Operation or observation? Ann Surg. 2002;236(4):492–500; dis- Thorac Surg. 2007;84(5):1704–1709.
cussion 500–501. 18. Nason KS, Luketich JD, Awais O, et al. Quality of life after col-
8. Ballian N, Luketich JD, Levy RM, et.al. A clinical prediction rule lis gastroplasty for short esophagus in patients with paraesopha-
for perioperative mortality and major morbidity after laparo- geal hernia. Ann Thorac Surg. 2011;92(5):1854–1860; discussion
scopic giant paraesophageal hernia repair. J Thorac Cardiovasc 1860–1861.
Surg. 2013;145(3):721–729. 19. Velanovich V, Vallance SR, Gusz JR, et al. Quality of life scale
9. Awais O, Luketich JD, Tam J, et al. Roux-en-Y near esophagoje- for gastroesophageal reflux disease. J Am Coll Surg. 1996;183(3):
junostomy for intractable gastroesophageal reflux after antireflux 217–224.
surgery. Ann Thorac Surg. 2008;85(6):1954–1959; discussion 20. Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health
1959–1961. survey (SF-36).I. Conceptual framework and item selection. Med
10. Hayden JD, Jamieson GG. Effect on iron deficiency anemia of Care. 1992;30(6):473–483.
laparoscopic repair of large paraesophageal hernias. Dis Esopha- 21. Maziak DE, Todd TR, Pearson FG. Massive hiatus hernia: evalu-
gus. 2005;18(5):329–331. ation and surgical management. J Thorac Cardiovasc Surg.
1998;115(1):53–60; discussion 61–62.
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LWBK1254-ch11_p121-136.indd 136 20/02/14 10:34 PM
12 Open Paraesophageal
Hernia: Transthoracic
Approach
Gail E. Darling and F. Griffith Pearson
The primary indication for the repair of a paraesophageal hernia is a symptomatic her
nia. The most common symptoms are postprandial pain (59%), vomiting (31%), and
dysphagia (30%), but may include postprandial dyspnea, acid reflux, iron deficiency
anemia, or symptoms of volvulus, acute incarceration or ischemia with severe retro
sternal chest pain mimicking myocardial ischemia.1 Repair of asymptomatic paraesopha
geal hernia may be considered in patients who are fit for surgery, given that these
hernias enlarge over time, often becoming symptomatic, although catastrophic compli
cations, such as gastric strangulation, are rare occurring in only about 3%.1–3 A transtho
racic approach may be used for repair of any paraesophageal hernia but is particularly
appropriate for Type III or IV hernias and should be considered for reoperative repairs,
obese patients, and those with acquired esophageal shortening. A transthoracic approach
facilitates the assessment of acquired esophageal shortening, which may be difficult to
appreciate through a transabdominal approach.
Contraindications for transthoracic repair include impaired cardiopulmonary
reserve or the inability to tolerate single-lung anesthesia. Previous left-sided thoracot
omy or pulmonary sepsis, wherein one may anticipate difficulty in exposure of the
hernia due to extensive adhesions, may be taken into consideration.
Preoperative assessment should include an assessment of the foregut anatomy, noting
particularly the location of the gastroesophageal junction, with barium swallow and
upper endoscopy. Prolonged exposure to acid reflux may lead to transmural inflammation
and acquired esophageal shortening. In such cases, an esophageal-lengthening procedure
is required for a successful durable repair. Factors that may be predictive of acquired
137
LWBK1254-ch12_p137-146.indd 137 19/02/14 7:14 AM

esophageal shortening include an incarcerated hiatus hernia, a large hiatus hernia (greater
than 5 cm), Type III hernia, peptic stricture, and Barrett’s esophagus.4,5 Assessment of
esophageal length is ultimately determined at the time of repair after mobilization of the
esophagus, but preoperative endoscopy, barium swallow, and the distance between upper
cervical and lower esophageal sphincters on esophageal manometry provide useful
insights that may advise intraoperative decision making.
Esophageal manometry should be included in the preoperative assessment if one is
considering performing a total or 360-degree fundoplication. This assessment is less
critical if one is planning a partial fundoplication. A 24-hour pH study is not required
but may be included in the preoperative assessment if the primary indication for repair
is acid reflux.
Other important components of the preoperative assessment include assessment of
cardiopulmonary reserve. The patient must have adequate pulmonary reserve to tolerate
single-lung anesthesia and maintain postoperative pulmonary toilet. Active esophagitis
should be treated with proton-pump inhibitors before proceeding with repair. Further,
any active pulmonary infection, for example, secondary to aspiration, should also
be treated prior to surgery. Active smokers should avoid smoking for a minimum of
2 weeks prior to surgery.
Surgery
The principles of repair are as follows:
n Tension-free reduction of the hernia contents back into the abdomen
n Removal of the hernia sac from the chest
n Closure of the defect by tension-free closure of the crura
n Anchor the stomach in abdomen through performance of fundoplication and crural
pexing sutures
The steps include the following:
1. Mobilization of the esophagus
2. Protection of the vagus nerves
3. Mobilization and resection of the hernia sac
4. Assessment of esophageal length and Collis gastroplasty, if required
5. Fundoplication
6. Crural closure
Anesthetic Considerations
Single-lung anesthesia is required using either a double-lumen endotracheal tube or
bronchial blocker. A thoracic epidural may be beneficial for postoperative pain control;
alternatively, a paravertebral catheter or intercostal nerve blocks may be placed at the
time of thoracotomy.
Positioning
The patient should be positioned in full right lateral decubitus position with an axillary
role in place and all pressure points well padded. The operative table may be slightly
flexed or “broken” at its midpoint to open up the intercostal spaces.
Incision
A posterolateral thoracotomy incision is performed preserving the serratus anterior
muscle, entering the chest through the sixth intercostal space. The dome of the dia
phragm will interfere with the exposure of the hiatus if the seventh intercostal space
is used. Some surgeons resect a segment of the sixth rib to facilitate exposure.
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Chapter 12 Open Paraesophageal Hernia: Transthoracic Approach 139
Technique

After entering the chest, the left lung is deflated by the anesthesiologist, and the inferior

pulmonary ligament is divided using an electrocautery. Using a malleable retractor and
one or more sponges, the lung may be packed out of the way superiorly and anteriorly.
The mediastinal pleura is then opened over the esophagus just anterior to the
descending aorta beginning at approximately the level of the inferior pulmonary vein
or higher, if necessary, to get above the hernia and at a level where the vagus nerves
are still identifiable adherent to the esophagus. Dissection may be accomplished using
scissors, electrocautery, or ultrasonic device. The esophagus is mobilized and encircled
with a Penrose drain or umbilical tape taking care to keep both vagus nerves with the
esophagus. The esophagus is mobilized proximally as far as the aortic arch if necessary
and distally to the hiatus. When mobilizing distally, the middle esophageal artery will
be divided. This artery must be controlled or troublesome bleeding will result. Traction
on the Penrose drain will facilitate both proximal and distal dissection of the intratho
racic esophagus.
The esophagus and hernia sac are mobilized from the mediastinum and pericar
dium and from the right chest and the contralateral pleura. Ideally, one should avoid
entering the contralateral pleural space to avoid unrecognized accumulation of blood
into the dependent hemithorax. This dissection may be completed using both sharp
dissection and gentle blunt dissection with a pledget or a sponge stick. When mobiliz
ing the esophagus and hernia sac away from the pericardium, care must be taken to
avoid excessive pressure on the heart to prevent hypotension or arrhythmia. Gentle
traction on the pericardium with an Allison lung retractor or sponge stick will facilitate
this dissection. Grasping the pericardium risks injury to the underlying heart and may
cause pericardial irritation leading to pericardial effusion or even cardiac tamponade
and should be undertaken with great care. The hernia sac is mobilized circumferentially
down to the diaphragmatic hiatus. This dissection can be quite challenging when
addressing very large paraesophageal hernias.
Once the hernia is completely mobilized, the sac is opened anteriorly (Fig. 12.1).
The hernia “sac” (which is actually the attenuated and greatly expanded transversalis
fascia draped over the herniated intrathoracic abdominal viscera) is divided circumfer
entially at the level of the hiatus from the short gastric vessels posteriorly around to
the pericardium anteriorly and then continuing posteriorly until joining the original
plane of dissection. As stated earlier, care must be taken to avoid injury to the vagus
nerves, particularly during this critical phase of the operation where orientation of the
transposed abdominal viscera and the esophagus can be challenging. Once this dissec
tion of the hernia sac is complete, the margins of the hiatus, the right and left crura,
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. The
hernia sac has been mobilized
circumferentially away from the
mediastinal structures and the dia-
phragmatic hiatus. The sac is incised
anteriorly. This opens the sac into the
peritoneal cavity. The sac is then
incised circumferentially so that the
proximal stomach and gastroesopha-
geal junction are freely mobile. The
sac is then dissected off the stomach
and esophagus.
LWBK1254-ch12_p137-146.indd 139 19/02/14 7:14 AM

Figure 12.2 The gastroesophageal fat

pad is then dissected and removed,
beginning just in front of the right
vagus nerve. The dissection is carried
over to the left, exposing the gastro-
esophageal junction, using the ultra-
sonic device. In completing this, both
vagus nerves are mobilized laterally so
that they lay behind the esophagus.
and the caudate lobe of the liver can be visualized. The cardia of the stomach will have
then been completely mobilized.
The “sac” is then dissected off the stomach. When resecting the sac off the gastro
esophageal junction, care should be taken to identify and preserve both vagus nerves.
After removing the anterior component of the sac, the stomach and esophagus are
retracted anteriorly, and the posterior component of the sac is identified and removed.
This dissection can be quite tedious as the sac is very thickened and vascular. Meticu
lous hemostasis is required to prevent excessive intraoperative blood loss. Once the sac
has been removed, the gastroesophageal fat pad is removed, beginning anterior to the
right vagus and continuing across to the left, mobilizing the left vagus off of the stom
ach to clearly identify the gastroesophageal junction (Fig. 12.2).
At this point, the diaphragmatic hiatus should be clearly exposed circumferentially,
the lower half of the intrathoracic esophagus fully mobilized, and the gastroesophageal
junction clearly identified. To completely mobilize the proximal stomach, the upper
portion of the lesser omentum should be divided. This may contain an artery termed
“Belsey’s artery,” which is a branch from the left gastric artery that anastomoses with
a branch of the inferior phrenic artery. It should be carefully controlled or it may retract
into the abdomen. At this point, the cardia should be freely mobile and easily delivered
into the chest. This should be adequate for a Belsey Mark IV repair. If a Nissen fundop
lication is planned, further mobilization of the fundus may be necessary and can be
accomplished by the division of one or two short gastric arteries.
The next step is to determine the need for an esophageal-lengthening procedure.
The stomach is reduced into the abdomen. The gastroesophageal junction should lie
comfortably in the abdomen with at least 2 cm of intra-abdominal esophagus sitting
below the level of the diaphragmatic hiatus without tension. If the stomach or gastro
esophageal junction tends to pull up into the chest or there is insufficient intra-
abdominal esophageal length, a Collis gastroplasty should be strongly considered to
ensure an adequate intra-abdominal length of esophagus.
LWBK1254-ch12_p137-146.indd 140 19/02/14 7:14 AM

Figure 12.3 If a Collis gastroplasty is

required, a Maloney bougie is
inserted and advanced into the stom-

ach. The gastroesophageal junction
and proximal stomach are delivered
into the chest and the greater curve
of the stomach is grasped with two
atraumatic graspers. Using a linear
stapler, the gastroplasty tube is
created by applying traction on the
greater curve of the stomach, using
the surgeon’s hand to push the
bougie tight against the lesser curve
and applying the stapler tight against
the bougie.
If a Collis gastroplasty is to be performed, a 48- or 52-French Maloney bougie is

inserted so that its tip is well within the stomach. The esophagus, gastroesophageal
junction, and proximal stomach are delivered into the chest. The greater curvature of
the stomach is grasped with two atraumatic graspers and a 60-mm linear stapler with
3.5-mm staples is applied tightly against the bougie so that the bougie is tight against
the lesser curve of the stomach (Fig. 12.3). Upward traction on the Penrose drain will
facilitate the placement of the stapler. An endoscopic or open stapler may be used.
Generally a 5-cm gastroplasty is created. After firing the stapler, the cut edge is over
sewn with a running 3-0 absorbable suture.
If a gastroplasty is not required or once the gastroplasty has been completed, the
crural sutures are placed (Fig. 12. 4). Babcock clamps are used to grasp and elevate each
pillar of the right and the left crus, placing them on slight tension. The stomach and
gastroesophageal junction are retracted to the right using an Allison lung retractor or a
sponge stick. Crural sutures of #1 silk or other heavy nonabsorbable suture are placed
0.5 cm apart beginning posteriorly. The distance between the sutures on the left pillar
is slightly longer than on the right. Crural sutures should incorporate some of the
tendinous portion of the diaphragm anteriorly taking care to avoid the inferior vena
cava on the right. If the hiatus is very large, some sutures may be placed in the anterior
hiatus in front of the esophagus to avoid significant angulation of the esophagus as it
passes through the hiatus, which may contribute to postoperative dysphagia. The crural
sutures are tagged and left untied until the fundoplication has been completed.
Belsey Fundoplication
A Belsey fundoplication is accomplished by placing two tiers of three horizontal mat
tress sutures. If a Collis gastroplasty has been performed, a third tier of three horizontal
mattress sutures is added. These sutures roll the fundus up over the distal esophagus
for a total distance of 3 or 4 cm creating a 270-degree fundoplication. Key steps to this
repair are removing the gastroesophageal fat pad so that the gastroesophageal junction
is clearly identified and mobilization of the vagus nerves at the level of the distal
esophagus and gastroesophageal junction so that they are not incorporated into the
fundoplication.
Using double-armed 2-0 silk with an atraumatic needle, the first suture is placed
quite posteriorly, just anterior to the mobilized right vagus. The suture is placed longi
tudinally in the esophageal muscle for a distance of 0.5 cm approximately 1.5 cm above
the gastroesophageal junction and then passed through the seromuscular layer of the
fundus 1.5 cm distal to the gastroesophageal junction (Figs. 12.4 and 12.5). The second
arm of the suture is placed in similar fashion 0.5 cm away from the first. The second
LWBK1254-ch12_p137-146.indd 141 19/02/14 7:14 AM

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. Then, using a heavy nonabsorbable suture such as #1 silk, the crural
sutures are placed beginning posteriorly. An atraumatic grasper is applied to each crural pillar and gentle
traction applied. The sutures are placed about 0.5 cm apart with slightly wider spacing on the left pillar. The
more anterior sutures should include some of the tendinous diaphragm. The fundoplication is begun by placing
the first tier of horizontal mattress sutures using double-armed 2-0 silk. The first arm of the suture is placed
longitudinally in the esophageal muscle for a distance of 0.5 cm approximately 1.5 cm above the gastro-
esophageal junction. A seromuscular suture is then placed in the stomach 1.5 cm below the gastroesophageal
junction in line with the esophageal suture. The second arm is placed adjacent to the first approximately
0.5 cm medially, placed 1.5 cm above the gastroesophageal junction, and carried longitudinally in the esopha-
geal muscle for a distance of 0.5 cm. A seromuscular suture in the stomach 1.5 cm below the gastroesopha-
geal junction completes the first stitch. The two arms of the suture are tagged. The first suture is placed quite
posteriorly pushing the right vagus posteriorly. The second suture is placed in similar fashion, 135 degrees
from the first. The middle suture should be aligned with the gastroplasty staple line. The third suture is placed
in similar fashion, 135 degrees from the second, pushing the left vagus posteriorly. After placing all three
sutures, they are tied down in sequence.
Figure 12.5 The second tier of sutures is placed in similar fashion, 1.5 cm above the first. If a Collis gastro-
plasty has been performed (as is illustrated), three tiers of horizontal mattress sutures are used. They are
placed in similar fashion 1 to 1.5 cm above and below the new “gastroesophageal junction.” Each tier of
sutures successively rolls the fundus up over the distal esophagus. It is important that the spacing of the
suture on the fundus is similar to the spacing on the esophagus so that the fundus does not bunch up around
the esophagus. When completed, the fundus envelops the distal esophagus for about 270 degrees of its
circumference, with the most lateral sutures lying about 1 cm apart with the vagi lying between them.
LWBK1254-ch12_p137-146.indd 142 19/02/14 7:14 AM

suture is placed in similar fashion at the midline of the esophagus approximately

135 degrees from the first. The third suture is then placed in similar fashion 135 degrees
from the second just anterior to the mobilized left vagus nerve. The left vagus will lie

just adjacent to the right vagus posteriorly. When placing the sutures in the esophagus,
it is important not to transgress the esophageal mucosa. Once all three sutures have
been placed, they are tied down in sequence. It is important when placing the sutures
in the fundus that the sutures are at a similar distance apart as on the esophagus so
that the fundus rolls up comfortably without bunching up.
The second tier of sutures is placed in similar fashion, 1.5 cm above the first,
again taking care not to place the fundic sutures too far apart (Fig. 12.5). Once tied,
the left lateral and right lateral sutures will be about 1 cm apart posteriorly (Fig. 12.5).
If no gastroplasty has been performed, only two tiers of sutures are required. The
needles should be left attached after placing the second tier. The stomach and gastro
esophageal junction with fundoplication is reduced into the abdomen by applying
gentle pressure from above and pulling up the second tier sutures while doing so to
remove the slack on the sutures. Once the fundoplication is reduced into the abdo
men, it is anchored to the diaphragmatic hiatus by passing the needles through the
diaphragm from the abdominal side to the thoracic side (Fig. 12.6). It is important to
protect the underlying abdominal viscera (using a spoon or a similar device) when
passing the anchoring sutures to prevent incorporating these structures into the fun
doplication. The sutures in the diaphragm should line up with the corresponding
suture in the esophagus and should be the same distance apart as those in the esopha
gus. Once all the sutures have been placed, they are tied down snugly in sequence,
ensuring that there is no slack or redundancy in the sutures but that the tissues are
not strangulated.
If a Collis gastroplasty has been performed, three tiers of sutures are placed rather
than two with approximately 1.5 cm between each tier (Figs. 12.4 to 12.6). In this
situation, the third or final tier of sutures is used to anchor the fundoplication to the
diaphragmatic hiatus.
Following completion of the fundoplication, the crural sutures are tied down
sequentially beginning from the most posterior. Upon completion of the crural closure,
the hiatus should allow a fingertip to pass easily between the esophagus and the adja
cent crus with the bougie in place (Fig. 12.7).
Figure 12.6 The needles are left

attached to the final tier of
sutures. The fundoplication and
distal esophagus are delivered
back into the abdomen. The
needles are passed from the
abdominal aspect of the hiatus up
into the chest using a spoon to
protect the abdominal viscera.
The right suture should line up
with the apex of the hiatus and
the left should lie just anterior to
the most anterior crural suture.
Applying traction to these sutures
and eliminating all slack, the
sutures are tied down in
sequence, completing the fundo
plication and anchoring it to the
undersurface of the diaphragm.
The lateral two sutures lie 135
degrees from the middle suture
and are 1 cm apart posteriorly.
LWBK1254-ch12_p137-146.indd 143 19/02/14 7:14 AM

Figure 12.7 Once the fundoplication is

complete, the crural sutures are tied
in sequence beginning with the most
posterior suture. Once the sutures are
tied, the hiatus should comfortably
admit a fingertip with the Maloney
bougie in place.
Upon completion of the repair, clips are applied at the upper and the lower end
of the gastroplasty (if used) or at the top of the fundoplication, and two clips are
placed on the apex of the hiatus. These serve as markers for follow-up on subsequent
chest x-rays allowing the surgeon to easily determine if there has been an anatomic
recurrence. An intercostal drain is placed through a separate stab wound and posi
tioned in the paravertebral gutter, and the chest is closed. Prior to closure, it is
important to ensure complete reinflation of the left lung and to evaluate the integrity
of the contralateral pleura and if not intact, to evacuate the contralateral pleural
space.
Perioperative prophylactic antibiotics (usually cefazolin) are given with one dose preop
eratively and one dose postoperatively. Good postoperative pain control, using intrave
nous narcotics administered using patient-controlled analgesia or a thoracic epidural
with continuous infusion of narcotics and local anesthetic supplemented by intermittent
boluses controlled by the patient, is essential to prevent inadequate cough and complica
tions such as pneumonia. Nonsteroidal anti-inflammatory drugs are also useful.
A nasogastric tube may be used for the first 12 to 24 hours or longer if there is
evidence of gastric stasis or distension. Barium swallow may be performed on the first
postoperative day (or later) to rule out leak and confirm the position of the repair. The
chest tube and nasogastric tube (if used) remain in situ until the absence of a leak has
been confirmed by a contrast study.
Complications
Complications in the early postoperative period include atelectasis (5%) and pneumonia
(2%).6,7 These are prevented through adequate pain control and chest physiotherapy.
The other potential complications that may occur in the early postoperative phase
include leak of gastrointestinal contents from either an injury to the stomach or the
esophagus in the course of mobilization of the hernia and sac or from a Collis gastroplasty.
The risk of these complications is 0% to 4%.6,7 Very large paraesophageal hernias tend
LWBK1254-ch12_p137-146.indd 144 19/02/14 7:14 AM

to have quite mature adhesions to both pleurae, and mobilization can be difficult and

tedious. The adhesions can be quite vascular as can the hernia sac itself. Meticulous
hemostasis is required during the dissection to prevent postoperative hemorrhage

(<1%).7 There is a small risk of injury to the spleen or short gastric vessels that is pre
vented by avoiding excessive traction on the stomach.
Vagal nerve injury may occur most commonly on the left. With very large paraesopha
geal hernia, the vagus nerves become attenuated and displaced from the esophagus and
may be difficult to identify particularly on the left. The risk of vagal nerve injury is
higher in reoperative surgery. The consequence of vagal nerve injury may be unnotice
able or may result in delayed gastric emptying or diarrhea. Even in the absence of vagal
nerve injury, delayed gastric emptying may occur as a consequence of prolonged incar
ceration of the stomach in the chest. For this reason, prolonged nasogastric drainage
may be required in some patients.
Failure of the crural sutures may occur in the immediate postoperative period with
acute herniation of the stomach into the chest requiring urgent reoperation. This may
occur when the patient wakes abruptly from anesthesia or has severe retching. This has
not been reported in the literature after a transthoracic Belsey approach but has been
reported in 1.6% of transthoracic Nissen repairs.7 Crural sutures may fail over time
leading to late herniation in up to 8%.6,7 Re-repair is indicated if the patient is symp
tomatic, but small recurrent hernias are rarely symptomatic. Symptoms associated with
recurrence are rarely those of the original presentation and are most commonly related
to acid reflux. Symptoms of acid reflux are generally managed medically, but re-repair
may be considered.
Obstructive symptoms or postprandial pain may result from inadequate mobiliza
tion of the fundus and cardia, failure to correct gastric volvulus, recurrent hernia, or
incarceration of the fundoplication in the hiatus. Early dysphagia occurs in 10% of
patients and acute gastric dilation in 2% to 5%.6,7
Results
The operative mortality for transthoracic repair is 0% to 5.5%.6–8 In laparoscopic
repairs, operative morbidity and mortality increases beyond 80 years of age.9 Although
this question has not been specifically addressed for transthoracic repair, it is reason
able to assume the same would be true for open transthoracic repairs. Postoperative
complications occur in 19% to 26% of patients although most are not life-threatening.6,7
The major drawback of this approach relates to postoperative pain from the thora
cotomy. The hospital length of stay reported in the literature is approximately
10 days but may be shorter in the modern era. Anatomic recurrence rate, determined
when routine barium swallow is performed in follow-up, is 8%.8 The rate of symp
tomatic recurrence is lower at 1% to 3%.6 The transthoracic repair is durable with
low rates of anatomic recurrence and with 18-year follow-up of the Belsey Mark IV
procedure, good control of reflux in 84% of patients and the ability to belch and
swallow comfortably.6
Conclusions
Transthoracic repair of paraesophageal hernia provides a durable repair with excellent
functional results. The transthoracic approach facilitates adequate mobilization of the
esophagus, dissection and removal of the hernia sac, meticulous hemostasis, and accu
rate assessment of esophageal length. It is very useful for reoperations, obese patients,
and complex hernias. This repair has stood the test of time but is performed less fre
quently as laparoscopic repairs are being performed more often with satisfactory and
durable results reported.10,11
LWBK1254-ch12_p137-146.indd 145 19/02/14 7:14 AM

Recommended References and Readings 7. Patel HJ, Tan BB, Yee J, et al. A 25-year experience with open
primary transthoracic repair of paraesophageal hiatal hernia.
1. Allen MS, Trastek VF, Deschamps C, et al. Intrathoracic stomach. J Thorac Cardiovasc Surg. 2004;127:843–849.
Presentation and results of operation. J Thorac Cardiovasc Surg. 8. Rathore MA, Bhatti MI, Andrabi SI, et al. Laparoscopic repair of
1993;105:253–259. paraesophageal hernia requires cautious enthusiasm. Int J Surg.
2. Stylopoulos N, Gazelle GS, Rattner DW. Paraesophageal hernias: 2008;6:404–408.
Operation or observation? Ann Surg. 2002;236(4):492–500. 9. Larusson HJ, Zingg U, Hahnloser D, et al. Predictive factors
3. Sihvo EI, Salo JA, Rasanen JV, et al. Fatal complications of adult for morbidity and mortality in patients undergoing laparo
paraesophageal hernia: A population-based study. J Thorac Car- scopic paraesophageal hernia repair: Age, ASA score and
diovasc Surg. 2009;137(2):419–424. operation type influence morbidity. World J Surg. 2009;33:980–
4. Urbach DR, Khajanchee YS, Glasgow RE, et al. Preoperative 985.
determinants of an esophageal lengthening procedure in laparo 10. Rathore MA, Andrabi SI, Bhatti MI, et al. Metaanalysis of recur
scopic antireflux surgery. Surg Endosc. 2001;15:1408–1412. rence after laparoscopic repair of paraesophageal hernia. JSLS.
5. Gastal OL, Hagen JA, Peters JH, et al. Short esophagus: Analysis 2007;11(4):456–460.
of predictors and clinical implications. Arch Surg. 1999;134(6): 11. Luketich JD, Nason KS, Christie NA, et al. Outcomes after a
633–636. decade of laparoscopic giant paraesophageal hernia repair.
6. Maziak DE, Todd TR, Pearson FG. Massive hiatus hernia: Evalu J Thorac Cardiovasc Surg. 2010;139:395–404.
ation and surgical management. J Thorac Cardiovasc Surg. 1998;
115:53–62.
LWBK1254-ch12_p137-146.indd 146 19/02/14 7:14 AM

13 Open Paraesophageal
Hernia and Hill Repair:
Open Abdominal Approach
Philip W. Carrott, Jr. and Donald E. Low
Paraesophageal hiatal hernias (PEH) are a rare surgical problem that afflicts older
adults, more commonly women. The relatively occult location of the hernia, a historic
impression of minimal or vague symptoms, and an incomplete understanding by most
physicians of the differing presentation and significance of PEH and sliding hiatus
hernias often leads to a delay in diagnosis. Patients often present with a long history
of symptomatic “hiatal hernia” and radiographic findings similar to the chest x-ray
shown in Figure 13.1. This patient has >50% of her stomach intrathoracic and thus
has a “giant” paraesophageal hernia, most likely type III. This picture of a large air
space in the lower mediastinum with an air–fluid level will typically be a PEH, but
will be labeled as a “hiatal hernia” by many physicians and radiologists. The symp-
toms in these patients can be subtle and the symptoms experienced by these patients
are quite different from those found in patients with standard GERD or a type I or
sliding hernia. Type I hernias are the “sliding” type, often producing symptoms of
reflux or regurgitation, with only the gastroesophageal junction (GEJ) herniating into
the chest. Type II hernias have the fundus of the stomach, but not the GEJ, herniating
into the chest; these are relatively uncommon. The most common PEH is type III,
which is where both the GEJ and the fundus or body of the stomach is herniated. The
larger type IV hernia encompasses both the stomach and other intra-abdominal viscera
such as the colon, small bowel, pancreas or spleen.
The PEH patient will typically describe symptoms that slowly evolved over years.
Early satiety, anemia, chest pain, and dyspnea are typical in a patient with a large
intrathoracic stomach. When the entire array of symptoms associated with PEH is
understood, we believe that patients are rarely asymptomatic at diagnosis. In addition,
following repair, the vast majority of patients demonstrate measurable improvements in
symptoms and quality of life. Reviews from experienced centers have shown that results
of repair have improved, with reports of good or excellent subjective outcomes in 83%
to 98% of patients.1
147
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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).
Initial case series suggested that a significant proportion of patients with PEH pre-
sented as a surgical emergency with incarceration and/or ischemia of the stomach.2
Older series showed rates of incarceration and strangulation of 30%, with a mortality
of 7%. Modern series and population analyses show that urgent or emergent presenta-
tions account for 5% to 15% of operative cases and up to 50% of admissions for PEH,
although surgical management is required at the time of acute presentation only a third
of the time.3 In cases of urgent presentation with incarceration and obstruction or ongo-
ing pain, decompression with endoscopy and subsequent nasogastric (NG) tube place-
ment (which may need to be placed with endoscopic guidance) typically relieves acute
symptoms and allows for more thorough preoperative preparation. In a review of
5 years of data from New York state, Polomsky et al. found that as more operations were
being done, the number of emergent presentations decreased.3–6 However, a population-
based study of a cohort of octogenarians showed that 43% of these patients had urgent
surgery, with a mortality of 15% in the urgent group.7
Dyspnea may be related to the hernia as a space-occupying lesion in the chest or
an effect on the diaphragmatic function, although effects of the hernia on respiratory
function are likely more complex. We have previously demonstrated a measurable
improvement in pulmonary function tests (PFTs) for most patients following repair;
thus, borderline PFTs should not disqualify a patient from consideration of elective
repair.8 We currently advocate that fit, symptomatic patients presenting with giant PEH
should meet with a surgeon to discuss elective repair to improve current quality of life
and avoid additional symptoms as these hernias continue to grow. The only contrain-
dications to repair would be medically unfit patients.
Paraesophageal Hernia Repair Indications

n Increasing symptoms or signs associated with giant PEH, which include heartburn,
regurgitation, dysphagia, early satiety, dyspnea, upper gastrointestinal (UGI) blood loss
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Chapter 13 Open Paraesophageal Hernia and Hill Repair: Open Abdominal Approach 149
anemia, chest and abdominal pain following meals, as well as eating or lifestyle mod-

ification as a result of ongoing early satiety or regurgitation.
n Semi-elective repair in patients presenting with acute nonischemic incarceration

treated with NG tube or endoscopic decompression.
n Urgent repair in the setting of unremitting chest or abdominal pain, UGI obstruction,
active gastrointestinal bleeding from Cameron lesions/ulcer disease or evidence of
ischemia on upper endoscopy.
Patients presenting with PEH should undergo a barium swallow to confirm the ana-
tomic conformation of the hernia, with an assessment of the esophageal and gastric
emptying as well as the degree of esophageal shortening. When possible, being
present for the barium swallow gives the surgeon the best information regarding
esophagogastric anatomy and motility of the esophagus and whether the hernia is
fixed or mobile. If this is not feasible, a video recording of the swallow is a good
alternative. Upper endoscopy is utilized to assess the degree of esophageal shorten-
ing, document esophagitis or Barrett’s esophagus, and assess the grade of the flap
valve, as well as evaluate for Cameron lesions or erosions in the stomach at the dia-
phragmatic hiatus (see Fig. 13.2). We recommend esophageal manometry routinely
to evaluate the lower esophageal sphincter (LES) pressure and assess esophageal
motility pattern. Inserting the current high-resolution catheters is often difficult in
large PEHs; therefore, we routinely combine manometry with upper endoscopy and
insert the catheter over a wire. Nonspecific motility disorders are common in older
patients with PEH, although motility pattern will often improve following repair.9 The
approach to repair may have to be modified in patients with esophageal dysmotility
(poor peristaltic progression) or hypomotility (mean wave amplitude <30 mm Hg).
We do not routinely perform gastric emptying or 24-hour pH-impedance studies in
this population. We do, however, routinely have patients perform PFTs before and
after surgery, as many will have measurable improvements following repair.
A B
Figure 13.2 UGI and EGD Passage: A: EGD view of the hiatal narrowing from above. B: UGI showing a near 100% intrathoracic stomach.
LWBK1254-ch13_p147-160.indd 149 19/02/14 5:08 PM

Preoperative Assessment
n Barium swallow
n Upper endoscopy, with or without wire-guided manometry
n Esophageal manometry
n PFTs, medical or cardiac clearance as necessary
Surgery
The open Hill repair is performed via a limited upper abdominal midline incision. We
currently utilize the laparoscopic approach in virtually all patients with type II hernia
and many patients with type III and type IV hernias whose GEJ is seen to be mobile on
UGI fluoroscopy study. The open Hill repair is our preferred approach in patients with
large type III and type IV hernias involving 75% to 100% of the stomach and significant
esophageal shortening, which either does not reduce or only minimally reduces during
witnessed preoperative barium studies. The advantages of this approach include the
fact that a primary closure of the diaphragm is virtually always possible. The Hill repair
is based on anchoring of the GEJ to reliable intra-abdominal structures posteriorly and
therefore avoids the need to utilize the Collis gastroplasty, thereby maintaining normal
anatomy. Originally, Dr. Hill used the median arcuate ligament to anchor the repair. Most
surgeons find the dissection of the celiac axis daunting which is one of the reasons that
the Hill repair is not more commonly utilized.10 We advocate utilizing the base of the
crura and the pre-aortic fascia for anchoring the repair. The Hill operation has distinct advan-
tages over other methods, as it firmly anchors the GEJ in the abdomen, re-establishing
the normal length of intra-abdominal esophagus.
Once the hernia sac is completely reduced and excised, the esophagus can undergo
extensive transhiatal mobilization, often up to the carina, to allow the GEJ to be reduced
into the abdominal cavity with little or no tension. The esophagus becomes foreshort-
ened and dysfunctional when elevated as in a type III or type IV PEH, and once it is
secured to its standard length, its normal contraction pattern is often restored.1 Esopha-
geal shortening is more prevalent when the patient has a history of esophagitis, esopha-
geal stricture, or Barrett’s esophagus. One of the biggest controversies in PEH repair is
that of recurrence. The diaphragmatic hiatus must be closed securely, but not to a point
that results in postoperative dysphagia. Many have supported the use of various syn-
thetic or biologic meshes to augment the hiatal closure. We have found that with appro-
priate mobilization of the right and left crura, closure can almost invariably be done
primarily. Secure fixation, as performed in the Hill repair, produces a low recurrence
rate that is similar to a Collis–Nissen fundoplication.11
Historically, the three options for dealing with clinically significant esophageal shorten-
ing were a thoracic approach with extensive esophageal mobilization, an esophageal-
lengthening procedure (such as the Collis gastroplasty), or the Hill repair.
Keys to the Operation

–n Adequate esophageal mobilization and mediastinal dissection, to establish 3 to 4 cm
of intra-abdominal esophagus should be the goal.
n Excision of the hernia sac
n Firmly anchoring repair sutures to reliable intra-abdominal structures to avoid recur-
rence
n Accentuating the angle of His and recreating the gastroesophageal flap valve to pro-
duce a viable antireflux mechanism.
Positioning
The patient is placed supine with the right arm tucked and left arm out at 90 degrees. We
use the “upper hand” retractor system (V. Mueller, Allegiance, Deerfield, IL) as well as a
stationary liver retractor to retract the left lobe of the liver. The “upper hand” retractor
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Figure 13.3

– Martin’s Arm and upper hand
retractors in place. Current incision

limited to half the distance from
xiphoid to umbilicus.
– Retractor setup for exposing the
abdominal esophagus. The upper
hand retractor verticalizes the
diaphragm.
– Following mobilization of left lobe of
liver, it is retracted with a Harrington
retractor held in place with a Martin’s
Arm retractor (See Figure 13.4).
blades are placed under the right and left costal margins, retracting each superiorly
and laterally. This works to verticalize the diaphragm and allow for good exposure of
the esophageal hiatus. A Balfour retractor is used for the lower portion of the incision
(see Figure 13.3).
Technique
The Hill operation is predicated on using the natural attachments of the esophagogastric
junction, specifically, the phrenoesophageal membranes to anchor the repair firmly in
the abdominal cavity to the condensation of the crura and the preaortic fascia, thereby
accentuating the angle of His and recreating a functional gastroesophageal flap valve.
n The operation is done through a limited upper midline incision between the tip of
the xiphisternum and 4 to 5 cm above the umbilicus. The xiphisternum is often excised
and an upper hand retraction device is used to elevate the costal margin and vertical-
ize the diaphragm to allow unobstructed access to the esophagogastric junction.
n Exposure is further improved by mobilizing the left lobe of the liver by taking down
the triangular ligament. The liver is then retracted to the patient’s right with a deep
Harrington retractor held in place with an upper arm or a retracting device (Figs.
13.3 and 13.4).
Figure 13.4 The hernia sac is freed

from mediastinal attachments and
reduced into the abdomen.
Harrington Retractor
Hernia Sac
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Right Crus
Hernia Sac
Left Crus
Hernia Sac
A B
Figure 13.5 Dissection of the right (A) and left (B) crura. Mobilization of mediastinal hernia sac starting inside right crus (edge of
sac held in right angle clamp) (A). (B) shows mobilized hernia sac which has been reduced into the abdominal cavity.
n The intrathoracic stomach is reduced into the abdominal cavity as much as possible.
The dissection begins along the medial border of the right crus taking down the
peritoneal reflection. There are often two sacs associated with paraesophageal her-
nias. The one along the right crus is typically smaller, although in rare circumstances,
it can go for an extensive distance into the mediastinum and right chest. Dissection
is continued outside of the sac, but inside the right crus. There are typically exten-
sive attachments to the right pleura, which can be easily separated from the hernial
sac, and then the dissection is continued up over the anterior aspect of the hiatus
where the raphe between the right and left sacs is regularly encountered (Fig. 13.5).
n Dissection is continued around the anterior edge of the hiatus and down onto the
left crus, once again separating the peritoneal reflection. The peritoneum in this area
can often be profoundly thickened due to the chronic nature of the hernia, and then
once again working outside of the sac, dissection is continued up into the mediasti-
num. The pleura is inevitably attached to the outside of the sac and once again needs
to be separated. Most of this dissection can be done without sharp or cautery dissec-
tion. Mobilization of the peritoneal reflection is then continued down onto the mid-
portion of the left crus. At this point, there is usually easy access to the mediastinum
and the esophagus can be encircled first manually and then encircled with a Penrose
drain (Fig. 13.4). In many cases, the posterior vagus nerve will be geographically sep-
arate from the posterior aspect of the esophagus and should be included in this dis-
section to avoid injuring it with the additional posterior dissection.
n With the esophagus encircled, it can be retracted inferiorly and the remainder of the
peritoneal reflection on the inferior aspect of the left crus is easily taken behind the
esophagus (Fig. 13.6). It should be noted that every effort should be made to preserve
the peritoneal coverings of both the right and left crura. The outside aspect of the left
crus is then mobilized to make this structure as mobile as possible. In older patients,
the left crus will often be seen to be smaller and, therefore, complete mobilization is
important. One of the advantages of the Hill procedure is the fact that the short gas-
trics do not need to be mobilized to carry out the operation.
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Figure 13.6 The posterior vagus nerve

(highlighted by the forcep) with the
dissected right and left crura immedi-

ately posterior.
Esophagus
Right crus
Left crus
n Working up through the esophageal hiatus, the esophagus should be circumferentially

mobilized. Taking note of the pathway and location of the anterior and posterior vagus
nerves, this dissection can be easily done for 10 or 12 cm and, depending on the body
habitus of the patient, often up to the subcarinal space to facilitate as tension free a reduc-
tion of the GEJ into the abdominal cavity as possible.
n With the esophagogastric junction completely reduced, the preaortic fascia can be
palpated as a rim over the surface of the aorta through the inferior aspect of the
hiatus. In many older patients, this tissue will either be attenuated or absent and, in
this case, the base of the left and right crura should be grasped with a large Babcock
clamp, and then the condensation of the crus is lifted away from the underlying aorta
and two 0-silk sutures with pledgets are placed above and below the Babcock clamp
and tied to initiate closure of the hiatus and also to act as retraction sutures to anchor
the repair (Fig. 13.7).
Esophagus
Esophagus
Right Crus
Left Crus
A B
Figure 13.7 A: The condensation of the crura are approximated with a Babcock clamp. There is a sponge in the hiatus and the
esophagus is retracted to the left. B: First crural sutures (held within the clamp) are left long to use as a retractor to elevate the
crura away from the aorta when the repair sutures are placed.
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Anterior Figure 13.8 The posterior phrenoesopha-

vagus nerve geal bundle or fat pad is just posterior to
Posterior the posterior vagus. It is grasped with a
vagus nerve Anterior Babcock clamp (not shown in this image),
phrenoesophageal placing the anterior clamp just posterior to
bundle the anterior vagus at the angle of His
Posterior (grasped within the Babcock clamp). The
phrenoesophageal initial repair suture has been placed
bundle through the anterior bundle.
n The hiatus is then closed with interrupted simple 0-silk sutures with pledgets placed
posterior to the esophagus. These are placed approximately 1 cm apart and, often
due to the size of these hernias, the hiatus can be selectively further plicated with 0
silk sutures placed at 10- and 2-o’clock positions to close the hiatus and minimize
the anterior deviation of the esophagogastric (EG) junction.
n The hernia sac is then trimmed away from the esophagogastric junction, carefully
identifying the anterior vagus nerve, which can often run across the anterior aspect
of the sac.
n The posterior phrenoesophageal bundle is identified and grasped by palpating the
posterior vagus nerve with the left hand placed behind the EG junction and using
the right hand to rotate the fundus, utilizing the posterior vagus as a fulcrum, and
identify the phrenoesophageal bundle and underlying serosa immediately posterior
to the posterior nerve (Fig. 13.8).
n The anterior phrenoesophageal bundle is identified at the base of the angle of His
anteriorly; depending on the patient’s body habitus, it can have a generous amount
of fatty tissue associated with it and it is important to grab the tissue right at the
base of the angle of His and include some underlying serosa of the fundus. Once
this tissue is grasped, it can be rotated down to the base of the crural approximation to
get an impression of the ultimate alignment of the repair (Fig. 13.8).
n The repair is carried out with four 0 silk sutures that are placed lateral to medial on
the anterior bundle, superior to inferior on the posterior bundle and through the
condensation of the crus (Fig. 13.9). Each suture is placed through the anterior
Figure 13.9 The anchoring sutures

are placed through the crural repair.
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Figure 13.10 The anchoring sutures in

place; the anterior Babcock clamp
has been removed.

bundle to the posterior bundle and then through the condensation of the crural fibers,
lifting them away from the underlying aorta with the retraction sutures (Figs. 13.10
and 13.11).
n Once these sutures are placed, the first two sutures are tied down to the condensation
of the crus with a single throw and clamped (Fig. 13.12). This provides the opportunity
to measure intraoperative manometric pressures. The targeted goal in an open
Posterior fundus
of stomach
A B
Figure 13.11 A, B: All sutures are placed from the anterior to the posterior paraesophageal bundle and then through the crural repair.
LWBK1254-ch13_p147-160.indd 155 19/02/14 5:08 PM

Figure 13.12 The first two repair

sutures are tied with a single knot
and held in place with clamps. This
allows adjustment depending on
manometric findings.
procedure is between 25 and 55 mm Hg, and if pressures exceed this level, the sutures
can be loosened and pressure measurements repeated (Fig. 13.13).
n Once suitable pressures are obtained, all four sutures are permanently tied and a final
manometric reading is obtained and recorded.
n The flap valve is then accentuated with two 0 silk sutures placed anteriorly and
laterally from the fundus to the esophageal muscularis and the rim of the esopha-
geal hiatus. This closes off the anterior hiatus and accentuates the valve (Fig.
13.14).
n The manometric catheter is removed and replaced with an NG tube and at this
point, palpation through the anterior stomach will reveal a well-formed and
functional flap-valve apparatus. In very large hernias, where recurrence or post-
operative nausea and vomiting are a concern, the selective placement of a gastros-
tomy tube can be considered to anchor the anterior body of the stomach and allow
gastric decompression should nausea occur in the 3 to 4 weeks following surgery.
Addition of a pexy to the diaphragm can also aid in preventing a recurrence (Fig.
13.15).
n Retractors are removed and closure is done in the standard fashion. Blood loss
should be <50 ml under normal circumstances. These operations are done with an
epidural catheter and the patient is typically mobilized on the day of surgery and
the NG tube is removed the following day.
Figure 13.13 With the first two repair sutures

clamped, manometric pressures are obtained
to ensure the repair is not too tight. Pres-
sures should be between 25 and 55 for
patients with normal esophageal function.
LWBK1254-ch13_p147-160.indd 156 19/02/14 5:08 PM


See-through illustration
of recreated flap valve
A B
Figure 13.14 A, B: The completed repair.
Postoperative management is similar to that for any other antireflux surgery. We give
antiemetic agents before the patient emerges from anesthesia, in most cases droperidol,
dexamethasone, and ondansetron. We do leave an NG tube overnight in most patients
following an open repair and aggressively treat nausea to minimize retching. Mobiliza-
tion, ideally, is started the day of surgery and continued throughout the hospital stay.
The NG tube is typically removed the next day and diet is advanced to clear liquids
Figure 13.15 Pexying the stomach to the

diaphragm at the hiatus.
LWBK1254-ch13_p147-160.indd 157 19/02/14 5:08 PM

on the second postoperative day. Patients are typically discharged on postoperative

day 3 or 4 on a pureed diet. We maintain patients on pureed and selective soft food
for about 2 weeks postoperatively, beginning on postoperative day 2 or 3. Following
this, a modified soft diet is used for another 2 weeks, limiting the amount of bread and
meat.
Complications
The most commonly encountered complications in the older population include atrial
fibrillation, delirium, wound complications, and incisional hernias.12 We have utilized
permanent suture to reinforce the inferior portion of the wound to minimize the inci-
dence of incisional hernia. The vast majority of complications in the immediate post-
operative period, however, are minor. Early dysphagia to solid food can occur, but is
typically not an issue when the patient adheres to the postoperative dietary protocol.
Results
Patients are typically extremely satisfied following repair. In our series, over the last 10
years, we have no operative mortalities and no recurrences requiring reoperation in 270
consecutive patients.1 Over 90% of those complaining of heartburn or regurgitation
were improved following repair. A substantial majority were also improved with regard
to their preoperative early satiety and dyspnea. We routinely obtain 3-month postopera-
tive barium swallows and PFTs. Repeat endoscopy is done in patients who have persist-
ent dysphagia or a history of Barrett’s esophagus. In our published series, a recurrence
was seen in 25 of 170 postoperative barium studies. Of these, 23/25 were described as
“small sliding hernias” or between 1 and 3 cm. These results are similar to the largest
laparoscopic series by Luketich et al., which demonstrated a 15% radiographic recur-
rence, although Collis procedures were used 53% to 86% of the time and crural mesh
reinforcement 12% to 17% of the time.11 The vast majority of radiographic recurrences
are small and rarely clinically significant.
Conclusions
The incidence of giant paraesophageal hernias is increasing in the United States.3 The
open Hill repair has specific benefits in this patient population in that the operation
involves firmly anchoring the repair in the abdominal cavity, which makes it unique
compared with other antireflux procedures. This firm anchoring, combined with an
extensive transabdominal mobilization, produces a reliable, functional repair without
the need for a thoracic approach or a Collis procedure. It can be done safely with a low
recurrence rate and significantly impacts patients’ preoperative symptoms.
n The symptomatic impact of PEH is underappreciated and typical and atypical symp-
toms routinely improve following repair.
n Symptomatic patients who are surgical candidates should meet with an experienced
surgeon to review the pros and cons of elective repair.
n Thorough preoperative workup should include UGI, EGD, and manometry. Nonspe-
cific esophageal motility diseases typically improve following repair.
n The Hill repair provides an excellent transabdominal alternative, especially in
patients with giant hernias and a potential for esophageal shortening.
n The Hill repair can be typically accomplished without the need for esophageal-
lengthening procedures (Collis) or mesh reinforcement of the hiatal closure.
n The Hill repair can be done safely with very low morbidity and mortality and a low
incidence of recurrence.
LWBK1254-ch13_p147-160.indd 158 19/02/14 5:08 PM

Recommended References and Readings 7. Poulose BK, Gosen C, Marks JM, et al. Inpatient mortality anal-

ysis of paraesophageal hernia repair in octogenarians. J Gas-
1. Low DE, Unger T. Open repair of paraesophageal hernia: Reas- trointest Surg. 2008;12:1888–1892.

sessment of subjective and objective outcomes. Ann Thorac 8. Low DE, Simchuk EJ. Effect of paraesophageal hernia repair on
Surg. 2005;80:287–294. pulmonary function. Ann Thorac Surg. 2002;74:333–337.
2. Hill LD. Incarcerated paraesophageal hernia. A surgical emer- 9. Hill LD. Progress in the surgical management of hiatal hernia.
gency. Am J Surg. 1973;126:286–291. World J Surg. 1977;1:425–436.
3. Polomsky M, Hu R, Sepesi B, et al. A population-based analysis 10. Hill LD. An effective operation for hiatal hernia: An eight year
of emergent vs. elective hospital admissions for an intrathoracic appraisal. Ann Surg. 1967;166:681–692.
stomach. Surg Endosc. 2010;24:1250–1255. 11. Luketich JD, Nason KS, Christie NA, et al. Outcomes after
4. Polomsky M, Jones CE, Sepesi B, et al. Should elective repair of a decade of laparoscopic giant paraesophageal hernia repair.
intrathoracic stomach be encouraged? J Gastrointest Surg. J Thorac Cardiovasc Surg. 2010;139:395–404.
2010;14:203–210. 12. Landreneau RJ, Del PM, Santos R. Management of paraesopha-
5. Schieman C, Grondin SC. Paraesophageal hernia: Clinical pres- geal hernias. Surg Clin North Am. 2005;85:411–432.
entation, evaluation, and management controversies. Thorac
Surg Clin. 2009;19:473–484.
6. Sihvo EI, Salo JA, Rasanen JV, et al. Fatal complications of adult
paraesophageal hernia: A population-based study. J Thorac
Cardiovasc Surg. 2009;137:419–424.
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LWBK1254-ch13_p147-160.indd 160 19/02/14 5:08 PM
Part II
Surgical Treatment of
Esophageal Motility
Disorders—Achalasia
and Esophageal
Diverticula
14 Laparoscopic Heller
Myotomy and Fundoplication
for Achalasia
Rachit D. Shah, Toshitaka Hoppo, and Blair A. Jobe
Achalasia is the most common esophageal motor disorder with an incidence of 0.03 to
1 case per 1,00,000 people per year. The underlying motor dysfunction includes aperi-
stalsis of the esophageal body and a failure of the lower esophageal sphincter (LES) to
relax. Approximately 50% of patients with achalasia have increased resting pressure of
the LES. Dysphagia is the most common symptom of achalasia, and its onset is usually
insidious. Most patients complain of dysphagia to both solids and liquids with the
progression of disease. Other symptoms include regurgitation of undigested food, aspi-
ration, and chest pain.
Histologic analysis using tissue specimens from autopsy and surgical myotomy in
patients with achalasia have demonstrated that the primary region of damage is the
esophageal myenteric (Auerbach’s) plexus, which exhibits loss of the inhibitory inner-
vation of the esophageal body and LES. Histologic characteristics of the myenteric
plexus include a prominent but patchy inflammatory response consisting of predomi-
nantly CD3- and CD8-positive cytotoxic T lymphocytes, variable numbers of eosinophils
and mast cells, loss of ganglion cells, and some degree of myenteric neurofibrosis. In
the early stage of the disease, an inflammatory reaction is more prominent and the
ganglion cells appear to be preserved; however, with the progression of disease, the
ganglion cells are completely lost and replaced by myenteric fibrosis. Although previ-
ous studies have suggested a familial predisposition to the development of the disease,
degenerative, autoimmune, and infectious factors are also listed as possible causes of
the inflammatory process that leads to the expression of the disease.
Because none of the available treatments can correct the underlying disease in patients
with achalasia, the foundation of therapy is palliative and centers on relieving esopha-
geal outlet obstruction while minimizing postmyotomy gastroesophageal reflux. Pneu-
matic dilation and surgical myotomy are the procedures most commonly performed for
achalasia. In current practice, pharmacologic therapies, such as botulinum toxin and
161
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162 Part II Surgical Treatment of Esophageal Motility Disorders—Achalasia and Esophageal Diverticula
smooth muscle relaxants, while minimizing the side effects of surgery, are reserved for
patients who are unable or unwilling to undergo surgical treatment or pneumatic dila-
tion. A recent meta-analysis suggested that surgical myotomy is superior to pneumatic
dilation in achieving long-term therapeutic success, although the included studies were
inadequately powered and exhibited a large degree of heterogeneity in study design and
likely in surgical techniques. The most recent European multicenter, randomized con-
trolled study to compare pneumatic dilation with laparoscopic myotomy demonstrated
that the short-term therapeutic success rate (up to 2 years) was equivalent between the
groups. In this study, the dilation was initially performed using a 35-mm balloon and
esophageal perforation occurred in 30% of patients. Subsequently, the protocol was
modified and the primary dilation was performed using a 30-mm balloon. The esopha-
geal perforation rate in the dilation group was 4% compared with 12% in the myotomy
group. Due to recurrent symptoms, 24% of the dilation group required additional dila-
tions or surgical myotomy, whereas only 14% of the myotomy group required dilation.
Up to 20% of the myotomy group had evidence of postmyotomy gastroesophageal
reflux. These findings suggest that the treatment algorithm for achalasia requires further
modification and individualization in order to improve the outcomes, regardless of
which procedure is employed. Although pneumatic dilation is the most effective non-
surgical option to treat achalasia, it is a process requiring several interventions that
result in submucosal microhemorrhage and fibrosis, and in our most recent review, we
noted an increased risk of mucosal perforation during surgical myotomy. In addition,
younger patients (<40 years) tend to require more dilations for recurrent symptoms, thus
we prefer to manage younger patients preferentially with surgical myotomy.
The Heller myotomy was first described as two parallel myotomies in 1913 and was
subsequently revised to a single anterior myotomy in 1923. With the advancement of
minimally invasive surgical techniques over the last two decades, laparoscopic myotomy
has become the first-line treatment option at most centers in the United States. Prior inter-
ventions (such as dilation or botulinum toxin injections), the presence of a sigmoid
esophagus, long duration of symptoms, and a low resting LES pressure may be associated
with an increased risk of failure with laparoscopic myotomy. In addition, preexisting daily
chest pain is a predictor of therapeutic failure and likely indicates vigorous achalasia with
simultaneous esophageal contractions as a cause contributing to the symptom complex.
Since Richards et al. demonstrated a significant benefit with the addition of a partial
fundoplication to reduce postmyotomy gastroesophageal reflux symptoms, the majority
of surgeons have incorporated a Dor or a Toupet partial fundoplication as an integral
component of the procedure. In this chapter, the technique of the laparoscopic Heller
myotomy combined with laparoscopic partial fundoplication (Dor or Toupet) is described.
Sigmoid Esophagus
Sigmoid esophagus is a dramatically dilated and tortuous thoracic esophagus that
reflects long-standing achalasia and chronic obstruction. Although somewhat controver-
sial, several authors have demonstrated good outcomes in patients with achalasia and
a sigmoid esophagus who had undergone myotomy and a partial fundoplication. Others
recommend esophagectomy for these patients.
Diagnosis and Preoperative Planning

Achalasia should be suspected for any patient with dysphagia and regurgitation of undi-
gested food and saliva. The diagnosis is based on clinical symptoms, barium esopha-
gram, and esophageal manometry. During the workup, it is crucial to exclude any organic
lesions, such as esophageal cancer, that may cause pseudoachalasia. Patients with pseu-
doachalasia may be older and have a quickly progressing dysphagia and remarkable
weight loss. If pseudoachalasia is still suspected after a meticulous workup, endoscopic
ultrasound and/or CT scan should be performed to rule out external compression or an
intramural neoplastic process. It should be noted that pseudoachalasia can follow
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Chapter 14 Laparoscopic Heller Myotomy and Fundoplication for Achalasia 163
l ong-standing dysphagia from an excessively tight anti-reflux wrap or can occur as a

component of a paraneoplastic syndrome, and the treatment of the primary tumor (i.e.,
colon cancer) can improve the symptoms of achalasia.
In patients with achalasia, a barium esophagram typically demonstrates a dilated
esophagus with a smooth distal tapering, and this finding is frequently described as a
“bird’s beak” narrowing at the gastroesophageal junction (GEJ). It should be noted that
esophageal dilation may not be present in the early stages of achalasia. Upper endos-
copy may show a dilated esophagus with undigested, retained food. A feeling of a “pop”
will often be experienced by the endoscopist when traversing the GEJ with the endo-
scope, which further supports the diagnosis. Endoscopy is also important to rule out
the presence of esophageal malignancy and/or Barrett’s esophagus and to remove the
retained fluid and the debris from the esophagus prior to surgery.
Esophageal manometry is the gold standard in making the diagnosis of achalasia,
typically demonstrating absent or incomplete relaxation of LES and an aperistaltic
esophageal body. The LES resting pressure is often elevated from baseline; however,
Part II: Surgical Treatment of Esophageal

many patients have relatively normal LES resting pressure but do not demonstrate
complete relaxation upon deglutition. The aperistalsis may be characterized by low-
amplitude (<30 mm Hg), simultaneous mirror image (isobaric) waves due to a common
cavity phenomenon. Vigorous achalasia is a rare variant of achalasia, which is charac-
Motility Disorders
terized by repetitive simultaneous contractions with no relaxation of the LES and can
be associated with chest pain. Because the interpretation of manometry is sometimes
difficult in patients with a dilated or a food-filled esophagus, the data should be inter-
preted as a component of the entire clinical picture. Recently, Pandolfino et al. catego-
rized patients with achalasia into three groups based on the findings exhibited on
high-resolution manometry (HRM): Achalasia without esophageal pressurization (type
I, classic), achalasia with esophageal compression or compartmentalization in the dis-
tal esophagus >30 mm Hg (type II), and achalasia with spastic contractions (type III)
(Fig. 14.1). Logistic regression analysis demonstrated that a type II pattern on HRM is
a predictor of positive treatment response, whereas type III is associated with negative
treatment response, suggesting that this classification system may be useful in predict-
ing the outcomes and tailoring therapeutic options.
Type I Type II Type III

Classic achalasia with minimal Achalasia with panesophageal Achalasia with esophageal
Pressure esophageal pressure pressurization spasm
(mm Hg)
100.0
Length along the esophagus (cm)
76.8
53.6
30.4
7.2
–16.0
Time (seconds)
Figure 14.1 Subclassification of achalasia based on high-resolution manometry. Type I: Classic achalasia with minimal to no esopha-
geal pressurization; Type II: Achalasia with panesophageal compression or compartmentalization in the distal esophagus >30 mm Hg;
Type III: Achalasia with spastic contractions. (Reproduced from: Eckardt AJ, Eckardt VF. Treatment and surveillance strategies in
achalasia: An update. Nat Rev Gastroenterol Hepatol. 2011;8:311–319, with permission.)
LWBK1254-ch14_p161-172.indd 163 19/02/14 7:18 AM

Prior to surgery, the possibility of the need for subsequent interventions due to
primary treatment failure should be explained, especially in patients with preexisting
chest pain, prior dilations or botulinum toxin injections, a sigmoid esophagus, and long
duration of symptoms. Preoperatively, the patient should be maintained on a liquid diet
for 3 days to reduce the amount of undigested food in the esophagus. Rapid sequence
intubation with cricoid pressure (Sellick’s maneuver) should be uniformly employed to
minimize the risk of aspiration.
Surgery
Positioning
n The operation is performed under a general anesthesia in a split-legged position.
Sequential compression devices are routinely applied to prevent deep venous throm-
bosis. The patient’s knees are supported and a footboard is placed to prevent patient
sliding when the table is placed in a steep reverse Trendelenburg position. The sur-
geon stands in between the patient’s legs, and the assistant stands on the left side.
Alternatively, the surgery can be performed with the patient in a supine position and
the surgeon standing on the right side of the table.
n Upper endoscopy is performed. Care is taken not to insufflate too much air and to
decompress the stomach thoroughly after the endoscopic examination. The endoscope
can be maintained in the proximal esophagus for evaluation following myotomy.
Port Placement
n We first create pneumoperitoneum by inserting a blunt port using a cut-down tech-
nique; others describe inserting a Veress needle in the left upper abdomen close to
the costal margin. A 5-mm port is subsequently placed in the left paramedian loca-
tion 3 to 5 cm above the umbilicus and the pneumoperitoneum is maintained at
15 mm Hg. This 5-mm port is used for the camera which is controlled by the assist-
ant’s left hand. A 5-mm 30-degree laparoscope is introduced through this port, and
exploratory laparoscopy is performed (Fig. 14.2A). We use VersaStep bladeless tro-
cars for all ports (Covidien Surgical, Mansfield, MA).
n The second port (10 mm) is placed in the left midclavicular line, 2 cm below the left
costal margin under direct visualization. This access is used for the surgeon’s right
hand. The third port (5 mm) is then placed within the left anterior axillary line along
the left costal margin and is used for the assistant’s right hand. The fourth port
Figure 14.2 A: Port placement.

Five-port technique is used.
B: Placement of Nathanson liver
retractor. The left lateral segment
of liver is retracted superiorly to
expose the diaphragmatic hiatus.
5 mm
10 mm
5 mm
5 mm
5 mm
A B
LWBK1254-ch14_p161-172.indd 164 19/02/14 7:18 AM

(5 mm) is placed immediately to the left of the xiphoid process. A Nathanson liver
retractor (Cook Medical, Bloomington, IN) is inserted through this port and secured
with a table-mounted holder to retract the left lateral segment of liver superiorly,
exposing the diaphragmatic hiatus (Fig. 14.2B). The last port (5 mm) is placed 2 to
3 cm below the right costal margin, immediately to the anatomic right position of
the falciform ligament and is used for the surgeon’s left hand.
Dissection
n The operation is started by dividing the gastrohepatic ligament using harmonic
shears (Ethicon Endo-Surgery, Inc., Cincinnati, OH). Other energy devices can be
used for this and the subsequent dissection. Once the right crus of the diaphragm is
identified, it is separated from the esophagus, keeping its peritoneal covering intact.
The dissection is continued anteriorly to the esophagus along the phrenoesophageal
membrane moving toward the left crus. Care should be taken to identify and preserve

the anterior vagus nerve trunk during this maneuver.
n The dissection is carried onto the left crus separating it from the esophagus. Again,
the peritoneal lining of the crus should be preserved. The acute angle of His and
gastric fundus are mobilized by dividing the gastrophrenic attachments and the
Motility Disorders
highest short gastric vessels with harmonic energy. If no hiatal hernia is identified,
posterior dissection is unnecessary and the posterior attachments of the phre-
noesophageal membrane and the esophageal hiatus are preserved.
n To clearly define the GEJ, the gastroesophageal fat pad is mobilized from left to the
right side starting along the cardia (Fig. 14.3). The anterior and the posterior vagus
nerve trunks are identified and preserved throughout the procedure. The fat pad and
the nerves are reflected to the right to expose the entire area of anterior wall of the
esophagus, GEJ, and proximal stomach for myotomy.
Myotomy
n The myotomy can be performed in several different ways—using blunt dissection,
hook electrocautery, or other energy devices. We start by bluntly separating the lon-
gitudinal muscle fibers with atraumatic graspers immediately proximal to the GEJ on
Figure 14.3 Dissection of the gastro-

esophageal fat pad and anterior vagus
nerve to identify the true gastro-
esophageal junction prior to myotomy.
LWBK1254-ch14_p161-172.indd 165 19/02/14 7:18 AM

5 cm
2–3 cm
A B
Figure 14.4 Myotomy. A: Myotomy can be performed bluntly and sharply. B: Myotomy is extended proximally 5 cm from the gastro-
esophageal junction (denoted by the thin black line) and distally 2 to 3 cm onto the gastric cardia.
the anterior wall of the esophagus until the circular muscle fibers are encountered.
The circular muscle fibers are then divided bluntly until the submucosal plane is
identified (Fig. 14.4A). Subsequently, the myotomy is extended proximally 5 cm from
the GEJ and distally 2 to 3 cm onto the gastric cardia (Fig. 14.4B). The muscle edges
are further separated from the underlying mucosa on both sides, leading to a distinc-
tive view of the bulging mucosa of the distal esophagus. In order to completely
divide the remaining muscle fibers, a 52-French dilator is carefully placed under
laparoscopic visualization, thus highlighting the remaining muscle fibers. These fib-
ers are individually divided sharply and bluntly. A sponge with dilute epinephrine
solution can be used to stop oozing at the myotomy site, should the surgeon wish to
avoid all forms of energy near to the exposed submucosa.
n At the completion of myotomy, upper endoscopy is performed to confirm a widely
patent GEJ and the absence of leak. If a perforation has occurred, it is repaired with
an interrupted absorbable suture.
Fundoplication
n We prefer to perform a Dor fundoplication to reduce postoperative reflux symptoms
while covering the myotomy site with the gastric serosa. To reconstruct the acute
angle of His, the gastric fundus 2 cm distal to the anatomic GEJ along the greater
curvature is sutured to the left crus at the 4-o’clock position, incorporating the left
side of the myotomy with a 2-0 nonabsorbable suture (Fig. 14.5A, B). Then, the ante-
rior surface of gastric fundus is folded toward the patient’s right side, covering the
myotomy site with the posterior gastric wall facing the anterior abdominal wall. An
interrupted greater curvature of fundus-to-myotomy-to-crura suture (2-0 nonabsorb-
able) is placed at the 2-o’clock postion to start the fundoplication (Fig 14.5C). An
additional three to four sutures are placed to secure the fundus to the right crura (7-
to 8-o’clock) and to the apex of the esophageal hiatus (11- to 1-o’clock). The stitches
along the right crura may include the right edge of the myotomy to keep it from clos-
ing (Fig. 14.5D). The appearance of a groove over the posterior gastric fundus, which
indicates a “tight” fundoplication, should be avoided. Care should be taken to avoid
any injury to the myotomy site when sutures are placed, and this can be avoided by
mobilizing the muscle away from the submucosa after longitudinal myotomy.
n A Toupet fundoplication is an option if circumferential esophageal mobilization is
performed. The gastric fundus is passed through the retroesophageal space to the
right side of the esophagus without redundancy or twisting, and two or three sutures
LWBK1254-ch14_p161-172.indd 166 19/02/14 7:18 AM


B
Motility Disorders
A
C D
Figure 14.5 Dor fundoplication. A, B: The first suture is placed between the proximal gastric fundus, left crus, and the left edge of
the myotomy to recreate the angle of His. C, D: The gastric fundus is sutured to diaphragmatic opening, covering the myotomy site.
are then placed between the posterior aspect of the gastric fundus and the right crus.
Additional sutures are placed between the left gastric fundus and the left crus to
align the fundoplication with the esophagus. Both the right and left sides of the
gastric fundus are then sewn to both edges of muscular layers along the myotomy
site with four or five interrupted sutures on each side (Fig. 14.6).
Sigmoid Esophagus
n Patients with sigmoid esophagus should undergo circumferential mobilization of the
distal thoracic esophagus and the GEJ. This maneuver helps to straighten the esopha-
geal axis, which may help with better postmyotomy emptying.
Closure
n After complete hemostasis is achieved, the liver retractor is removed under laparo-
scopic visualization. The skin incisions are closed with absorbable suture.
LWBK1254-ch14_p161-172.indd 167 19/02/14 7:18 AM

A B
Vagus nerve
Myotomy
Fundus wrap
C
Figure 14.6 Toupet fundoplication. The gastric fundus is passed through the retroesophageal space to the right side of the esophagus.
Both right and left sides of gastric fundus are sewn to both edges of the myotomy, attempting to prevent reapproximation of the
myotomy edges.
The patient is extubated in the operating room. A chest radiograph is obtained in the
recovery room to ensure there are no acute pulmonary issues such as atelectasis or
pneumothorax. The urinary catheter is removed in the recovery room or the following
morning. Prophylactic anticoagulation, in conjunction with sequential compression
stockings, is routinely employed to decrease risk of deep venous thrombosis and pul-
monary embolism. The nursing staff is instructed not to place a nasogastric tube at any
LWBK1254-ch14_p161-172.indd 168 19/02/14 7:18 AM

point in the setting of nausea or emesis to avoid iatrogenic perforation along the myo-
tomy. If the patient develops persistent nausea or has significant abdominal distension,
we perform an upper endoscopy and place a nasogastric tube under direct visualization.
The patient is admitted to the surgical ward and encouraged to ambulate and use the
incentive spirometer to maximize physical and pulmonary function, thus preventing
cardiopulmonary complications. Usually, a patient-controlled analgesic pump is used
to provide adequate pain relief for the first 24 hours. In the absence of nausea, abdom-
inal distension, or a large gastric bubble on chest x-ray, a barium esophagram is per-
formed on postprocedure day 1 to rule out a leak. If appropriate, a liquid diet is started.
A dietary consultation is routinely performed prior to discharge to counsel and educate
the patient on a postfundoplication diet. Most patients are discharged on a liquid diet
by the second postoperative day. Soft diet can be initiated after a week and a regular
diet by 4 weeks. Patients are instructed to avoid heavy lifting (greater than 10 kg) for
6 weeks and to crush their pills or switch to a liquid form, if possible.

Complications
In a meta-analysis comparing various endoscopic and surgical modalities for the treat-
Motility Disorders
ment of achalasia, Campos et al. reviewed 39 papers involving 3,086 patients who had
undergone laparoscopic myotomy with a mean follow-up of 35.4 months. Complica-
tions were reported in 6.3% of patients, and mortality was 0.1%. Intraoperative perfora-
tion was seen in 182 patients (6.9%). Postoperative clinical manifestation of perforation
requiring additional therapy was observed in 19 patients (0.7%). With the laparoscopic
technique, the incidence of wound infection or port site hernia is extremely low. Despite
performing antireflux surgery, postoperative gastroesophageal reflux can occur in up to
10% of patients, and reflux symptoms can be controlled with medical therapy. Postop-
erative dysphagia can be caused by incomplete myotomy (especially on the gastric
side), submucosal fibrosis, a tight fundoplication, anatomic obstruction secondary to
megaesophagus, or gastroesophageal reflux-related mucosal injury such as esophagitis
and peptic stricture.
Results
The controversies as they relate to surgical myotomy include approach, whether or not
to use a fundoplication, type of fundoplication, length of myotomy, and therapeutic
approach to sigmoid esophagus.
Surgical Approach
In the meta-analysis by Campos et al., laparoscopic myotomy provided better symptom
relief (89.3%; median follow-up, 35.4 months) compared with open abdominal myot-
omy (84.5%; median follow-up, 87.4 months), transthoracic myotomy (83.3%; median
follow-up, 102 months), or thoracoscopic myotomy (77.6%; median follow-up, 36.4
months). The incidence of postmyotomy gastroesophageal reflux was lower with the
addition of a fundoplication after laparoscopic myotomy than without (8.8% vs. 31.5%,
respectively, p = 0.003). It is generally accepted that the laparoscopic Heller myotomy
is the optimal operative approach for patients with achalasia.
Sigmoid Esophagus
Several authors have described good long-term results with a laparoscopic myotomy in
patients with sigmoid esophagus. Mineo et al. showed significant improvement in dys-
phagia score and quality of life in 14 patients with sigmoid esophagus treated with open
and laparoscopic myotomy at a median follow-up of 85 months. Schuchert et al. showed
37.5% failure rate of myotomy in 24 patients with sigmoid esophagus. Age and symptom
LWBK1254-ch14_p161-172.indd 169 19/02/14 7:18 AM

duration were associated with higher risk of myotomy failure. In a study by Sweet et
al., 12 patients with sigmoid-shaped esophagus and esophageal diameter greater than 6
cm were treated with laparoscopic Heller myotomy. Excellent-to-good results were seen
in 91% of these patients. At a median follow-up of 45 months, 33% of patients had
persistent or recurrent dysphagia that improved significantly with esophageal dilation.
In a retrospective review, Faccani et al. showed improved outcomes in 18 patients who
had sigmoid esophagus who underwent myotomy and a “pull-down” technique. These
patients had 360-degree mobilization of the GEJ along with the application of U stitches
on the right of the lower esophagus to rotate the GEJ to the right and straighten the
distal esophagus. In light of these reports, Heller myotomy can be considered as a first-
choice treatment in selected patients with a sigmoidal esophagus and achalasia before
undertaking an esophagectomy.
Need for Fundoplication

In a double-blind randomized study by Richards et al., 43 patients were divided into
two groups—21 with myotomy alone and 22 with myotomy and a Dor fundoplication.
Postoperative LES pressures and symptom improvement were similar at 6-month
follow-up. Based on 24-hour pH monitoring, the myotomy alone group had significantly
higher incidence of pathologic reflux compared with the myotomy plus Dor group
(47.6% vs. 9.9%; p = 0.005). Median distal esophageal acid exposure time was lower
in the myotomy plus Dor group (0.4%; range, 0 to 16.7) compared with the myotomy
group (4.9%; range, 0.1 to 43.6; p = 0.001). In a retrospective study of 149 patients, Rice
et al. demonstrated that although postmyotomy resting and residual LES pressures were
higher in patients with the addition of Dor fundoplication, it did not impair esophageal
emptying and significantly reduced reflux symptoms. It is generally accepted that par-
tial fundoplication should be included with laparoscopic Heller myotomy.
Dor versus Toupet Fundoplication

In a retrospective study comparing Dor (n = 41) with Toupet fundoplication (n = 23)
following Heller myotomy, Arain et al. demonstrated no differences between Dor and
Toupet fundoplication with regard to dysphagia resolution and the postoperative use of
proton pump inhibitors. Recently, a multicenter, randomized controlled trail to compare
laparoscopic Dor (n = 36) with Toupet fundoplication (n = 24) following Heller myotomy
demonstrated that there were no significant differences in efficacy to improve dysphagia
and regurgitation symptoms based on the type of partial fundoplication. The Dor group
was more likely to have abnormal pH testing compared with the Toupet group (41.7%
vs. 21.1%, respectively), although this difference was not significant (p = 0.152). A Dor
or a Toupet partial fundoplication can be used interchangeably with equivalent reflux
control in patients with achalasia who undergo laparoscopic Heller myotomy.
Dor Versus Nissen Fundoplication

A randomized controlled trial to compare Dor (n = 71) with Nissen fundoplication
(n = 67) following Heller myotomy demonstrated no significant difference in reflux
symptoms, but dysphagia rates were significantly higher in the Nissen fundoplication
group at a mean follow-up period of 125 months (15% vs. 2.8%; p < 0.001). Nissen
fundoplication should not be used as an antireflux procedure in patients with achalasia
who undergo laparoscopic Heller myotomy.
Extension of Myotomy
In a retrospective study to evaluate the outcomes of 102 patients who had undergone
laparoscopic Heller myotomy (7 cm myotomy including 1.5 cm onto the gastric wall)
with Dor fundoplication, Patti et al. suggested that an inadequate myotomy onto the
gastric cardia is an avoidable cause of postoperative persistent dysphagia. Oelschlager
LWBK1254-ch14_p161-172.indd 170 19/02/14 7:18 AM

et al. reported the outcomes of patients who had undergone extended myotomy (3 cm
onto the cardia) with a Toupet fundoplication (n = 63), and compared the results with
those who had undergone standard myotomy (1.5 cm onto cardia) with a Dor fundop-
lication (n = 52). Nine patients (17%) with standard myotomy required repeat interven-
tion due to postoperative dysphagia, including four who required a redo myotomy,
whereas three patients (5%) with extended myotomy required reintervention (endo-
scopic dilation) with no need for redo operations (p < 0.005). An extended gastric
myotomy (≥2.5 cm) should be performed in all patients with achalasia who undergo
laparoscopic Heller myotomy.
Conclusions
Treatment of achalasia aims to release of esophageal outlet obstruction at the GEJ, while
minimizing gastroesophageal reflux. Laparoscopic Heller myotomy with a partial fun-

doplication is a reasonable option to treat achalasia and can be performed with minimal
morbidity and almost zero mortality when patients are appropriately selected. Extension
of the myotomy onto the gastric cardia for at least 2 to 3 cm is essential to achieve
excellent symptomatic improvement. It should be noted that none of the treatments for
Motility Disorders
achalasia can restore the impaired function of LES and esophageal body, so the ultimate
goal of the surgeon is to direct patients to the optimal initial treatment option, most
likely to achieve long-term symptom control rather than just initial symptomatic
improvement.
Recommended References and Readings 11. Rawlings A, Soper NJ, Oelschlager B, et al. Laparoscopic Dor
versus Toupet fundoplication following Heller myotomy for
1. Arain MA, Peters JH, Tamhankar AP, et al. Preoperative lower achalasia: Results of a multicenter, prospective, randomized-
esophageal sphincter pressure affects outcome of laparoscopic controlled trial. Surg Endosc. 2012;26:18–26.
esophageal myotomy for achalasia. J Gastrointest Surg. 2004; 12. Rebecchi F, Giaccone C, Farinella E, et al. Randomized control-
8(3):328–334. led trial of laparoscopic Heller myotomy plus Dor fundoplica-
2. Boeckxstaens GE, Annese V, des Varannes SB, et al. Pneumatic tion versus Nissen fundoplication for achalasia: Long-term
dilation versus laparoscopic Heller’s myotomy for idiopathic results. Ann Surg. 2008;248:1023–1030.
achalasia. N Engl J Med. 2011;364(19):1807–1816. 13. Rice TW, McKelvey AA, Richter JE, et al. A physiologic clinical
3. Campos GM, Vittinghoff E, Rabl C, et al. Endoscopic and surgical study of achalasia: Should Dor fundoplication be added to Hel-
treatments for achalasia: A systematic review and meta-analysis. ler myotomy? J Thorac Cardiovasc Surg. 2005;130:1593–1600.
Ann Surg. 2009;249:45–57. 14. Richards WO, Torquati A, Holzman MD, et al. Heller myotomy
4. Faccani E, Mattioli S, Lugaresi ML, et al. Improving the surgery versus Heller myotomy with Dor fundoplication for achalasia: A
for sigmoid achalasia: long-term results of a technical detail. prospective randomized double-blind clinical trial. Ann Surg.
Eur J Cardiothorac Surg. 2007;(32):827–833. 2004;240(3):405–412.
5. Mineo TC, Pompeo E. Long-term outcome of Heller myotomy in 15. Richter JE. Update on the management of achalasia: Balloons,
achalasic sigmoid esophagus. J Thorac Cardiovasc Surg. 2004; surgery and drugs. Expert Rev Gastroenterol Hepatol. 2008;
128:402–407. 2(3):435–445.
6. Oelschlager BK, Chang L, Pellegrini CA. Improved outcome after 16. Schuchert MJ, Luketich JD, Landreneau RJ, et al. Minimally-
extended gastric myotomy for achalasia. Arch Surg. 2003; invasive esophagomyotomy in 200 consecutive patients: Factors
138:490–497. influencing postoperative outcomes. Ann Thorac Surg. 2008;
7. Pandolfino JE, Kwiatek MA, Nealis T, et al. Achalasia: a new 85(5):1729–1734.
clinically relevant classification by high-resolution manometry. 17. Schuchert MJ, Luketich JD, Landreneau RJ, et al. Minimally
Gastroenterology. 2008;135(5):1526–1533. invasive surgical treatment of sigmoidal esophagus in achalasia.
8. Park W, Vaezi MF. Etiology and pathogenesis of achalasia: The J Gastrointest Surg. 2009;13(6):1029–1035.
current understanding. Am J Gastroenterol. 2005;100:1404–1414. 18. Sweet MP, Nipomnick I, Gasper WJ, et al. The outcome of lapar-
9. Patti MG, Molena D, Fisichella PM, et al. Laparoscpic Heller oscopic Heller myotomy for achalasia is not influenced by the
myotomy and Dor fundoplication for achalasia: Analysis of suc- degree of esophageal dilatation. J Gastrointest Surg. 2008;12:159–
cesses and failures. Arch Surg. 2001;136:870–877. 165.
10. Patti MG, Pellegrini CA, Horgan S, et al. Minimally invasive 19. Wright A, Williams C, Pellegrini C, et al. Long-term outcomes con-
surgery for achalasia: An 8-year experience with 168 patients. firm the superior efficacy of extended Heller myotomy with Tou-
Ann Surg. 1999;230:587–594. pet fundoplication for Achalasia. Surg Endosc. 2007;21:713–718.
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LWBK1254-ch14_p161-172.indd 172 19/02/14 7:18 AM
15 Transthoracic Approach
for Achalasia
Richard F. Heitmiller and Lynne A. Skaryak
Introduction
Open transthoracic surgery for achalasia is nearly 100 years old. Heller is credited with
the first description of an open transthoracic surgery for achalasia in 1913.1 This involved
dual distal esophagomyotomies, one on each side of the esophagus. In 1918, De Brune
Groenveldt2 showed that a single myotomy was equally effective and this is the approach
that is used today. At first, this method was not universally accepted. Up until the 1950s,
many surgeons believed that the region of narrowing in achalasia was hypoplastic, and
therefore proposed methods commonly used for open pyloroplasty to relieve the lower
esophageal obstruction. While these methods did relieve obstruction, they also resulted in
profound and unacceptable rates of reflux. After increasing reports came out to this effect
the technique of esophagomyotomy won the day. More recently, the effectiveness of myo-
tomy has not been questioned but the length and extent of myotomy have been debated.
In 1967, Ellis et al.3 described an open surgery that restricted the esophagomyotomy to the
distal esophagus, thus striking a balance between releasing the muscular obstruction yet
avoiding reflux. Others advocate a longer myotomy, onto the stomach, with an added
fundoplication. Both methods have their supporters and good results. This chapter will
describe the methods of open transthoracic surgery for patients with achalasia.
The age distribution of patients with achalasia is a bell-shaped curve ranging from the very
young to those of advanced age. The peak age for clinical presentation is 30 to 40 years.
There is no cure for achalasia, and there are limited treatment options. The first principle
of care, therefore, is to ensure that any treatment for patients with achalasia fits into a
lifelong plan for their care. This is especially true for patients presenting at a younger age.
The indications for management of patients with achalasia include dysphagia lead-
ing to weight loss, prominent regurgitation especially with associated aspiration pneu-
monia, and pain from spasm. In general, despite its effectiveness, open surgery is no
longer considered the best first-line therapy for achalasia. Treatment plans should pro-
ceed from less to more invasive methods. Laparoscopic esophagomyotomy has emerged
173
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as the leading primary treatment, especially in younger patients. Still, there is a role for
open surgery.
Indications for open myotomy include the following.
n Failure of prior laparoscopic esophagomyotomy, especially if the results were ini-
tially favorable
n Failure of medical therapy such as botulinum toxin injections or pneumostatic dilatation
n Patients whose esophagus has been perforated during nonopen treatment methods
n Patients who are not candidates for laparoscopic methods due to adhesions or prior
surgeries
n Associated intrathoracic or esophageal pathology such as diverticular disease or asso-
ciated ipsilateral lung pathology requiring surgery
n Vigorous achalasia
n An irreparable esophagus secondary to size, tortuosity, or injury
Contraindications for open surgery include the following.

n Patient is not a candidate for open surgery due to the risk of surgery from comorbidities
n Young patients who have not been evaluated for laparoscopic esophagomyotomy
Indications for esophageal replacement include the following.

n Failed prior surgeries for esophagomyotomy with scarring, stricture, and adhesions
n Markedly dilated esophagus (>6 cm diameter), also referred to as megaesophagus,
especially when associated with tortuosity
Preoperative preparation involves confirming the diagnosis of achalasia, ruling out or
identifying any associated conditions, assessing overall gastrointestinal motility, and
assessing the patient’s risk for thoracotomy.
Manometry remains the gold standard for diagnosing achalasia. If this is not avail-
able or not tolerated by the patient, video esophagography by an experienced radiologist
serves well to confirm the clinical suspicion of achalasia. A standard contrast swallow
is less accurate but is sometimes clear in cases of dilated esophagus with a classic bird’s
beak narrowing of the lower esophagus at the esophagogastric junction.
Associated esophageal conditions that should be looked for include evidence for
spasm, as seen with vigorous achalasia, or diverticular disease. Flexible esophagogas-
troscopy should be performed to rule out an occult esophageal malignancy presenting
as pseudoachalasia. Finally, any other intrathoracic pathology that might need to be
managed or evaluated at thoracotomy should be identified before surgery. Computed
tomography, though not needed routinely before transthoracic esophagomyotomy, will
best define any ipsilateral thoracic pathology if it is suspected.
Rarely a patient is suspected of having achalasia clinically, who in fact has global,
severe, gastrointestinal hypomotility. The patient’s dysphagia and regurgitation, a prod-
uct of pan-gastrointestinal lack of inertia, are falsely interpreted as a primary esophageal
disorder. Proceeding with esophagomyotomy in these patients does not solve their
clinical problem.
Patients should undergo standard preoperative workup for thoracotomy. The need
for a more detailed evaluation of cardiorespiratory status, including detailed cardiac or
pulmonary function, depends on a patient’s clinical history and physical findings.
Surgery
The objectives of transthoracic esophagomyotomy are to relieve lower esophageal
obstruction by myotomy, address any associated esophageal pathology if present, and
prevent or minimize postoperative gastroesophageal reflux.4 The following procedures
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Chapter 15 Transthoracic Approach for Achalasia 175
will be discussed: (1) esophagomyotomy (Heller procedure), (2) esophagomyotomy

with partial fundoplication (“modified Heller procedure”), (3) extended esophagomyo-
tomy for vigorous achalasia, (4) reoperative esophagomyotomy, and (5) esophageal
replacement.
Transthoracic Esophagomyotomy
Double-lumen general endotracheal anesthesia is used. Special attention must be
directed toward protection against aspiration during intubation, given the potential for
regurgitation of retained esophageal contents in achalasia patients. A nasogastric tube
is placed prior to patient positioning to empty the esophagus, facilitate esophageal
mobilization, and for postoperative esophagogastric decompression if needed. Patients
are then positioned in the right lateral decubitus position. A left lateral thoracotomy
through the sixth, seventh, or eighth intercostal space is used. The specific interspace
should be individually selected based on the level of the left side of the diaphragm so

that optimal exposure of the lower esophagus is obtained. If the incision is too low, the
left hemidiaphragm obstructs the operative field. If it is too high, it is extremely difficult
to see or reach the lower chest to complete the surgery. The ideal interspace should
open just over the dome of the ipsilateral hemidiaphragm (Fig. 15.1). Ellis et al.3,5 are
Motility Disorders
credited with championing the method of esophagomyotomy that is limited to the dis-
tal esophagus. The distal esophagus is circumferentially mobilized taking care not to
injure the vagus nerves or to disrupt the esophageal hiatal attachments. An encircling
0.25-inch Penrose drain works well to lift the lower esophagus up from the mediasti-
num. A longitudinal myotomy is performed down to the mucosa that characteristically
pouts out (Fig. 15.2). The myotomy extends distally just across the esophagogastric
junction onto the stomach for a length of 1 cm or less. Proximally, it is continued for
a 5 to 7 cm total length. The cut edges of the muscle are further dissected back to widely
free the mucosal lumen and to prevent rehealing of the cut muscle (Fig. 15.3). Adding
additional procedures, such as vagotomy, gastric drainage, or fundoplication, according
to Ellis,6 “merely complicates an otherwise simple operation.”
The technique of open myotomy that we prefer uses blunt-tipped Metzenbaum
scissors to divide the muscle down to the mucosa. This yields a very controlled myo-
tomy with easy muscle layer identification and a minimal chance of mucosal damage.
Once the mucosa is identified the myotomy is easily and rapidly extended in either
direction. Other methods include using a straight or hooked cautery, or a long-handed
knife to divide the muscle. If a knife is used, passing a midsized bougie into the esopha-
gus first can serve as an “anvil” upon which to cut with greater control.
Thoracotomy closure with chest tube drainage is routine.
Figure 15.1 Operative exposure. The

Heart narrowed distal esophagus is mobi-
lized in preparation for myotomy.
Diaphragm
Aorta
Mediastinal
pleura
LWBK1254-ch15_p173-182.indd 175 19/02/14 5:14 PM

Figure 15.2 Esophagomyotomy is

performed with scissor dissection
exposing the underlying mucosal
surface.
Esophageal
hiatus
Figure 15.3 Two methods of myotomy

are shown. In (A), the myotomy
extends well onto the stomach. A
partial fundoplication is then added. In
(B), the myotomy extends just onto the
stomach. No fundoplication is added.
Dissection of the divided muscle on
either side minimizes rehealing of the
cut edges (inset).
Stomach
Stomach
LWBK1254-ch15_p173-182.indd 176 19/02/14 5:14 PM

Modified Heller Esophagomyotomy

Esophagomyotomy plus antireflux fundoplication is referred to as a modified Heller
myotomy.7 The rationale for combining these procedures is based on the fact that many
surgeons find it difficult to determine just how far to extend the myotomy onto the
stomach. By extending the myotomy well onto the stomach, the chance of leaving per-
sistent, obstructing lower esophageal sphincter (LES) muscle fibers is minimized, and
reflux is then managed by means of fundoplication.
Double-lumen endotracheal anesthesia is used. A nasogastric tube is placed after
induction and before positioning. Patients are placed in the right lateral decubitus posi-
tion and a left sixth to eighth interspace incision is used. The pulmonary ligament is
divided, the ipsilateral lung deflated, and the lower esophagus circumferentially mobi-
lized. Care is taken to avoid vagal nerve injury. In contrast to myotomy alone, the
esophageal hiatus is opened and the peritoneum entered. The gastroesophageal (GE)
junction is identified and delivered into the chest. The GE junction fat pad is split in
the midline. Each half, along with the vagus, is reflected to either side of the esophagus.

A myotomy is made on the lower 5 to 7 cm of esophagus and extended for approxi-
mately 2 cm onto the stomach. Again, the cut edge of the myotomy is dissected back
to minimize reapproximation with healing. The hiatus is narrowed by interrupted non-
Motility Disorders
absorbable sutures placed in the crus laterally that displace the esophagus medially and
anteriorly. These sutures are placed but not tied as yet. A two-stitch “Belsey type”
partial fundoplication is performed (Fig. 15.4). A double-armed nonabsorbable suture
is ideal for this. No pledgets are used. The two-stitch fundal wrap, in addition to its
antireflux role, is ideal at helping to keep the cut edges of the myotomy separated. Once
the fundoplication is completed and the GE junction returned to the abdomen, the
lateral crural sutures are tied and cut (Fig. 15.5). The hiatus should be tightened to
where it just accommodates the tip of a finger alongside the esophagus posteriorly.
Thoracotomy closure and chest drainage proceed in routine fashion.
Extended Myotomy For Vigorous Achalasia

In some patients with achalasia, esophageal spasm pain is especially prominent. This
entity is termed vigorous achalasia, and it should be screened for as part of the preop-
erative workup for open achalasia surgery.
Treatment options for this variant of achalasia are similar to those described above.
However, for vigorous achalasia patients, the myotomy is extended proximally to
include the region of esophagus identified preoperatively to produce high-amplitude,
Figure 15.4 A two-stitch fundoplication

is illustrated.
Esophageal
hiatus
LWBK1254-ch15_p173-182.indd 177 19/02/14 5:14 PM

Figure 15.5 The completed modified

Heller myotomy.
Diaphragm
Nasogastric tube
Stomach
nonperistaltic waves. If a specific site cannot be identified, a myotomy that extends to

the level of the aortic arch is used (Fig. 15.6). The chest incision is closed per routine.
Reoperative Transthoracic Esophagomyotomy

Reoperative surgery after a previous failed esophagomyotomy can be a challenge. For
reoperative chest surgery, it helps to have either a nasogastric tube or an esophageal
bougie in the esophagus to assist with esophageal remobilization. Another maneuver to
consider is to open the hemidiaphragm through its central tendon to assist with mobi-
lization of the esophagogastric junction from below.
Esophageal Resection and Replacement

Either a transthoracic or transhiatal esophagectomy method may be considered for
esophageal resection and gastric pull-up. If there has been no previous intrathoracic
surgery with adhesions, a transhiatal approach with gastric pull-up and cervical esoph-
agogastric anastomosis has been reported. The steps for transhiatal esophagectomy are
standard (see Chapter 20) and will not be detailed in this chapter focusing on transtho-
racic methods. If this approach is used, extra care must be taken during the mediastinal
dissection to avoid esophageal injury with spillage, injury of mediastinal structures,
Figure 15.6 A long myotomy extends

from the stomach to the aortic arch.
Aorta
Stomach
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Figure 15.7 An achalasia patient with a

distended, sigmoid esophagus. The
three incision points for esophagectomy
are noted.

B
Motility Disorders
C
and bleeding because of the enlarged size, tortuosity, and hypervascular nature of the
“end-stage” achalasia esophagus.
We prefer a three-incision approach to esophagectomy for achalasia patients who
need esophageal replacement for controlled, direct visualization during transthoracic
esophageal mobilization (Fig. 15.7). General double-lumen endotracheal anesthesia is
used. A nasogastric tube is placed after induction. Again, care must be taken to avoid
aspiration during induction, intubation, and positioning. Patients are placed in the left
lateral decubitus position and a right fifth or sixth intercostal space lateral thoracotomy
incision is employed sparing the anterior serratus muscle. The ipsilateral lung is deflated
and retracted medially. The mediastinal pleura is opened just distal to the azygos vein
arch and the esophagus encircled with a 0.25-inch Penrose drain. The esophagus is
mobilized distally toward the hiatus. Generous use of the electrocautery is recom-
mended. The chance of injury to mediastinal structures is minimized by progressively
lifting the esophagus out of its bed. Proximally, it is best to leave the azygos arch and
the superior mediastinal pleura intact (Fig. 15.8). This serves to isolate the proposed
cervical esophagogastric anastomosis from the chest. Apical dissection is completed
using a transhiatal method. The thoracic duct is routinely suture-ligated in the lower
right chest, a chest tube placed, the lung expanded, and the chest closed. The patient
is then returned to the supine position, reintubated with a single-lumen tube, and posi-
tioned as for a transhiatal esophagectomy. The remainder of the procedure is identical
to a transhiatal esophagectomy except that the intrathoracic esophageal mobilization
has already been completed. Modified left collar and midline abdominal incisions are
employed. In the neck, the previously mobilized esophagus is encircled. The stomach
is mobilized preserving the right gastroepiploic vascular arcade. A greater curvature-
based gastric tube is created using a linear stapler. The staple line is secondarily closed
with an absorbable running suture. The esophagus and the gastric cardia are then with-
drawn out through the neck incision, and the stomach tube passed through the esopha-
geal bed into the neck using a technique previously reported8 (Fig. 15.9). A two-layered,
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Azygos Aorta Figure 15.8 Preservation of the azy-

vein gos vein arch and upper mediastinal
pleura separates the upper gastric
tube and anastomosis from the right
chest. The location of the thoracic
duct is shown (inset).
Spine
Thoracic
duct
Esophagus
Thoracic
duct
Azygos
vein
Figure 15.9 The completed gastric

pull-up is shown.
LWBK1254-ch15_p173-182.indd 180 19/02/14 5:14 PM

handsewn, end-to-side esophagogastric anastomosis is used as previously described.9 A

jejunostomy is placed in a fashion that permits percutaneous replacement later on.10
Myotomy
Following esophagomyotomy alone, the target discharge will be after 2 to 3 days. The
limiting factors are pain control and chest drain management. Nasogastric tube place-
ment is not routine. A contrast esophagogram is not mandatory before resuming oral
feedings; however, a “baseline” postsurgery study is helpful to document the anatomy
in the event that the patient presents with recurrent symptoms in the future.
Following modified Heller procedure, the target discharge will be after 3 to 4 days.
A nasogastric tube may be used to prevent retching and disruption of the partial fundal

wrap. The chest drain is managed as per usual. Again, a contrast study is helpful as a
baseline but not needed before resuming oral intake.
Motility Disorders
Esophagectomy
Management of postesophagectomy achalasia patients is the same as for patients under-
going surgery for esophageal cancer.11 Our patient care pathway targets a discharge on
postoperative day 6 or 7. Patients are kept intubated overnight after surgery to protect
against aspiration pneumonia, then extubated per routine criteria. Nasogastric drainage
continues for 3 or 4 days. Low-rate tube feedings (10 to 30 mL maximum) begin on day
3. Contrast esophagography is performed on day 5 and oral feedings then resumed in
a graded fashion prior to discharge.
Complications and Outcomes

Operative mortality is 0% to 1%. Vigorous pulmonary toilet and adequate pain control
are crucial to prevent pulmonary complications postoperatively. Early results demon-
strate good-to-excellent symptom improvement in 83% to 98% of patients.12–14 Although
symptom relief may be durable, most series document a steady decline in swallowing
quality as symptoms recur. In a series involving 159 patients, Liu et al. demonstrated
favorable symptom relied in 97% to 98% of patients early on, that fell to 53% to 55%
depending on whether myotomy alone versus myotomy plus Belsey antireflux wrap was
used. Late dysphagia is independent of whether fundoplication is performed. Gastro-
esophageal reflux symptoms occur in 13% to 24% of patients. Gaissert et al. noted that
early postoperative dysphagia was an indicator of early failure but that sigmoid esopha-
gus was not.
Esophageal resection for failed achalasia is a complex undertaking because of the
invariable previous surgeries. Miller et al.15 presented their series with 37 patients.
Indication for surgery was recurrent obstruction (81%), cancer (8%), bleeding (5.5%),
or perforation (5.5%). Operative mortality was 5.4% and good-to-excellent long-term
results were achieved in 91.4% of patients.
Conclusions
Transthoracic surgery for patients with achalasia, primarily esophagomyotomy with or
without fundoplication, has a proven track record as it approaches its 100th year anni-
versary. It is a safe and an effective treatment for symptomatic patients, and it must be
considered the gold standard against which to measure all new competing treatment
surgeries.
LWBK1254-ch15_p173-182.indd 181 19/02/14 5:14 PM

Recommended References and Readings 8. Heitmiller RF. Results of standard left thoracoabdominal esoph-
agogastrectomy. Semin Thorac Cardiovasc Surg. 1992;4:314–
1. Heller E. Extramukose Cardiaplastik beim chronischen Car- 319.
diospamus mit Dilatation des Oesophagus. Mitt Grenzgeb Med 9. Stone CD, Heitmiller RF. Simplified, standardized technique for
Chir. 1913;27:141–149. cervical esophagogastric anastomosis. Ann Thorac Surg. 1994;
2. De Brune Groenveldt JR. Over cardiospasmus. Ned Tijdschr 58:259–261.
Geneeskd. 1918;54:1281–1282. 10. Heitmiller RF, Venbrux AC, Osterman FA. Percutaneous replace-
3. Ellis FH Jr, Kiser JC, Schlegel JF, et al. Esophagomyotomy for ment jejunostomy. Ann Thorac Surg. 1992;53:711–713.
esophageal achalasia: Experimental, clinical, and manometric 11. Zehr KJ, Dawson PB, Yang SC, et al. Standardized clinical care
aspects. Ann Surg. 1967;166:640–656. pathways for major thoracic cases reduce hospital costs. Ann
4. Heitmiller RF. Surgery of achalasia and other motility disorders. Thorac Surg. 1998;66:914–919.
In: Kaiser LR, Kron IL, Spray TL, eds. Mastery of Cardiothoracic 12. Gaissert HA, Lin N, Wain JC, et al. Transthoracic Heller myot-
Surgery. Philadelphia–New York: Lippincott-Raven; 1998:151– omy for esophageal achalasia: Analysis of long-term results. Ann
159. Thorac Surg. 2006;81:2044–2049.
5. Ellis FH Jr, Schlegel JF, Code CF, et al. Surgical treatment of 13. Campos GM, Vittinghoff E, Rabl C, et al. Endoscopic and surgi-
esophageal hypermotility disturbances. JAMA. 1964;188:862– cal treatments of achalasia: A systematic review and meta-
866. analysis. Ann Surg. 2009;249:45–57.
6. Ellis FH Jr. Disorders of the esophagus in the adult. In: Sabiston 14. Liu HC, Huang BS, Hsu WH, et al. Surgery for achalasia: Long-
DC, Spencer FC, eds. Gibbon’s Surgery of the Chest. 3rd ed. term results in operated achalasic patients. Ann Thorac Cardio-
Philadelphia, PA: W.B. Saunders Company; 1976:694. vasc Surg. 1998;4(6):312–320.
7. Mansour KA, Symbas PN, Jones EL, et al. A combined surgical 15. Miller DL, Allen MS, Trastek VF, et al. Esophageal resection
approach in the management of achalasia of the esophagus. Am for recurrent achalasia. Ann Thorac Surg. 1995;60(4):922–
Surg 1976;42:192–195. 925.
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16 Open Esophageal Myotomy
and Resection of
Epiphrenic Diverticula
André Duranceau
Introduction
Epiphrenic diverticula are outpouchings in the distal 1/3 of the esophagus due to her-
niation of the esophageal mucosa and submucosa through the muscular layers of the
esophageal wall. Most patients with an epiphrenic diverticulum (>75%) have abnormal
esophageal motility. Therefore, epiphrenic diverticula are typically treated with divert-
iculectomy to correct the outpouching and myotomy to address the underlying motor
disorder.
Indications/CONTRAINDICATIONS
Dysphagia, food regurgitation, and chest pain are the presentation symptoms recorded
in patients with epiphrenic diverticula. The main reason for suggesting a surgical
approach is the regular and progressing discomfort resulting from the underlying motor
dysfunction. The condition is usually present in high-strung individuals and proper
physiologic and psychological investigation is indicated. Up to one-third of all patients
with an epiphrenic diverticulum are asymptomatic. These patients can be treated con-
servatively but kept under observation as 20% will show an increase in size of the
diverticulum. Inflammation, bleeding, fistulisation, and cancer formation are complica-
tions that may result from an intrathoracic epiphrenic diverticulum.
Indications • Severity of symptoms associated with the diverticulum

• Complications related to the diverticulum
• Progression in size of the diverticulum
Contraindications • Asymptomatic patient
• Associated medical condition
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Symptom evaluation is important as symptom frequency, duration, and severity repre-
sent the main indicators to proceed with surgery.
Radiologic evaluation of the esophagus is essential to document the anatomy and
exact location of the diverticulum. Epiphrenic diverticula are found on the distal 10 cm
of the esophagus above the cardia (Fig. 16.1). They usually develop on the right pos
terolateral side of the esophageal wall and are frequently associated with a small sliding
hiatal hernia.
Manometric evaluation of esophageal function is essential as a majority of the
patients will be documented with a primary idiopathic motor disorder of the spastic or
achalasic variety. Dysfunction of the lower esophageal sphincter (LES) may be recorded
intermittently but is still a significant abnormality that probably plays a major role in
the functional obstruction of the distal esophagus and the eventual appearance of hyper
pressures and diverticular herniation through the esophageal wall. Endoscopy is essen-
tial to document location and orientation of the diverticulum but mostly to rule out
associated benign or malignant esophageal lesions.
Essential evaluation • Symptoms

• Esophagram
• Motor function evaluation
• Endoscopy
Figure 16.1 Barium esophagram of an

epiphrenic diverticulum.
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Chapter 16 Open Esophageal Myotomy and Resection of Epiphrenic Diverticula 185
Figure 16.2 Thoracotomy above the

eighth rib with the patient in the right
lateral decubitus position.
Eighth rib

SURGERY
Motility Disorders
n The patient is positioned in a right lateral decubitus and a left thoracotomy above
the eighth rib is completed. The rib is sectioned at the anterior and posterior extrem-
ities. Ventilation is via a double-lumen endotracheal tube, allowing the exclusion of
the left lung. The inferior pulmonary ligament is divided and the lobe is retracted
anteriorly and superiorly (Fig. 16.2).
n The mediastinal pleura is opened along the anterior border of the thoracic aorta, along
the left crus of the diaphragm and then following the posterior pericardial reflection.
The esophagus is mobilized progressively with careful separation of the contralateral
pleura from mediastinal tissues. The integrity of both vagi nerves is protected.
n The diverticulum location has been determined by radiologic and endoscopic inves-
tigation and Penrose drains are placed around the esophagus proximally at the level
of the inferior pulmonary vein and distally at the level of the cardia (Fig. 16.3).
n Most of the epiphrenic diverticula will look toward the right pleural cavity. Thus,
the esophagus and the diverticulum are freed progressively from fascia and vascular
tissues of the mediastinum. Inflammation can be significant around the diverticulum,
and frequently there are adhesions between the diverticulum and surrounding struc-
tures (Fig. 16.4).
Figure 16.3 Penrose drains placed

around the esophagus.
LWBK1254-ch16_p183-192.indd 185 20/02/14 1:38 PM

Figure 16.4 Visualization of the diver-

ticulum after dissection from the
fascia and vascular tissues of the
mediastinum.
Diverticulum
n The esophagus is freed between the inferior pulmonary vein and the diaphragm. A
small hiatal hernia is frequently present, and we free all anterolateral hiatal attach-
ments to mobilize the gastric fundus from the gastrosplenic vessels. The whole gas-
troesophageal junction is delivered into the chest through the hiatus.
n With the esophagus and proximal stomach completely mobilized, the esophagus and
the diverticulum can be rotated easily to allow easy access for dissection of the
diverticulum by the surgeon. With a Duval clamp holding the diverticulum, the
fibromuscular tissue covering its neck or collar is freed progressively and the defect
in the esophageal muscularis is identified (Fig. 16.5). A large, weighted bougie (50 to
56 French) is passed into the stomach and helps to free the esophageal mucosa above
and below the collar of the diverticulum.
n The diverticulum generally develops due to the presence of a motor dysfunction of
the esophagus. Depending on its position in the esophageal circumference, the diver-
ticulum may be part of the myotomy that needs to be completed or may need to be
treated separately.
Diverticulum Figure 16.5 Duval clamp grasping the

diverticulum, which has been freed
from surrounding fibromuscular tissue.
LWBK1254-ch16_p183-192.indd 186 20/02/14 1:38 PM

Figure 16.6 Typical orientation of an

Diverticulum
Right vagus
nerve

Motility Disorders
Left vagus
nerve
n A large-mouthed diverticulum developed toward the left chest may be managed with
a long myotomy surrounding the collar of the diverticulum and extending proximally
to its upper limit. The diverticulum, if shallow, can then be suspended to the rim of
the divided muscularis in order to eliminate any dependency of the sac.
n Usually, the diverticulum will be oriented toward the right chest and will need to
be resected (Fig. 16.6).
n Special care must then be taken to protect the integrity of the esophageal lumen by
ensuring the presence and correct positioning of the large endoesophageal bougie
(Fig. 16.7A).
Figure 16.7 A: Large bougie placed in the

esophagus. B: Esophagus after resection of
the epiphrenic diverticulum.
Large endoesophageal
bougie
LWBK1254-ch16_p183-192.indd 187 20/02/14 1:38 PM

A B
Figure 16.8 A: Placement of traction sutures and resection of the diverticulum. B: Suture closure of the esophagomyotomy.
n The resection is at the level of the collar with the bougie offering protection against
excess mucosal resection. The resection is completed either with an open handmade
repair or using a stapler technique (Fig. 16.7B).
n Traction sutures are placed on the proximal and distal borders of the diverticulum
collar, and the diverticulum is resected (Fig. 16.8A).
n The esophagotomy is closed as for a standard handmade anastomosis; inverted total
layers sutures are used for the extremities, and the closure is completed by single
sutures tied externally (Fig. 16.8B).
n Using the same precautions for protection of the esophageal lumen integrity, a linear
5- or 6-cm stapler can be used to close the neck of the diverticulum. A 1-cm rim of
mucosa is left distal to the stapling line and a second row of suture integrates that
rim of mucosa with closure of the muscularis over the resection line (Fig. 16.9).
n The esophagus resumes its normal position following resection of the diverticulum.
n A posterolateral long esophageal myotomy is planned contralaterally, from a level
above the upper border of the diverticulum collar and extending distally 2 to 3 cm
Figure 16.9 Stapled closure of the

esophagomyotomy.
LWBK1254-ch16_p183-192.indd 188 20/02/14 1:38 PM


Motility Disorders
A C
Figure 16.10 (A–C) Posterolateral, long esophageal myotomy.
on the stomach wall. The myotomy is planned as an inverted T where distal lateral
transection will allow suture eversion of the gastric muscularis. The spastic motor
abnormality present in these patients motivates this type of myotomy, and the LES
effects must be removed as well as it is also dysfunctional (Fig. 16.10).
n When myotomy is performed, many surgeons also do a partial fundoplication. The inci-
dence of gastroesophageal reflux disease (GERD) in patients who have undergone a
myotomy after resection or suspension of an epiphrenic diverticulum is unknown. How-
ever, GERD occurs in ∼50% of patients who have undergone myotomy for achalasia.
n At the completion of the operation, the patient has:
1. An epidural catheter for the control of pain during the first 3 to 4 postoperative
days
2. A thoracic-drainage catheter in the left side of the chest
3. A nasogastric tube to decompress the stomach
4. Many surgeons also leave a small drain near the esophageal suture line in case of
a postoperative leak
n Prophylactic antibiotics to cover aerobes and anaerobes are used preoperatively and
for the first day after the operation if the diverticulum has been resected. The nasogas-
tric tube is removed as soon as proper peristaltic activity has been identified.
n The chest tube is removed when no air leak has been documented for 48 hours and
when less than 200 mL of chest drainage is recorded for the last 24 hours.
n A barium swallow is obtained when all drainage catheters have been removed, to
ascertain the integrity of the diverticulum transection line. A soft-food diet is started
the same day.
n The patient is usually discharged the 5th or 6th day and with follow-up ensured at
the outpatient clinic a few weeks later.
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Complications
In our series of 23 patients who underwent transthoracic diverticulectomy and myotomy,
morbidity was observed in 2 patients. The morbidity was related to pulmonary atelecta-
sis in one patient and to pulmonary embolism in another. There was no mortality. In
other series, morbidity ranged from 0% to 33% and mortality ranged from 0% to 9%.
In a systematic review of 13 studies, morbidity occurred in 18% of patients (41/224)
and mortality in 4% (9/224).
Reported complications can be related to the operative technique, for example, nar-
rowing of the lumen at the diverticulectomy site when insufficient protection of the
esophageal lumen integrity has been offered. Leakage at the diverticulum transection
line is the most feared complication as it can result in severe sepsis and death. Leakage
is usually associated with not performing an esophagomyotomy that includes the LES
after resecting the diverticulum. Reflux disease may result over time after the myotomy,
despite the partial fundoplication usually offered to prevent it. Proper follow-up and
medication may prevent this.
Results
n Significant improvement of dysphagia and chest pain.
n In Benacci’s series of 33 patients who underwent transthoracic surgical repair
of epiphrenic diverticula, 29 of 30 postoperative survivors were followed for up to
15 years (median 6.9 years, range 4 months to 15 years). Excellent long-term results
were seen in 14 patients (48%) who were symptom-free and able to eat normally; 8
patients (28%) reported minimal symptoms; 5 (17%) had improved symptoms but
required either antireflux medication or esophageal dilation; and 2 (7%) had no
improvement in their preoperative symptoms.
n In Varghese’s series of 35 patients who underwent transthoracic surgical repair of
epiphrenic diverticula, all patients were satisfied with the results of the operation
during follow-up (median follow-up: 33 months). The surgery completely resolved
the preoperative symptoms in 76% of patients; 21% had mild dysphagia requiring
intermittent esophageal dilation. One patient had a poor outcome and required regu-
lar esophageal dilations to relieve dysphagia.
n Widening of the esophageal lumen.
n Weakening of LES.
n Frequent reflux disease over time.
Conclusions
n Basic investigation of the epiphrenic diverticulum should include symptom assess-
ment with radiologic–endoscopic and esophageal motor function evaluation.
n A symptomatic diverticulum is the main indication for operation.
n The essential aspect of the operation is the esophageal myotomy that must include
the LES and extend to the proximal neck of the diverticulum.
n One of the most feared complications is a postoperative leak near the esophageal
staple line; therefore, many surgeons choose to leave a drain near this area.
n The diverticulum itself should be seen as the complication of the dysfunction. It is
either resected or suspended.
LWBK1254-ch16_p183-192.indd 190 20/02/14 1:38 PM

Recommended References and Readings 4. Duranceau A. Long esophageal myotomy and excision of diver-
ticula. In: Kaiser LR, Jamieson GG, eds. Operative Thoracic Sur-
1. Benacci JC, Deschamps C, Trastek VF, et al. Epiphrenic diver- gery. Hodder Arnold Publisher; 2006.
ticulum: Results of surgical treatment. Ann Thorac Surg. 1993; 5. Soares R, Herbella FA, Prachand VN, et al. Epiphrenic diver-
55(5):1109–1113. ticulum of the esophagus. From pathophysiology to treatment.
2. D’Journo XB, Ferraro P, Martin J, et al. Lower oesophageal J Gastrointest Surg. 2010;14(12):2009–2015.
sphincter dysfunction is part of the functional abnormality in 6. Varghese TK Jr., Marshall B, Chang AC, et al. Surgical treatment
epiphrenic diverticulum. Br J Surg. 2009;96(8):892–900. of epiphrenic diverticula: A 30-year experience. Ann Thorac
3. Duranceau A. Diverticula of the esophageal body. In: Jamieson Surg. 2007;84(6):1801–1809.
GG, ed. Surgery of the Esophagus. New York, NY: Churchill 7. Zaninotto G, Portale G, Costantini M, et al. Therapeutic strate-
Livingstone. 1988; Chapter 53:489–500. gies for epiphrenic diverticula: Systematic review. World J Surg.
2011;35(7):1447–1453.

Motility Disorders
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LWBK1254-ch16_p183-192.indd 192 20/02/14 1:38 PM
17 Minimally Invasive
Approach to Resection of
Thoracic and Epiphrenic
Diverticula
Virginia R. Litle, James D. Luketich, and Hiran C. Fernando
Introduction
Esophageal diverticula of the mid- and distal esophagus are rare lesions with an esti-
mated prevalence of less than 0.1% of the United States population. They are classified
by location and extent of esophageal wall involvement. Midesophageal “true” diver-
ticula are typically traction diverticula involving all layers of the esophageal wall and
associated with mediastinal inflammation. In the majority of patients, midesophageal
diverticula are small and frequently asymptomatic. Occasionally, especially individuals
from regions where histoplasmosis is endemic, traction-type diverticulum of the mid
esophagus may enlarge and take on the appearance of epiphrenic diverticula without
any associated apparent distal luminal obstruction or motor disorder. Distal esophageal
diverticula are typically “false” or pulsion diverticula that are most commonly present
in the epiphrenic location due to esophageal motility disorders including achalasia.
With advances in minimally invasive approaches to treat esophageal pathology over the
past two decades, thoracoscopic and laparoscopic techniques are available to surgically
resect symptomatic or large diverticula.
Indications for surgical intervention for esophageal diverticula include symptoms, large
diverticula size, bleeding, and rarely cancer of the diverticulum (Avisar, 2000). Symptoms
commonly include chest pain, dysphagia, and regurgitation of food or pills. Some patients
are treated primarily for an achalasia pattern of symptoms and likely will need resection
of the diverticulum and myotomy. Most patients seen by a surgeon are referred for symp-
toms, and the decision to operate is fairly straightforward, but in some cases, we have
193
LWBK1254-ch17_p193-202.indd 193 19/02/14 5:16 PM

operated on asymptomatic patients depending on the size of the diverticulum and the
degree of motor dysfunction that is revealed on workup. If the decision is made not to
operate due to absent or minimal symptoms, we recommend follow-up, as it is likely that
the epiphrenic diverticulum will enlarge and become symptomatic over time.
Our treatment of choice for diverticula in an epiphrenic location, associated with
achalasia, hypertensive lower esophageal sphincter, or other motility disorders with
abnormal manometry isolated to the distal esophagus is a right thoracoscopic diverti-
culectomy and a distal myotomy down onto the stomach. While some surgeons have
advocated a laparoscopic approach, it can be quite difficult to retract the diverticulum
at a right angle to the esophagus, expose the narrow neck, dissect this away from the
musculature, and completely resect the diverticulum at its base laparoscopically. The
laparoscopic approach does make the distal portion of the myotomy easier and also
facilitates the creation of a partial fundoplication. However, we have seen several
patients, both who have been treated exclusively by our practice and who have had a
diverticulectomy performed elsewhere and then been referred to us, over the years with
incompletely resected epiphrenic diverticula performed laparoscopically. Regardless of
the approach, it is essential that a careful myotomy be performed distal and to some
degree proximal to the diverticulum to allow adequate exposure of the neck. The larger
the diverticulum is, and if there is an extension into the chest, the more compelling the
argument to perform these cases via a video-assisted thoracoscopic (VATS) approach. If
the VATS approach does not afford the view or access for a complete myotomy onto the
stomach, one can always perform a laparoscopy at the end of the VATS portion of
the case, complete the myotomy, and perform the anterior fundoplication.
Indications for Diverticulectomy

n Dysphagia.
n Regurgitation.
n Cancer or dysplastic degeneration within the diverticulum.
n Weight loss.
n Aspiration.
n Large diverticula with minimal to no symptoms in low-risk surgical patients.
Considerations for Observation

n No symptoms.
n Small diverticula (<5 cm) with minimal to no symptoms.
n Significant mediastinal adenopathy in patients with midesophageal diverticula. An
open approach should be considered. This may have to be determined intraoperatively.
n Elderly, high-risk surgical patients with minimal symptoms.
For midthoracic and epiphrenic diverticula, a barium swallow and an upper endoscopy
should be performed preoperatively (Fig. 17.1). At some point, the surgeon should also
perform his or her own flexible upper endoscopic examination of the patient prior to the
procedure to identify the location of the diverticulum and to assess other potential-
associated esophagogastric pathology. Ideally, manometry should be performed to assess
the degree of esophageal motor dysfunction. This can generally be performed by an expe-
rienced esophageal testing center; it may require fluoroscopic or endoscopic guidance.
Patients with epiphrenic diverticula should have a clear liquid diet instituted at
least 2 to 3 days before surgery to reduce risk of aspiration related to uncleared/retained
esophageal and diverticular debris. This is especially important in patients with large
diverticula and when a large diameter esophagus is present in the setting of achalasia.
If significant debris is present at the time of the on-table endoscopy, careful clearance
of all esophageal contents should also be performed. These interventions and periop-
erative risks should be discussed with the patient prior to surgery.
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Chapter 17 Minimally Invasive Approach to Resection of Thoracic and Epiphrenic Diverticula 195

Motility Disorders
A B
Figure 17.1 A: Barium esophagram of a large epiphrenic diverticulum. B: Endoscopic view of an epiphrenic diverticulum. The
diverticulum is in the upper right corner of the field.
SURGERY
n In the operating room, the patient is maintained in a supine position, and rapid
sequence induction of general anesthesia is performed to minimize aspiration risk.
The surgical team should be present at this time to assist with a Sellick maneuver
and to alert the entire team to the risk of aspiration.
n An esophagogastroduodenoscopy (EGD) should be performed at the start of the pro-
cedure to ensure that the esophagus and diverticula are clear of food debris. Esophagos-
copy should also be performed after completion of the diverticulectomy during the
surgical intervention, regardless of whether a myotomy was performed, to ensure that
the mucosa and muscular wall of the esophagus at the area of the diverticulectomy
are intact, and that no leak is present.
VATS Approach
n The patient is placed in lateral decubitus position after double-lumen endotracheal
intubation has been successfully accomplished to establish contralateral single-lung
ventilation during the thoracic procedure. Proper endotracheal tube position is
assured with bronchoscopic examination.
n A right VATS approach can be used for epiphrenic and midesophageal diverticulum
with the surgeon standing on the right side of the table (posterior aspect of the
patient). In some cases, some surgeons will prefer a left VATS approach to the epi-
phrenic diverticulum as it may make easier to carry the myotomy down onto the
stomach.
n In our practice, we have successfully used the right VATS approach for virtually any
mid- to distal esophageal diverticulum. In this setting, we place a retraction suture on
the diaphragm to gain lower exposure, and put the patient in a moderate reverse Tren-
delenburg position to allow gravity to facilitate better exposure of the lower esophagus.
n A 10-mm port is placed in the seventh or eighth intercostal space (Fig. 17.2) anteri-
orly for the initial thoracoscopic exploration and direction of subsequent intercostal
access sites. Placing the port as low as possible has advantages for exposure of the
LWBK1254-ch17_p193-202.indd 195 19/02/14 5:16 PM

Figure 17.2 Port placement for

thoracoscopic repair.
distal esophagus and, frequently, we place this port right at the costophrenic angle.
Posteriorly, we place another 10-mm port near the eighth intercostal space; again,
keeping this port lower will facilitate the dissection angles. A 5-mm access site is
established near the posterior scapular tip. During resection of true epiphrenic diver-
ticulum, it may be wise to lower this port one interspace, especially in tall patients.
Next, another 5-mm port is placed two to three interspaces above the camera port
and just medial (toward the sternum) to allow a suction irrigator to keep the plane
of dissection bloodless. The final 10-mm port is place higher, medial to the anterior
axillary line, to allow placement of a fan-type lung retractor.
n The presence of a first and second assistant allows the operation to flow more expe-
ditiously as the first assistant holds the camera and the suction device and the second
assistant retracts the lung. Alternately, a self-retaining retractor can be used for the
lung retraction.
n Division of the azygos vein with a vascular endoscopic stapler is often required to
gain clear access/dissection for midesophageal dissection.
n The esophagus is mobilized above and below the diverticulum with sharp dissection
using autosonic shears, a harmonic scalpel, or similar device.
n The diverticulum is identified and completely mobilized, and its neck/base is exposed
for subsequent resection (Fig. 17.3). The epiphrenic and the larger midesophageal
diverticula are commonly “false diverticula” and the delineation of the submucosa of
the diverticula neck will be evident during the course of this dissection.
Figure 17.3 Exposed base of an

LWBK1254-ch17_p193-202.indd 196 19/02/14 5:16 PM

n The start of this dissection should be away from the true esophageal lumen until the
dissection planes are well established. Care should be taken to retract upward on the
diverticulum itself as this portion will be later resected and frequently is quite fibrous
even though it is primarily made up of only esophageal mucosa.
n It is important during the initial phases of the operation to identify the course of the
right vagus nerve from the right VATS approach. Sometimes this is best accom-
plished by first opening the mediastinal pleura above and below the diverticulum
and starting the myotomy; care must be taken as the myotomy extends down near
the junction of the native esophageal lumen with the diverticulum.
n The lateral separation of the longitudinal muscle layers and the remaining circular
fibers at the neck of the diverticulum, both proximal and distal, is critical to allow
a clear stapling plane to the diverticulum. Failure to precisely visualize the narrow
neck, compared with the broad body of the diverticulum, will lead the inexperienced
surgeon to staple early and incompletely remove the diverticulum. It is essential that
the lateral muscle wall is free from the neck of the diverticulum in a 360-degree

fashion before preparing to staple off the diverticulum.
n At any point during the dissection, placement of a soft-tipped bougie will facilitate
stabilization of the esophageal lumen and allow the surgeon to concentrate on the
plane between the mucosa and the muscle walls. We use a 50- to 54-French bougie.
Motility Disorders
This also will lower the risk of narrowing the native lumen of the esophagus exces-
sively during stapling of the diverticulum.
n An endoscopic gastrointestinal stapler (typically a rotating and articulated 45-mm
stapler with a 3.5-mm staple cartridge) is placed across the neck/base of the diver-
ticulum delineated by the line of defect in the longitudinal musculature of the
esophagus, and the diverticulum is stapled and excised with the bougie in place
within the esophagus (Fig. 17.4).
n We prefer to use an articulating head on the stapler to gain an angle of 45 degrees or
more. If the stapler is inserted from the lowest anterior port possible, one can generally
get a satisfactory angle of the stapler relative to the bougie. This is critical to get the
staple flush on the neck of the diverticulum to avoid leaving a residual diverticulum.
n Prior to resection of the diverticulum, we generally use the diverticulum as a handle
to some degree to facilitate the distal myotomy down onto the stomach. The surgeon
can open the pleura at this level and visualize the crus and deliver a small amount
of gastric cardia into the chest. If this can be accomplished via the VATS procedure,
then the myotomy can be extended distally onto the stomach (Fig. 17.5). The com-
pleteness of the myotomy is best assessed by removing the bougie and endoscopi-
cally evaluating the esophagus to (1) rule out any staple line leaks, (2) make sure all
of the diverticulum is resected, and (3) make sure all of the distal muscle ring is
opened up to allow easy passage of the endoscope into the stomach.
n At this point, the surgeon must decide if a partial fundoplication is needed. In the
past, using a left VATS approach we performed a small series of these diverticula
repair with a VATS Belsey but were not satisfied with the technical outcome. There-
fore, we prefer to do these using a right VATS approach with selective laparoscopy
to complete the distal myotomy if needed, or to add a partial wrap laparoscopically.
In some cases, we discuss with the patient that the latter part of the operation may
be via a staged approach. That is if the myotomy and diverticulectomy lead to a
satisfactory outcome, then no further surgery would be indicated. If however, sig-
nificant reflux develops, a second stage of performing a laparoscopic partial fundop-
lication may be indicated.
n Of note, we have performed over 40 thoracoscopic diverticulectomies with this
selective approach, and less than 10% of patients developed any significant reflux
after a careful myotomy and diverticulectomy using the right VATS approach. If
there is manometric evidence of achalasia, we would consider adding the laparo-
scopic portion.
n After diverticulectomy, we prefer to reapproximate the muscle layers in a running
or interrupted fashion and end this closure at the start of the distal esophageal myo-
tomy as it extends onto the stomach. We then lay a Jackson-Pratt (JP) drain near the
LWBK1254-ch17_p193-202.indd 197 19/02/14 5:16 PM

Diverticulum
Bougie Esophagus B
A
Figure 17.4 A: A bougie is placed in the esophagus and the endoscopic stapler is used to excise the diverticulum. B: Stapler on the
neck of the diverticulum. C: Excision of the diverticulum with the stapler.
Submucosa Muscle fibers
Figure 17.5 A myotomy is made with ultrasonic shears or hook cautery.
LWBK1254-ch17_p193-202.indd 198 19/02/14 5:16 PM

staple-line repair, but not directly on it, and close the mediastinal pleura over this
drain.
n A 28-French chest tube is placed outside of the reapproximated mediastinal pleura.
Laparoscopic Approach
Generally, a laparoscopic approach is considered as the first operation when there is obvi-
ous concurrent achalasia necessitating not only a myotomy extending onto the stomach
but also a partial fundoplication. The biggest problem we have seen with the laparoscopy
only approach is that there can be significant difficulty in retracting the diverticulum
at a right angle to the native esophagus. If this is not done, it can be very difficult to
dissect out the epiphrenic diverticulum, which can be quite large. Difficulty in retract-
ing the diverticulum can also lead to significant retraction against the right crus leading
to damage to these muscles. We use a laparoscopic approach primarily for smaller epi-
phrenic diverticulum with clear manometric evidence of achalasia. Following the
esophagomyotomy, a concurrent antireflux procedure is performed. A partial fundopli-

cation (Dor or Toupet) is routinely utilized in these circumstances. Similar to the VATS
approach, if the surgeon is not happy with the conduct of the laparoscopic resection of
the diverticulum, it may be necessary to complete the myotomy, and the partial wrap
Motility Disorders
and then do a right VATS to complete the resection of the diverticulum.
General Considerations for Laparoscopy

n The patient is placed in the supine position, slightly to the right side of the table to
facilitate placement of a lateral port for a liver retractor.
n A footboard is used, so as to prevent patient sliding when the patient is in the reverse
Trendelenburg position during the operation.
n The surgeon stands on the patient’s right side, the first assistant surgeon stands on
the patient’s left.
n Five laparoscopic ports are used with one 10-mm port and four 5-mm ports (Fig. 17.6).
n Our preference is to use ultrasonic coagulating shears for the major portion of the
dissection.
n The gastrohepatic ligament is opened using the ultrasonic shears.
Figure 17.6 Port placement for laparo-

scopic repair.
LWBK1254-ch17_p193-202.indd 199 19/02/14 5:16 PM

n The right crus is identified and the esophagus dissected away from this with care
taken to preserve the peritoneal lining over the crus.
n The proximal two or three short gastric vessels are ligated and divided using the
ultrasonic shears. This will allow for tension-free mobilization of the fundus for
future partial fundoplication.
n The anterior gastric fat pad is dissected from the gastroesophageal junction. This is
performed from left to right taking care to protect and mobilize the anterior vagus
nerve with the fat pad. The posterior vagus nerve is also carefully protected. This
dissection allows the surgeon to clearly identify the gastroesophageal junction and
determine the optimal length and location of the myotomy.
n The distal esophagus is dissected at the hiatus into the mediastinum, and the epi-
phrenic diverticulum is identified.
n The epiphrenic diverticulum is then dissected with careful exposure of the entire
neck of the diverticulum in relation to the longitudinal musculature of the esophagus.
n A 54-French bougie is placed in the esophagus.
n The epiphrenic diverticulum is resected with an endoscopic gastrointestinal stapler
(typically a rotating and articulated 45- or 60-mm stapler with a 3.5-mm staple cartridge).
n Following resection of the epiphrenic diverticulum, the overlying esophageal muscle
layer is closed using the surgeon’s preferred laparoscopic suturing technique with
interrupted 2-0 permanent suture.
n Attention is then turned to the contralateral esophageal wall for the long esoph-
agogastric myotomy. Epinephrine (1 mL of 1:1,000 in 19 mL normal saline) is injected
into the muscular layers of the anterior wall of the distal esophagus, the gastro-
esophageal junction and the proximal stomach on the opposite side of the stapled
diverticulum. This improves hemostasis during the myotomy and also elevates the
submuscular–submucosal plane for the myotomy dissection.
n The myotomy is then performed on the opposite side of the diverticulum extending
from the level of the diverticulum down onto the first 2 to 3 cm of the stomach. The
myotomy is performed using a combination of sharp dissection with ultrasonic
shears or a hook cautery and blunt dissection with endopeanut dissectors.
n Esophagogastroscopy is performed upon completion of the myotomy by the operating
surgeon to assess for mucosal violation and potential leak. If a mucosal injury is
identified, laparoscopic suture repair is performed with coverage of this area with
the anterior partial Dor fundoplication.
n If performing the procedure entirely by laparoscopy, we would position a JP drain
off to the side of the diverticulectomy.
n We routinely include a partial fundoplication (an anterior modified Dor (Fig. 17.7)
or a posterior Toupet) with the laparoscopic approach. Sutures are placed between
Figure 17.7 A partial anterior fundopli-

cation (Dor) is done after completion of
the long esophagogastric myotomy.
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the fundus and the myotomized esophageal muscle to help keep the myotomy open
when a posterior fundoplication is performed.
n We strongly prefer not to use a nasogastric tube due to concerns about traumatizing
the myotomized esophagus. If placement of a nasogastric tube is the surgeon’s prefer-
ence, the nasogastric tube should be placed carefully, and it should be made clear in
the postoperative orders that no one should manipulate the tube and that suction
should be intermittent or with very low vacuum to avoid injury to the esophageal
mucosa.
VATS or Laparoscopy

n If a nasogastric tube has been used, it is typically removed on the first postoperative
day; a postoperative ileus is uncommon with either VATS or laparoscopy.
n We recommend obtaining a barium swallow on postoperative day 1 or 2 before ini-
Motility Disorders
tiating an oral diet. This study is used to assess esophageal leak and to get a good
baseline examination to confirm complete diverticulectomy (Fig. 17.8).
VATS
n The chest tube is removed on the day of the barium swallow, if negative.
n The JP drain is generally moved slightly after a negative swallow but left in place.
We remove the JP drain on the first postoperative visit, which is about the twelfth
postoperative day.
n Routine pain management is administered with patient-controlled analgesia, and
then oral liquid pain medication.
Figure 17.8 Barium esophagram of the esophagus after repair of the large
epiphrenic diverticulum shown in Figure 17.1.
LWBK1254-ch17_p193-202.indd 201 19/02/14 5:16 PM

Complications
Perioperative complications occur in 0% to 45% of patients and include the following.
n Intraoperative perforation risk is low (<2%), and perforations should be repaired
carefully with interrupted sutures.
n Postoperative esophageal leak ranges from 0% to 23% in larger series, which provides
the indication for the JP drain in all cases.
n Leak is minimized by a careful dissection between the sac and the diverticular neck,
closure of the muscle layer over the mucosal staple line, and performing an adequate
myotomy onto the gastric cardia.
n Pneumothorax from invasion of the mediastinal pleura during laparoscopic dissec-
tion of the diverticulum is common and should be recognized intraoperatively. If
needed, a pigtail thoracostomy can be placed intraoperatively.
n Aspiration pneumonia can be minimized by attention to the preoperative bowel
preparation and by assuming there is a full esophagus during intubation.
n Empyema generally occurs only if there is an undrained leak or unrecognized leak.
n Mortality is less than 1% in most published series.
Results
In published series with small numbers of patients treated with minimally invasive
approaches, recurrence rates are low (10%) as identified on barium swallows done for
symptoms. Symptomatic relief of the chest pain, dysphagia, and regurgitation is seen
in over 90% of patients in most series. The need for reoperation for a symptomatic
recurrent diverticulum should be low if both the myotomy and diverticulectomy are
complete (Fernando, 2005; Kilic, 2009).
Conclusions
Esophageal diverticula are rare benign esophageal lesions that can be treated minimally
invasively when symptomatic or large. Approach via VATS or laparoscopy is deter-
mined by the location of the diverticulum within the esophagus and the skill set of the
surgeon. An underlying motility disorder must be suspected in patients with epiphrenic
diverticula, and a myotomy should be performed. The addition of a partial wrap should
be considered in cases where a manometric diagnosis of achalasia is confirmed. In many
cases, a VATS diverticulectomy and myotomy can be performed onto the gastric cardia.
If only a nonspecific motor disorder is present, this generally leads to a very good post-
operative relief of symptoms with minimal reflux. The esophageal leak rate after diver
ticulectomy and myotomy using a minimally invasive approach can reach 20%, as
reported in larger series, and therefore most surgeons leave a drain and obtain a routine
barium swallow. The perioperative mortality has been less than 1% in most series.
Recommended References and Readings 6. Melman L, Quinlan J, Robertson B, et al. Esophageal manometric
characteristics and outcomes for laparoscopic esophageal divert-
1. Avisar E, Luketich JD. Adenocarcinoma in a mid-esophageal iculectomy, myotomy, and partial fundoplication for epiphrenic
diverticulum. Ann Thorac Surg. 2000;69(1):288–289. diverticula. Surg Endosc. 2009;23(6):1337–1341.
2. Benacci JC, Deschamps C, Trastek VF, et al. Epiphrenic diver- 7. Palanivelu C, Rangarajan M, John SJ, et al. Laparoscopic trans-
ticulum: Results of surgical treatment. Ann Thorac Surg. 1993; hital approach for benign supra-diaphragmatic lesions of the
55(5):1109–1114. esophagus: A replacement for thoracoscopy? Dis Esophagus.
3. Del Genio A, Rossetti G, Maffetton V, et al. Laparoscopic 2008;21:176–180.
approach in the treatment of epiphrenic diverticula: Long-term 8. Rosati R, Fumagalli U, Bona S, et al. Laparoscopic treatment of
results. Surg Endosc. 2004;18(5):741–745. epiphrenic diverticula. J Laparoendosc Adv Surg Tech A. 2001;
4. Fernando HC, Luketich JD, Samphire J, et al. Minimally invasive 11(6):371–375.
operation for esophageal diverticula. Ann Thorac Surg. 2005; 9. Schuchert MJ, Luketich JD, Landreneau RJ, et al. Minimally-
80(6):2076–2080. invasive esophagomyotomy in 200 consecutive patients: Factors
5. Kilic A, Schuchert MJ, Awais O, et al. Surgical management of influencing postoperative outcomes. Ann Thorac Surg. 2008;
epiphrenic diverticula in the minimally invasive era. JSLS. 85(5):1729–1734.
2009;13(2):160–164.
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18 Open Cricopharyngeal
Myotomy and Correction
of Zenker’s Diverticulum
André Duranceau
Introduction
Zenker’s diverticula are outpouchings of the pharyngeal mucosa through the posterior
pharynx (Fig. 18.1). Zenker’s diverticula arise in the posterior midline of the esophagus
in Killian’s triangle, between the thyropharyngeus muscle and the cricopharyngeus
muscle. High hypopharyngeal pressure during swallowing, due to a dysfunctional
upper esophageal sphincter (UES), is thought to cause a pulsion diverticulum.
Open myotomy of the cricopharyngeal muscle at the pharyngoesophageal junc-
tion is the operation of choice in patients with hypertonicity of the UES resulting in
significant oropharyngeal dysphagia. Neurologic damage, striated muscle disease,
iatrogenic damage to the junction, and idiopathic disorders are the known causes
that explain the dysphagia. Cricopharyngeal (Zenker’s) diverticulum is classified
within the idiopathic disorders where sphincter dysfunction has been explained by
the presence of a constrictive pathology with muscle atrophy, chronic inflammation,
and fibrous and fatty infiltration. The etiology of this muscle pathology remains
unknown.
Indications/CONTRAINDICATIONS
Open cricopharyngeal myotomy is indicated in any patient in whom significant oropha-
ryngeal dysphagia is documented. Aspiration, regurgitation, and weight loss are also
common presenting symptoms. As the difficulty in swallowing is at the confluence of
the esophageal opening and the tracheobronchial tree, the surgeon needs to be ready to
manage persistent aspiration by laryngeal exclusion or excision. Relative contraindica-
tions to the operation are dictated by the medical condition of the patient. Recently,
some surgeons have advocated transoral stapling in patients with significant medical
comorbidities.
203
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Figure 18.1 Radiographic image of a

Zenker’s diverticulum.
Etiology
n Neurologic
n Myogenic
n Iatrogenic
n Idiopathic
n UES dysfunction alone
n UES dysfunction with pharyngoesophageal diverticulum
n Clinical assessment of symptoms. Assessment of clinical symptoms is essential as
they are the main reason for the intervention. Quantification of the symptoms
by a scoring system or by the patient on a numerical scale is seen as an objective
index of symptom severity with the advantage of allowing post-treatment
assessment.
n Videoradiology of the pharyngoesophageal junction. Videoradiology is an impor-
tant method of investigation, as it describes the very rapid events that occur with
swallowing. The documentation of abnormal sphincter opening, of laryngeal
competence, and of the type and size of the herniated pouch is important for
planning the type of operation to be offered. Distal esophageal pathology must
be ruled out.
n Radionuclide quantification of emptying. Radionuclide scintigrams are used to
quantify bolus retention before surgery and the improved clearance after treatment.
Manometric studies help to understand the pathophysiology of the condition. They
require strict interpretation criteria. The presence of symptoms without any evi-
dence of abnormality on investigation must raise doubts regarding the indication for
surgical treatment.
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Chapter 18 Open Cricopharyngeal Myotomy and Correction of Zenker’s Diverticulum 205
Cricoid cartilage 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.
Incision line

Surgery
Motility Disorders
General Principles
n Myotomy is the essential part of treatment to remove the restrictive dysfunction.
n Treatment of the diverticulum is seen as managing the complication of the
dysfunction.
n Minute diverticula disappear with the myotomy.
n 1- to 3-cm diverticula are suspended.
n Diverticula larger than 4 cm are resected.
Surgical Technique
n The patient lies supine with a pillow under the shoulders. The head is in hyperex-
tension, rotated toward the right. The incision follows the anterior border of the left
sternomastoid muscle and extends from the sternal notch to a few centimetres from
the ear lobe (Fig. 18.2).
n The plane of access to the pharyngoesophageal junction must be developed anterior
to the carotid artery and the deep jugular vein, just lateral and posterior to the thy-
roid gland (Fig. 18.3).
Thyroid gland Trachea Recurrent Figure 18.3 Anatomic structures in the

laryngeal nerve access plane.
Esophagus Common Internal

carotid artery jugular vein
LWBK1254-ch18_p203-210.indd 205 19/02/14 7:28 AM

Prethyroid muscles Omohyoid muscle Figure 18.4 Exposed sternomastoid,

omohyoid, and prethyroid muscles
after division of the subcutaneous
tissues and platysma.
Line of incision Sternocleidomastoid muscle
n Subcutaneous tissues and platysma are divided first. A branch of the cervical cuta-
neous nerve traverses the incision, often in its middle or proximal part, and must
be divided for proper exposure; submandibular cutaneous anaesthesia results. The
sternomastoid muscle is dissected free and the omohyoid and the prethyroid mus-
cles are exposed. They are divided along the incision line, freeing the thyroid gland
(Fig. 18.4).
n Traction is exerted on the thyroid gland by the assistant. The middle thyroid vein is
located and ligated. The deep cervical fascia is then under tension, and it is opened
and divided progressively along the line of the incision. The inferior thyroid artery
is identified and ligated just under the fascia (Fig. 18.5). Occasionally, the vascular
supply to the superior pole of the thyroid must be ligated for proper exposure of the
pharynx and hypopharynx.
n The cellular plane between the buccopharyngeal fascia and the prevertebral fascia is
freed progressively and the whole pharyngoesophageal junction can be lifted and
everted toward the surgeon. The pharyngoesophageal diverticulum develops between
the cricopharyngeus, the cervical esophagus muscularis, and the buccopharyngeal
fascia. The buccopharyngeal fascia must be divided, usually with the use of dia-
thermy, to free the diverticulum (Fig. 18.6).
Inferior thyroid Figure 18.5 Deep cervical fascia is

artery covered by divided along the line of the incision.
deep cervical fascia Thyroid gland
Middle thyroid vein
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Recurrent Figure 18.6 Freeing the plane

laryngeal nerve between the buccopharyngeal fascia
and the prevertebral fascia.
Bulge created
by diverticulum

n Once the pharyngoesophageal diverticulum is freed from the muscularis and the
cricopharyngeus, it is uplifted and a 36-French bougie is passed through the mouth
Motility Disorders
and directed manually into the esophagus. The bougie will serve as a stent during
the cricopharyngeal myotomy and will protect the integrity of the pharyngoesopha-
geal lumen, if the diverticulum needs to be resected. The myotomy is then planned,
using low-powered diathermy, starting 2 cm on the right side of the cervical esopha-
gus, extending 2 more centimetres along the right collar of the diverticulum and then
2 more centimetres on the hypopharynx (Fig. 18.7).
n The myotomy is then transected laterally at its proximal and distal extremities, and
the muscular flap resulting is unwrapped from around the collar of the diverticulum.
It is resected along the left esophageal line for histologic analysis.
n The diverticulum itself must be seen as the complication of the muscle dysfunction.
If it is very small, it will disappear within the mucosa of the myectomized area. If
larger (usually 1 to 4 cm), it is usually uplifted, and its tip is fixed to the transected
muscle of the pharyngeal wall using four or five 3-0 silk stitches (Fig. 18.8). Full-
thickness bites of the diverticulum tip may lead to soiling the operation field with
bacteria from the diverticular pouch.
n When the diverticulum is at 4 cm or larger, it is usually resected. With the intraesopha-
geal bougie secured, a 3-cm linear stapler is placed transversely, at the collar of the
diverticulum, which is then resected, leaving a 1-cm rim of mucosa distal to the
stapled line (Fig. 18.9). This will allow uplifting of the collar to eliminate any
dependency of the remaining mucosal sac.
Figure 18.7 The freed pharyngoesophageal

diverticulum is lifted and a 36-French
bougie is passed into the esophagus
through the mouth.
Hurst 36F bougie
Line of division
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Figure 18.8 Tip of the diverticula is fixed

to the transected muscle of the pharyn-
geal wall using four or five stitches.
Transverse application Figure 18.9 Resection of a large diver-

of linear stapler ticulum via transverse application of a
linear stapler.
Figure 18.10 Fixing the transected collar

of the diverticulum to the hypopharyngeal
musculature.
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Nasogastric tube Figure 18.11 Verifying the integrity of

the mucosa at the resection and myec-
tomy sites by injecting air through a
nasogastric tube while the pharyn-
goesophageal junction is submerged.

Motility Disorders
n The transected mucosa of the collar of the diverticulum is fixed on the muscularis
of the hypopharyngeal musculature. The myectomized area below the diverticulec-
tomy site is left wide open (Fig. 18.10).
n The intraesophageal bougie is removed and meticulous hemostasis is ensured. Integ-
rity of the mucosa at the resection and myectomy sites is verified by injecting air
through a nasogastric tube while the pharyngoesophageal junction is submerged (Fig.
18.11). The nasogastric tube is then directed toward the stomach. Gastric decompres-
sion is ensured for the initial 12 hours. Two small Penrose drains are left along the
myotomy area.
n Many surgeons obtain a postoperative barium esophagram to assess a satisfactory
myotomy and rule out leaks.
n The nasogastric tube installed during the operation is removed the next morning,
and a soft food diet started that same day. The Penrose drains are removed the second
day, and the patient is usually discharged home with oral pain medicine.
n Antibiotics are used prophylactically to protect against aerobic and anaerobic infec-
tions. The patient is seen at the outpatient clinic 1 week after the operation to rule
out any infection or retropharyngeal collection.
Complications
In published series, complications have occurred in 4% to 24% of patients and include
fistula, hematoma, and leaks. Temporary recurrent laryngeal nerve palsy is reported in
2% to 15% of patients, but permanent recurrent laryngeal nerve paralysis is rare.
Typical complications of open myotomy with or without diverticulum resection are
described in Table 18.1.
Results
n Results of Zenker’s diverticulum treatment are uniformly good.
n Resolution of symptoms in >90% of patients.
n For diverticula <3 cm, open cricopharyngeal myotomy, with or without diverticulec-
tomy, was associated with improved symptom outcomes as compared with transoral
diverticulectomy.
LWBK1254-ch18_p203-210.indd 209 19/02/14 7:28 AM

Ta b l e 1 8 . 1
Complications in Patients with Zenker’s Diverticulum
Type of Operation
Total Resection Suspension Myotomy Alone First Operation Reoperation
Number of patients 90 13 64 13 81 9
Specific complications 14 — — — 6 8
Recurrent nerve paralysis 1 0 1 0 0 1
Seroma 1 1 0 0 0 1
Hematoma 3 1 2 0 3 0
Superficial skin infection 2 2 0 0 2 0
Deep cervical abscess — — — — — —
Without fistula 4 1 3 0 0 4
With fistula 2 1 1 0 0 2
Cervical fasciitis 1 0 1 0 1 0
General complications 13 — — — — —
Pneumonia 1 — — — — —
Inappropriate antidiuretic 1 — — — — —
hormone secretion
Urinary retention 9 — — — — —
Cardiac arrhythmia 2 — — — — —
Modified from: Brigand C, Ferraro P, Martin J, et al. Risk factors in patients undergoing cricopharyngeal myotomy. Br J Surg.
2007;94:978–983.
n In a study with up to 10 years of patient follow-up by Bonavina et al., 98% (30/31)

of patients who underwent open diverticulectomy and cricopharyngeal myotomy
were asymptomatic 5 years after surgery and 84.2% (16/19) were asymptomatic
10 years after surgery.
n Mortality after open diverticulectomy or diverticulopexy and cricopharyngeal myo-
tomy is rare, and many published series report no perioperative deaths.
Conclusions
n Cricopharyngeal myotomy removes the obstructive effects of the UES when it is
affected by disease or dysfunction.
n The indications for cricopharyngeal myotomy include the following.
● Neurologic disease
● Muscular disease of striated muscle
● Idiopathic dysfunction of the UES
● Iatrogenic effects of operations in the neck and the oropharyngeal area
n Objective documentation of the dysfunction is essential.
n The cervical approach along the anterior border of the sternocleidomastoid muscle
provides the best exposure to the pharyngoesophageal function.
Recommended References and Readings 5. Duranceau A. Treatment of Zenker’s diverticulum. In: Robert E.
Condon, ed. Current techniques in general surgery. New York,
1. Bonafede JP, Lavertu P, Wood BG, et al. Surgical outcome in 87 NY: Lawrence A. DellaCorte; 1994:3(3):1–8.
patients with Zenker’s diverticulum. Laryngoscope. 1997; 6. Lerut TEMR, Luketich JD, Bizekis C. Esophageal Diverticula. In:
107(6):720–725. Patterson GA, Cooper JD, Deslauriers J, Rice TW, Luketich JD,
2. Bonavina L, Bona D, Abraham M, et al. Long-term results of Lerut AE. (eds). Pearson’s thoracic and esophageal surgery.
endosurgical and open surgical approach for Zenker diverticu- 3rd ed. Philadelphia, PA: Churchill Livingstone/Elsevier; 2008;
lum. World J Gastroenterol. 2007;13(18):2586–2589. chap. 65, pp. 702–713.
3. Brigand C, Ferraro P, Martin J, et al. Risk factors in patients under- 7. Rizzetto C, Zaninotto G, Costantini M, et al. Zenker’s diverticula:
going cricopharyngeal myotomy. Br J Surg. 2007;94:978–983. Feasibility of a tailored approach based on diverticulum size.
4. Cook IJ, Blumbergs P, Cash K, et al. Structural abnormalities of J Gastrointest Surg. 2008;12(12):2057–2065.
the cricopharyngeal muscle in patients with pharyngeal (Zenk- 8. Sideris L, Chen LQ, Ferraro P, et al. The treatment of Zenker’s diver-
er’s) diverticulum. J Gastroenterol Hepatol. 1992;7:556–562. ticula: A review. Semin Thorac Cardiovasc Surg. 1999;11:337–351.
LWBK1254-ch18_p203-210.indd 210 19/02/14 7:28 AM

19 Transoral Repair of
Zenker’s Diverticula
Christopher R. Morse and Peter F. Ferson
Introduction
Zenker’s diverticula are a form of pulsion diverticulum, also referred to as “false”
diverticula as they do not include all layers of the esophageal wall. Zenker’s diver-
ticula occur in an area of muscular weakness (Killian’s triangle) located posterolater-
ally between the inferior constrictor and cricopharyngeal muscles. The condition was
first described by Ludlow in 17641 and subsequently, Zenker published a series of
23 cases in 1877.2 Some surgeons hypothesize that dysfunction of the lower esophageal
sphincter leads to gastroesophageal reflux, thereby stimulating a high tonicity of the
upper sphincter. Years of unabated reflux may lead to a Zenker’s diverticulum essen-
tially as a physiologic, protective response to long-standing failure of the lower esopha-
geal sphincter. In fact, personal communication between Antoon Lerut and James
Luketich revealed that over 50% of Lerut’s patients with Zenker’s diverticula had
pathologic acid reflux and over 80% of the patients with Zenker’s diverticulum in our
series3 had a coexisting hiatal hernia or history of significant reflux (Luketich JD, per-
sonal communication).
Symptoms of Zenker’s diverticula include dysphagia, regurgitation of undigested
food, globus sensation, halitosis, and aspiration pneumonia. Surgical intervention via
an open neck incision has been recognized as the only effective treatment and improves
symptoms and quality of life with little morbidity. Recently, transoral endoscopic repair
of Zenker’s diverticulum has been described and is gaining popularity.
Because many patients with Zenker’s diverticula are elderly, an endoscopic approach
offers potential advantages by avoiding neck incision. However, several technical points
need to be emphasized. It is important to divide the cricopharyngeus muscle completely,
and the diverticulum should be at least 3 cm in size if considering the transoral approach
to allow for entrance of the stapler and a complete cricopharyngeal myotomy. Signifi-
cantly larger diverticula (>6 cm) are also a relative contraindication when considering a
211
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transoral approach, particularly when the diverticulum deviates markedly to one side,
or when there are bilateral pouches, as this approach may leave a considerable residual
diverticulum. Other relative contraindications include the presence of prominent upper
incisors, limited mouth opening, and the inability to adequately extend the neck; these
anatomic features make an endoscopic repair technically difficult.
All patients should be evaluated by a barium swallow and upper gastrointestinal
esophagoscopy. The Zenker’s diverticulum should be at least 3 cm in size to allow a
complete transoral cricopharyngeal myotomy. In addition, patients should be evaluated
for limited mouth opening and inability to adequately extend the neck, which can make
placement of the Weerda laryngoscope difficult. An esophagogastroduodenoscopy (EGD)
should be performed at the time of the procedure by the operating surgeon (even if it
has been done preoperatively) to evaluate the diverticulum, remove any debris from the
diverticulum, and examine the esophagus for any other pathology. During flexible
endoscopy, the anatomy and entry into the native esophagus can be challenging. If there is
difficulty in identifying the normal anatomy, we place a flexible guidewire into the
native esophageal lumen and advance this into the stomach. This facilitates identifying
the anatomy when inserting of the Weerdascope.
Surgery
Necessary equipment for a transoral Zenker’s diverticulectomy includes the following.
n Weerda laryngoscope (Karl Storz, Tuttlingen, Germany)
n Low-profile endostapler to allow stapling and cutting of the sphincter muscle to the
end of the stapler (Fig. 19.1)
n 5-mm 30-degree laparoscope to allow for additional visualization
n 0.035 flexible guidewire
Positioning
Patient is placed supine on the operating table with the head positioned at the top of
the operating table. General anesthesia is established using a small diameter (7 mm)
endotracheal tube. Arms are typically tucked at the patient’s sides. The operating table
should be rotated so that the anesthesia team is to the left.
Technique
n With the patient adequately anesthetized, flexible esophagoscopy is performed to
assess the diverticulum and also to suction any retained material from the diverticu-
lum. At this time, we sometimes place a guidewire in to the native esophagus to help
us place the Weerdascope properly.
Figure 19.1 Stapler with anvil.
LWBK1254-ch19_p211-216.indd 212 19/02/14 7:28 AM

Chapter 19 Transoral Repair of Zenker’s Diverticula 213
Figure 19.2 Weerda laryngoscope.

(With kind permission from: Morse
CR, Fernando HC, Ferson PF, et al.
Figure 1: Preliminary experience by
a thoracic service with endoscopic
transoral stapling of cervical
(Zenker’s) diverticulum. J Gastrointest
Surg. 2007;11:1901–1904, Springer
Science+Business Media).

n Rigid esophagoscopy is performed using the Weerda laryngoscope (Karl Storz,
Motility Disorders
Tuttlingen, Germany). This scope has two jaws (Figs. 19.2 and 19.3). The upper jaw,
which is longer, is placed into the native esophageal lumen and the second is placed
in the diverticulum. The jaws are then expanded which allows clear visualization of
the diverticulum and the common septum formed by the cricopharyngeus muscle
and the esophagus.
n The placement of a 5-mm 30-degree laparoscope alongside the Weerda laryngoscope
can further enable visualization of the distal anatomy during stapler placement and
firing.
n A traction suture (US Surgical Endostitch, Norwalk, Connecticut) is placed in the
common septum (Fig. 19.4). The traction suture helps to expose the septum and
facilitates a complete cricopharyngeal myotomy.
n Using the suture to provide proximal traction on the common septum, the stapler is
placed across the septum and fired (Fig. 19.5). When positioning the stapler, the flat
part of the stapler is placed within the diverticulum, and the disposable cartridge is
placed within the esophageal lumen. Further firings of the stapler are performed as
needed to ensure the common septum is divided to the base of the diverticulum.
Occasionally, the traction stitch is replaced after a firing of the stapler to further expose
any residual septum.
n It is essential to realistically evaluate the progress of the procedure, and to abandon
the transoral approach if it becomes unusually difficult. It is far safer for the patient
to have a well-performed open operation than a complication of an endoscopic
procedure.
Figure 19.3 Placement of the Weerda

laryngoscope.
LWBK1254-ch19_p211-216.indd 213 19/02/14 7:28 AM

Figure 19.4 Placement of traction

suture in the common wall between
the esophagus and the diverticulum.
A nasogastric tube is not inserted. A barium swallow is obtained on the first postop-
erative day. If the barium swallow demonstrates satisfactory results and no leaks, a
liquid diet is initiated and slowly advanced over several weeks. A small residual diver-
ticulum is often noted at the inferior aspect of the divided cricopharyngeus. If it is
small, and the cricopharyngeal septum has been completely divided, the residual diver-
ticulum has minimal clinical significance.
Complications
A leak from the staple line is extremely uncommon and can typically be handled con-
servatively with antibiotic therapy and prohibiting oral intake (nothing by mouth). If
cervical crepitus, erythema, and tenderness develop, drainage may be indicated. Dental
injuries from the placement of the laryngoscope are more commonly reported.
Results
The first report of an endoscopic approach was by Mosher in 1917, where a knife blade
was used to divide the common wall.4 Because of complications, little attention was
paid to endoscopic approaches until Dohlman and Mattsson reported endoscopic divi-
sion of the common septum using a diathermy knife.5 Other subsequent reports have
involved use of a laser to divide the common septum.6 A disadvantage of the above
endoscopic methods is that a mucosal closure is not performed, leaving the possibility
of contamination and infection of the adjacent cervical space. Collard revolutionized
the endoscopic treatment of Zenker’s diverticulum by the introduction of an endoscopic
Figure 19.5 Stapling of diverticulum.
LWBK1254-ch19_p211-216.indd 214 19/02/14 7:28 AM

Chapter 19 Transoral Repair of Zenker’s Diverticula 215
stapler to divide the common septum.7 The stapler completely divides the common
septum, and applies three rows of staples on each side of the section line which provide
excellent closure and hemostasis of the mucosal edges. A study from Gutschow et al.8
compared open surgical intervention with endoscopic repair by either endoscopic sta-
pling or endoscopic laser division. They noted that in larger diverticulum (3 cm or
larger), there was no difference between the endoscopic and open procedures when
examining patients who were either asymptomatic or who had mild occasional symp-
toms. We compared open repair with endoscopic stapling and found no difference in
preoperative and postoperative dysphagia scores with equivalent length of stay and
complications.3
Conclusions
n Transoral repair requires general anesthesia.

n Small diverticula are contraindicated for transoral repair. The diverticulum needs to
be greater than 3 cm to allow for entrance of the stapler and a complete cricopha-
ryngeal myotomy. Significantly larger diverticula (>6 cm) are also a concern when
considering a transoral approach as they may leave a significant residual diverticu-
Motility Disorders
lum, which may lead to symptoms.
n Introduction of scope and stapler is limited in some patients due to limited mouth
opening or neck flexion. This is much less of a problem in the edentulous patient
with a generous mouth opening, which can be assessed preoperatively.
n The stapler chosen should have a low-profile tip to allow stapling and cutting to the
base of the diverticulum.
n A traction stitch in the common septum greatly facilitates exposure and stapling of
the diverticulum and minimizes the tendency for the thick septum to be pushed away
by the stapler instead of being completely divided. A 5-mm 30-degree laparoscope
can also assist with visualization when placed alongside a Weerda laryngoscope.
n A residual distal diverticulum is often present on postoperative barium swallow but
has minimal clinical significance if it is small and if the septum has been completely
divided.
Recommended References and Readings 5. Dohlman G, Mattson O. The endoscopic approach for hypopha-
ryngeal diverticula. Arch Otolarngol. 1960;71:744–752.
1. Ludlow A. A case of obstructed deglutition from a preternatural 6. Knegt PP, de Jong PC, Van der Schans EJ. Endoscopic treatment
bag formed in the pharynx. Med Obs Inquiries. 1769;3:85–101. of the hypopharyngeal diverticulum with the CO2 laser. Endos-
2. Zenker FA, Ziemssen H Von. Dilations of the esophagus. In: copy. 1985;17:205–206.
Cyclopedia of the practice of medicine. Vol 3. London: Low, 7. Collard JM, Otte JB, Kestens PJ. Endoscopic stapling technique
Marston, Searle, Rivington; 1878; 46–68. of esophagodiverticulostomy for Zenker’s diverticulum. Ann
3. Morse CR, Fernando HC, Ferson PF, et al. Preliminary experience Thorac Surg. 1993;56:573–576.
by a thoracic service with endoscopic transoral stapling of cervical 8. Gutschow CA, Hamoir M, Rombaux P, et al. Management of
(Zenker’s) diverticulum. J Gastrointest Surg. 2007;11(9):1091–1094. pharyngoesophageal (Zenker’s) diverticulum: which technique?
4. Mosher HP. Webs and pouches of the esophagus, their diagnosis Ann Thorac Surg. 2002;74(6):1917–1922.
and treatment. Surg Gynecol Obstet. 1917;25:175–187.
LWBK1254-ch19_p211-216.indd 215 19/02/14 7:28 AM

LWBK1254-ch19_p211-216.indd 216 19/02/14 7:28 AM
Part III
Techniques and
Approaches for
Esophageal
Resection
20 Transhiatal Esophagectomy
Darroch W.O. Moores and Dennis J. Rassias
Introduction
Transhiatal esophagectomy (THE) is a safe, expeditious, and effective technique for
resection of benign and malignant diseases of the esophagus. It has several potential
advantages over transthoracic esophagectomy (TTE) and minimally invasive esophagec-
tomy (MIE). It is less costly than MIE and avoids thoracotomy and intrathoracic anas-
tomosis associated with TTE. THE allows access to all of the abdominal gastrointestinal
conduits that may be necessary for reconstruction. This chapter discusses the princi-
ples, indications, diagnostic evaluation, operative techniques, postoperative course, and
potential complications for THE. Our experience is also reviewed.
History
The first blunt transmediastinal esophagectomy without thoracotomy was reported by
Denk in 19131 using a vein stripper to avulse the esophagus in cadavers. In 1933, the
British surgeon Turner2 performed the first successful THE for carcinoma. In that opera-
tion, he re-established gastrointestinal continuity with an anterior thoracic skin tube at
a second procedure.
Ong and Lee (1960) and Le Quesne and Ranger (1966) reported the first successful,
primary pharyngogastric anastomosis after laryngopharyngectomy and total esophagec-
tomy. In 1975, Orringer and Sloan3 described the use of substernal gastric bypass and
thoracic esophageal exclusion for palliation of dysphagia for incurable esophageal car-
cinoma. These results demonstrated that with proper mobilization the stomach is able
to reach above the level of the clavicles for cervical esophagogastric anastomosis. If they
occur, cervical anastomotic leaks are usually less severe than disruption of an intratho-
racic anastomosis. Based on these principles, Orringer and Sloan4 reported a series in
1978 of 28 patients who underwent THE. The experience at the University of Michigan
now includes over 2,000 patients who have undergone THE over the past 3 decades
with 96% of those utilizing stomach as an esophageal substitute.5,6 This experience has
confirmed, in their opinion, that few patients who undergo esophagectomy for benign
or malignant disease require a thoracotomy.
Principles and Justification

In all patients with resectable carcinoma of the esophagus, surgery remains the mainstay
of treatment in conjunction with neoadjuvant chemoradiotherapy. Multiple studies have
217
LWBK1254-ch20_p217-234.indd 217 19/02/14 10:04 AM

218 Part III Techniques and Approaches for Esophageal Resection
concluded that chemotherapy and radiotherapy followed by surgery improves survival

in patients with potentially resectable carcinoma over surgery alone.7,8 Although very
few randomized, prospective trials have demonstrated a benefit,8,9 a recent meta-analysis
lends further credence to the survival advantage provided by neoadjuvant therapy for
esophageal cancer.10 This analysis comparing neoadjuvant chemoradiation and surgery
versus surgery alone in over 1,200 patients showed a statistically significant survival
advantage for patients receiving induction therapy followed by surgery. Orringer reported
583 patients who received neoadjuvant chemoradiation. One hundred twenty-five
patients (21%) were complete responders (T0N0 tumors). These patients had a 2- and
5-year survival of 80% and 58%, respectively.6
The main causes of morbidity and mortality after standard TTE are pulmonary
complications and mediastinitis. Resecting the entire thoracic esophagus via THE vir-
tually eliminates mediastinitis and empyema. It also provides maximal proximal resec-
tion margins. Significant gastroesophageal reflux after THE is also uncommon. 5
Mediastinitis follows disruption of an intrathoracic anastomosis and is associated with
an average mortality of 50%. The technique of THE reduces the physiologic insult to
the patient by avoiding the need for a thoracotomy. A leak after THE is often managed
by simple drainage and establishment of a salivary fistula. When compared with MIE,
THE avoids the prolonged operative time and high costs of performing esophageal
resection. With MIE, the learning curve is exceedingly high and usually requires two
surgeons to perform.
THE has been criticized for ignoring several key surgical principles—exposure,
hemostasis, and inability to perform a complete oncologic resection. From an oncologic
standpoint, lower esophageal lymph nodes are easily resected as are celiac nodes.
Because the overall survival of patients after THE for carcinoma is similar to that
reported after transthoracic resections, it is difficult to argue that the method of esopha-
geal resection determines survival in patients with carcinoma.5
Regardless of which technique of esophageal resection is used, it is very important that
the operation be well tolerated by the patient with low morbidity and complication
rates. It should offer a reasonable expectation to resect all evident tumors without the
cost or risk being prohibitive. Treatment is usually palliative, and an outcome that leads
to a long drawn-out hospitalization is to be avoided.
Orringer et al.5 have stated that all patients being evaluated for an esophagectomy
for benign or malignant disease should be considered potential candidates for THE. We
reserve THE for those patients with lower third esophageal malignancies or benign
disease. Middle third esophageal cancers are treated by an Ivor Lewis approach or a
three-incision technique including laparotomy, thoracotomy, and cervical incision with
anastomosis performed in the neck.
Patients who have positive subcarinal lymph nodes picked up either by positron
emission tomography (PET) or endoscopic ultrasound (EUS) are not offered THE. Those
patients are offered Ivor Lewis or three-field dissection. In cases of gastroesophageal
junction tumors, if the bulk of the mass is on the gastric side of the GE junction, this
is treated as gastric carcinoma with preoperative chemotherapy and esophagogastrec-
tomy by a left thoracoabdominal approach.
At our institution, contraindications to performing THE include middle and upper
third lesions, patients with stage IV cancer, and patients who have bronchoscopic evi-
dence of tracheobronchial invasion.
THE can also be performed in patients with periesophageal fibrosis from previous
surgeries, corrosive injuries, or radiation therapy. If significant adhesions are encoun-
tered during surgery via palpation through the hiatus, the surgeon should be prepared
to convert to a transthoracic approach.
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Chapter 20 Transhiatal Esophagectomy 219
The initial history and physical examination of patients with esophageal carcinoma is
vital. The presence of palpable adenopathy, stigmata of liver disease, and evidence of
malnutrition could indicate unresectability or high operative risk, respectively. A bar-
ium swallow is routinely obtained on all our patients.
PET scan has become an integral tool in the preoperative staging of esophageal
cancer. It can detect metastatic disease which may preclude resection. PET scan can
also be used to determine response to neoadjuvant chemoradiation therapy. EUS is now
also used routinely to define the depth of tumor invasion and presence of mediastinal,
paraesophageal, and celiac axis nodal metastases. All patients at our institution are
evaluated with EUS and PET scans. All patients with T3 or greater tumors or patients
who have nodal involvement undergo neoadjuvant chemoradiation therapy.
Patients should undergo pulmonary function testing and smoking cessation for at
least 2 weeks before THE. All patients receive a cardiology evaluation. When patients
have exhibited severe weight loss and dehydration, percutaneous gastrostomy or jeju-
nostomy feeding tubes can be placed. All patients undergo bowel preparation preop-
eratively in the unlikely event that a colon interposition is needed.
Surgery
Anesthetic Management
We routinely place an arterial line, triple-lumen catheter, and epidural in all patients.
The epidural is vital for postoperative pain control, which then leads to improved pul-
monary function. A Foley catheter is inserted at the start of the case. A dose of IV
cefazolin and metronidazole is given prior to incision. A standard endotracheal tube is
Part III: Techniques and Approaches

used. During the mediastinal dissection, close cooperation and communication between
for Esophageal Resection

the surgeon and the anesthesiologist are required as episodes of hypotension can occur
during the transhiatal dissection. All patients are given volume expansion with albumin
before starting the transhiatal dissection as it appears to prevent hypotension during
this stage of the operation. Patients are started on low dose (2.5 mg) of IV dopamine to
improve splanchnic blood flow. Both the epidural and IV dopamine are continued for
5 days postoperatively.
Positioning
The patient is positioned supine with the head turned toward the right (Fig. 20.1). The
neck is extended by placing a gel pad behind the shoulders. The operative field extends
from the mandibles to the suprapubic area and anterior to both midaxillary lines. The
arms are padded and tucked at the sides. A self-retaining, table-mounted upper abdom-
inal retractor (upper hand retractor) is used to facilitate exposure of the upper abdomen
and hiatus (J. Hugh Knight Instrument Co., Slidell, Louisiana). THE is performed in four
separate phases—abdominal, transhiatal, cervical, and anastomotic.
Abdominal Phase
The procedure is performed through an upper midline incision (Fig. 20.2). The falci-
form ligament is divided. The upper hand retractor is put into place (Fig. 20.3). Assess-
ment of the liver, hiatus, and peritoneal cavity is performed to determine resectability.
The triangular ligament is divided and the liver is retracted laterally. Our dissection
begins at the pars flaccida where gastrohepatic attachments and lesser omentum are
taken down as we proceed superiorly on the lesser curve. These attachments are taken
down sharply with electrocautery or the Ligasure Impact device (Valley Lab, Covidien,
LWBK1254-ch20_p217-234.indd 219 19/02/14 10:04 AM

Figure 20.1 Patient positioned

supine with head toward the
right and a gel pad between the
shoulders. (© 2014 Wm. B.
Westwood, CMI.)
Mansfield, Massachusetts). The right gastric artery is preserved as the dissection is

continued along the lesser curve. The right crus is dissected. The left crus and the angle
of His are mobilized with electrocautery. The hiatus is opened (Fig. 20.4) and the tumor
palpated in the mediastinum to ensure mobility and hence respectability (Fig. 20.5).
The lower esophagus including the periesophageal fat, nodes, and vagus nerves are
encircled with a Penrose drain. At this point, the course of the right gastroepiploic
artery is identified from the pyloroduodenal area to the middle of the greater curvature,
where it generally terminates as it enters the stomach or divides into smaller branches
that anastomose with the left gastroepiploic artery. This vessel will serve as the main
blood supply of the gastric conduit.
Starting at the esophagogastric junction proceeding inferiorly on the greater curve,
the left gastroepiploic and short gastric vessels are ligated with the Ligasure. As the
dissection proceeds down the greater curvature and the omentum is separated from the
Figure 20.2 Upper midline incision is

depicted. (© 2014 Wm. B. Westwood,
CMI.)
LWBK1254-ch20_p217-234.indd 220 19/02/14 10:04 AM

Figure 20.3 A self-retaining table-

mounted upper abdominal retrac-
tor (upper hand retractor, J. Hugh
Knight Instrument Co., Slidell,
Louisiana) is used to facilitate
exposure of the upper abdomen
and hiatus. (© 2014 Wm. B.
Westwood, CMI.)
stomach, care is taken to apply the Ligasure device at least 2 cm below the right gas-
troepiploic artery. Dissection proceeds down to the pylorus. With gentle upward trac-
tion of the stomach, the filmy posterior attachments on the stomach are sharply divided.
The left gastric artery is identified and transected at its origin usually with a linear
vascular stapler. Lymphadenectomy at the celiac axis at this point is also performed
(Figs. 20.6 and 20.7).

Figure 20.4 The hiatus is opened

with cautery, and arterial blood
supply to the conduit is reviewed.
(© 2014 Wm. B. Westwood, CMI.)
LWBK1254-ch20_p217-234.indd 221 19/02/14 10:04 AM

Figure 20.5 Tumor is palpated to ensure

resectability. (© 2014 Wm. B. Westwood,
CMI.)
Figure 20.6 Short gastric

arteries divided by the
Ligasure Impact device
(Valley Lab, Covidien,
Mansfield, Massachusetts).
(© 2014 Wm. B. Westwood,
CMI.)
LWBK1254-ch20_p217-234.indd 222 19/02/14 10:04 AM

Figure 20.7 Celiac lymph nodes are

excised with the Ligasure Impact
device (Valley Lab, Covidien, Mans-
field, Massachusetts). (© 2014 Wm. B.
Westwood, CMI.)
The mobility of the esophageal tumor is once again assessed to ensure that it is not
fixed to the prevertebral fascia, aorta, or surrounding mediastinal structures. The dia-
phragm is incised up to the pericardium to open the hiatus. Retractors can be placed
into the hiatus to allow ligation of the periesophageal tissues to the level of the carina
under direct vision. The value of the Ligasure for this part of the procedure cannot be
overstated. At least 10 cm of the distal esophagus can be mobilized under direct vision.
For this maneuver to be effective, the esophagus should be retracted from one side to
the other in the lower mediastinum to create tension on the tissues on the opposite side
and facilitate their division (Fig. 20.8). Then, with downward traction on the esophagus,
the surgeon’s hand is inserted into the hiatus and further blunt, gentle mobilization of
the esophagus, to at least the level of the carina, is carried out. Mobility of the esophagus

within the posterior mediastinum is assessed. If the esophagus is not fixed and transhi-

atal resection is possible, the mediastinal dissection is completed for now. Throughout
the gastric and esophageal mobilization process, the utmost care in handling the stom-
ach is required.
Figure 20.8 Division of the peri

esophageal attachments are divided
with the Ligasure Impact device
(Valley Lab, Covidien, Mansfield,
Massachusetts). (© 2014 Wm. B.
Westwood, CMI.)
LWBK1254-ch20_p217-234.indd 223 19/02/14 10:04 AM

Figure 20.9 A Kocher maneuver is depicted.

After gastric mobilization has been completed, a generous Kocher maneuver is per-
formed (Fig. 20.9) to allow mobilization of the pylorus to the level of the hiatus. A
20-French jejunostomy tube is placed before proceeding with the cervical phase. This
is usually placed 40 to 45 cm distal to the ligament of Treitz in a Stamm fashion.
Cervical Phase
An oblique incision is made along the anterior border of the left sternocleidomastoid
muscle (Fig. 20.10). The incision is centered on the cricoid cartilage and extends infe-
riorly to the suprasternal notch. Dissection is taken down medially to the carotid sheath.
The omohyoid muscle is divided. Two Gelpi retractors are placed for soft tissue retrac-
tion. The middle thyroid vein and the inferior thyroid artery are ligated. The recurrent
Figure 20.10 A neck incision is made

anterior to the sternocleidomastoid
muscle. (© 2014 Wm. B. Westwood,
CMI.)
LWBK1254-ch20_p217-234.indd 224 19/02/14 10:04 AM

Figure 20.11 The cervical anatomy

is depicted including the relation-
ship of the recurrent laryngeal
nerve to the surrounding struc-
tures. (© 2014 Wm. B. Westwood,
CMI.)
laryngeal nerve is identified and protected. At no time should metal come into contact
with the recurrent laryngeal nerve (Fig. 20.11).
After dissecting to the prevertebral fascia, blunt finger dissection is continued into
the superior mediastinum. The plane between the trachea and esophagus is developed
by sharp dissection; the dissection is kept as posterior to the tracheoesophageal groove
as possible to avoid injury to the recurrent laryngeal nerve. The cervical esophagus is
bluntly mobilized from adjacent tissues circumferentially with attention not to injure
the posterior membranous portion of the trachea. The esophagus is encircled with a
Harkin clamp and is encircled with a small Penrose drain. The upper thoracic esopha-
gus is mobilized almost to the level of the carina using blunt dissection and keeping
the fingers directly against the esophagus. When sufficient mobilization has been accom-
plished, the nasogastric tube is removed and the Sweet scissors (an angled instrument)

are used to transect the esophagus, at the level of the thoracic inlet. It is important to

preserve as much cervical esophagus as possible provided that the blood supply and
the resection margin are adequate (Fig. 20.12).
Transhiatal Phase
Attention is now focused on transhiatal dissection of the esophagus. Esophageal mobi-
lization is begun in an orderly fashion. One hand is inserted through the diaphragmatic
Figure 20.12 The proximal esopha-

gus is transected preserving as
much cervical esophagus as
possible. (© 2014 Wm. B.
Westwood, CMI.)
LWBK1254-ch20_p217-234.indd 225 19/02/14 10:04 AM

Figure 20.13 The surgeon’s hand is

inserted through the hiatus, posterior
to the esophagus, dissecting per-
iesophageal tissue. (© 2014 Wm. B.
Westwood, CMI.)
hiatus, posterior to the esophagus, dissecting periesophageal tissue (Fig. 20.13). The
blood pressure is carefully monitored to prevent hypotension. Anterior mobilization of
the esophagus is done with the fingers directly against the anterior esophagus avoiding
injury to the posterior membranous portion of the trachea. The esophagus is then held in
the superior mediastinum, between the index and the middle fingers of the hand
inserted through the hiatus, and the remaining attachments are lysed with a downward
motion. Subcarinal or subaortic attachments can be finger fractured. The esophagus is
then delivered out of the hiatus. Retractors through the hiatus are placed to inspect for
hemostasis. The posterior mediastinum can be packed to tamponade minor bleeding.
The stomach is separated from the esophagus with multiple loads of a GIA (gastroin-
testinal anastomosis) stapler along the lesser curve. Each time the stapler is removed,
LWBK1254-ch20_p217-234.indd 226 19/02/14 10:04 AM

Figure 20.14 Proximal stomach is

transected leaving a conduit (∼6 cm
wide) preserving collateral circu-
lation to the fundus. (© 2014 Wm.
B. Westwood, CMI.)
traction is applied to the fundus to allow the stomach to be straightened progressively

so that its most cephalad portion is reached. We do not typically tubularize the stomach

as some have advocated. We like to leave a rather broad conduit (about 6 cm wide) to

try and preserve collateral circulation to the fundus (Fig. 20.14). We do not oversew the
staple line. The specimen is now passed off the field.
At this point, a 28-French chest tube is passed through the cervical incision down
through the mediastinum and out the hiatus. We suture the chest tube to the tip of the
stomach using a heavy silk stitch (Fig. 20.15). The chest tube is then pulled up through
the incision, and the stomach is then gently grasped with fingers and pulled out through
the cervical incision. While the stomach is passing through the hiatus, we assure proper
orientation so that the gastric staple line is facing the right side of the patient. The
stomach can be palpated through the hiatus to ensure that there is no torsion. Once the
fundus of the stomach can be seen in the neck, it is grasped with a Babcock clamp and
gently brought up further into the operative field. The suture holding the chest tube is
cut, and we are now prepared for esophagogastric anastomosis.
Cervical Esophagogastric Anastomosis

Over the years, our technique for cervical esophagogastric anastomosis has come full
circle. Techniques used have included one-layer handsewn, modified Orringer, and
end-to-end (EEA) anastomoses. Of all our techniques, we have come to favor the end-
to-side (functional end-to-end) handsewn technique. Our incidence of leaks and need
for dilations have lessened since switching to a one-layer, full-thickness, 2-0 vicryl
(Ethicon, Inc., Somerville, NJ), handsewn anastomosis.
A gastrotomy is made using a cautery away from the gastric staple line. Immedi-
ately, succus entericus is drained out of the stomach using a pool suction. Two stay
sutures are placed on the esophagus marking the lateral edges and keeping proper ori-
entation (Fig. 20.16). Interrupted full-thickness 2-0 vicryl sutures are placed completing
the back wall first (Fig. 20.17). The knots are on the inside on the back wall. The
LWBK1254-ch20_p217-234.indd 227 19/02/14 10:04 AM

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. (© 2014 Wm. B.
Westwood, CMI.)
Figure 20.16 Two stay

sutures are placed on the
esophagus marking the
lateral edges and keeping
proper orientation. (© 2014
Wm. B. Westwood, CMI.)
Figure 20.17 The back wall

of the anastomosis is
completed first with inter-
rupted full-thickness 2-0
vicryl sutures. (© 2014 Wm.
B. Westwood, CMI.)
LWBK1254-ch20_p217-234.indd 228 19/02/14 10:05 AM

Figure 20.18 The anterior wall

of the anastomosis is now
completed using interrupted
full-thickness 2-0 vicryl
sutures. (© 2014 Wm. B.
Westwood, CMI.)
Figure 20.19 Anatomy of the completed

procedure depicted after the stomach
has been pulled down from the hiatus
straightening it. The anastomosis is at
the level of the thoracic inlet, and the
gastrectomy staple line is properly
oriented. (© 2014 Wm. B. Westwood,
CMI.)

LWBK1254-ch20_p217-234.indd 229 19/02/14 10:05 AM

Figure 20.20 A pyloromyotomy is

performed using straight scissors.
a nterior portion is completed in a similar fashion except the knots are on the outside.
When suturing, it is vital to keep mucosal to mucosal apposition (Fig. 20.18). The
stomach is then pulled down from the hiatus to straighten the anastomosis making a
linear relationship of the remnant esophagus and stomach. At the end of the procedure,
the anastomosis is found at the thoracic inlet (Fig. 20.19). Upon completion of the
anastomosis, a nasogastric tube is gently passed. A small Penrose drain is placed at the
level of the anastomosis and brought out through a separate stab incision. The cervical
wound is then closed in two layers after proper irrigation.
Closure
A pyloromyotomy is performed (Fig. 20.20). We start by scoring the proposed incision
with cautery, then we cut the muscle fibers with straight Mayo scissors. Any bleeding
from the pyloromyotomy site is controlled with topical hemostatic agents. Cautery is
to be avoided. After the pyloromyotomy, the gastric conduit is sutured to the hiatus as
it passes into the mediastinum with two to three 3-0 silk sutures. This is done to pre-
vent herniation of bowel into the mediastinum. Bilateral 28-French chest tubes are
placed via anterior thoracostomy incisions. The abdomen is then irrigated and the clo-
sure is performed with running no. 1-looped PDS (polydioxanone) suture.
We prefer to keep the patient intubated overnight. A chest radiograph is obtained in
the recovery room to evaluate for hemothorax, pneumothorax, or mediastinal widening
suggestive of postoperative hemorrhage. Patients are admitted to the ICU after a short
recovery room stay. They are extubated on postoperative day 1 and are transferred to
our thoracic surgery unit. Ambulation begins on the first postoperative day. Incentive
spirometry and aggressive pulmonary toilet are emphasized throughout the remainder
of the patient’s hospitalization. Thoracic epidural anesthesia, intravenous low dose
dopamine, and Foley catheter drainage are continued for 5 days postoperatively. Anti-
biotic coverage is continued for 24 hours postoperatively. Jejunostomy tube feedings are
begun at 10 mL per hour on postoperative day 2 and are advanced as tolerated until
nutritional goals are reached. The nasogastric tube is removed on postoperative day 5,
LWBK1254-ch20_p217-234.indd 230 19/02/14 10:05 AM

and an esophagram is typically performed on postoperative day 5 or 6. Once confirma-

tion of an intact anastomosis and gastric emptying is obtained, the patient is given a
clear liquid diet and is advanced to a soft mechanical diet by postoperative day 7. The
patient is then discharged on the same day. The cervical Penrose drain is also removed
after the patient has passed their swallow examination. If oral intake is poor, nocturnal
supplements are given by jejunostomy tube; however, in most cases, patients are eating
well and the jejunostomy tube is removed 2 weeks postoperatively.
Complications
Intraoperative complications include pneumothorax, hemorrhage, and tracheal tear.
Early complications that can occur within 10 days include hoarseness or difficulty
swallowing due to recurrent laryngeal nerve injury, disruption of the anastomosis,
arrhythmias, chylothorax, and sympathetic pleural effusion. Late complications are
relatively uncommon and include diaphragmatic hernia and cervical anastomotic
stricture.
Hemorrhage
Aortic esophageal arteries are small branches and generally thrombose if avulsed during
esophagectomy. The average intraoperative blood loss is less than 300 mL if patients
are properly selected. Patients who have tumors fixed to the aorta or periesophageal
tissues should undergo TTE. If intraoperative hemorrhage occurs, retractors are placed
into the hiatus, a sump catheter is placed, and the bleeding is identified and controlled.
If the point of bleeding cannot be identified, the mediastinum is packed for 5 to
10 minutes with volume resuscitation. If the bleeding continues, the procedure is
converted to thoracotomy.

Tracheal Tear

Tracheal tears are rare, are generally small and linear, and generally involve the
membranous portion of the trachea. Upon identifying a tracheal tear, the surgeon
should guide the endotracheal tube distal to the tear. If possible, the esophagectomy
should be completed to achieve better exposure before repair. A partial upper ster-
notomy provides direct visualization of the upper trachea, if necessary. Extensive tears
involving the carina or main stem bronchi may require posterolateral thoracotomy. In
these cases, the abdominal and cervical wounds are closed, and the patient is reposi-
tioned for a right thoracotomy. After repair, the patient is again placed supine, and the
THE is completed.
Recurrent Laryngeal Nerve Injury

Injury to the recurrent laryngeal nerve can result in hoarseness as well as cervical dys-
phagia and potentially serious aspiration pneumonia. This complication is preventable
by avoiding the placement of retractors in the tracheoesophageal groove. Cautery is also
avoided. Recurrent laryngeal nerve injury has not occurred at the author’s institution
in the last 17 years.
Anastomotic Leak
If the patient develops a fever of 101°F or more 48 hours after THE, this is assumed to
be the result of an anastomotic leak until proven otherwise. A dilute barium study is
obtained. Assurance is made that no distal obstruction is present. If a leak is confirmed,
the patient is allowed to drink water for good mechanical wound cleansing out into the
Penrose drain. Most cervical anastomotic leaks heal within 1 week. Tube feeds are
continued until the leak has stopped.
LWBK1254-ch20_p217-234.indd 231 20/02/14 10:35 PM

Postoperative Chylothorax
If chylothorax is suspected, the chest tube effluent is sent for assessment of triglyceride
levels for confirmation. Treatment at our institution consists of a transthoracic approach
to the thoracic duct with direct identification and suturing of the leak facilitated by
cream administration through the jejunostomy tube. We prefer this over prolonged chest
tube drainage and parenteral administration.
Anastomotic Stricture
Dysphagia secondary to anastomotic stricture formation occurs in about 50% of all
patients who have undergone THE. With early dilation with Savary and Maloney dila-
tors under anesthesia, the need for subsequent dilations is often greatly reduced or
eliminated completely. Comfortable swallowing is achieved if a 46-French Maloney or
15-mm Savary dilator can be passed.
Results
The largest reported single institution series of 2,007 patients treated over 30 years was
published by Orringer et al.6 Seventy-six percent (1,525 patients) were treated for carci-
noma. THE was technically possible in >98% of cases. Twenty-two patients required
thoracotomy for hemorrhage or esophageal fixation. Stomach was used for reconstruc-
tion in 97% (1,942 patients). In a previous series of more than 1,000 THEs, Orringer
concluded that the stomach is the preferred conduit for esophageal replacement because
it is well vascularized, usually has sufficient length to reach the neck, and is prone to
the redundancy that occurs with intestinal substances.11 It is also relatively easy to mobi-
lize and requires only a single anastomosis. In Orringer’s earlier series, intraoperative
blood loss averaged 652 mL in patients who had carcinoma.11 With increasing experience
in performing more of the esophageal dissection under direct vision, the intraoperative
blood loss was reduced to 368 mL for 739 patients who underwent THE for carcinoma
between 1998 and 2006.6 Injury to the membranous trachea occurred in 8 patients and
splenectomy was performed in 2% due to intraoperative injury. Less than 1% of patients
(24 patients) had persistent laryngeal nerve injury. Thoracic duct injury occurred in 1%
(25 patients). Cervical anastomotic leak occurred in 12% (232 patients) and was more
common after retrosternal placement, radiation therapy, and prior operation at the gas-
troesophageal junction. The cervical side-to-side stapled anastomosis has significantly
decreased the anastomotic leak rate.12 Orringer et al. reported a hospital mortality rate
of 3% (51 deaths) in 2,007 patients. There were four intraoperative deaths due to uncon-
trollable hemorrhage.6
Katariya and colleagues13 evaluated 23 series with a total of 1,353 patients (99%
esophageal cancer) published between 1981 and 1992. Complications included anasto-
motic leak (15.1%), recurrent laryngeal nerve injury (11.3%), cardiac complications
(11.9%), splenectomy (2.6%), chylothorax (0.7%), and tracheal injuries (0.67%).
Although pulmonary complications occurred in 50% of patients, a wide variety of
complications were included, such as pneumothorax, pneumonia, and pleural effu-
sions. Conversion to thoracotomy occurred in 1.3% of cases for hemorrhage, and 30-day
mortality was 7.1%; however, 69.5% of the series included fewer than 50 patients and
may not reflect the results of more experienced surgeons.
At our institution, 319 THEs were performed from January 1992 to December 2009.
Complications included anastomotic leak (9.4%), recurrent laryngeal nerve injury (0%),
cardiac arrhythmia (12.5%), splenectomy (0%), chylothorax (0%), and tracheobronchial
injuries (0%). Conversion to thoracotomy because of hemorrhage occurred in 2/319
patients (0.63%). Mean operative time was 158 minutes. Our mean length of stay was
10.9 days (4 to 55 days). Thirty-day mortality was 1.9%. Twenty-six out of 30 patients
(86.6%) who had a postoperative anastomotic leak did receive neoadjuvant chemora-
diation therapy. Since converting back to the handsewn, one-layer, interrupted 2-0 vicryl
anastomosis, we have had no anastomotic leaks in the last 50 patients.
LWBK1254-ch20_p217-234.indd 232 19/02/14 10:05 AM

Controversy still remains regarding the appropriateness of THE as a cancer operation.

Critics argue that without an en bloc mediastinal lymphadenectomy, THE does not pro-
vide accurate staging or the potential for a curative procedure.14–16 Orringer et al. reported
that the Kaplan–Meier actuarial survival of 1,525 patients who underwent THE for carci-
noma was similar to that reported after TTE; the overall 2-year survival was 51% and the
5-year survival was 29%.6 In addition, several authors have reported survival after THE is
similar to that reported after TTE17–19 as well as after radical esophagectomy with medias-
tinal lymphadenectomy.20 The most important determinants of survival appear to be the
biologic behavior of the tumor and the stage at the time of resection rather than the opera-
tive approach, and esophageal carcinoma will likely require systemic therapy for a cure.
Conclusions
The optimal technique to esophagectomy remains controversial. Perhaps more impor-
tant than the approach to esophageal resection; however, is the case volume and the
experience of the centers that perform the operation. Operative mortality rates ranged
from 12.2% in low volume centers to 3% in high volume centers.21 At our center, 30-day
mortality was 1.9%.
THE is a technique that we use in the resection of benign and lower third esopha-
geal malignancies. It has several potential advantages over TTE including significantly
decreased respiratory complications and mediastinitis due to avoidance of thoracotomy
and intrathoracic anastomosis. Advantages over MIE include decreased cost and shorter
operative time. With experience, THE is safe, well tolerated, and can be performed with
low morbidity and mortality rates in properly selected patients.
Recommended References and Readings 11. Orringer MB, Marshall B, Iannettoni MD. Transhiatal esophagec-
tomy: Clinical experience and refinements. Ann Surg. 1999;230:
1. Denk W. Zur Radikaloperation des osophaguskarfzentralbl [Rad-

392–400.
ical operation for esophageal reconstruction]. Chirurg. 1913;40: 12. Orringer MB, Marshall B, Iannettoni MD. Eliminating the cervi-
1065–1068 [in German]. cal esophagogastric anastomotic leak with a side-to-side-stapled

2. Turner GC. Excision of thoracic esophagus for carcinoma with anastomosis. J Thorac Cardiovasc Surg. 2000;119:277–288.
construction of extrathoracic gullet. Lancet. 1933;2:1315. 13. Katariya K, Harvey JC, Pina E, et al. Complications of transhiatal
3. Orringer MB, Sloan H. Substernal gastric bypass of the excluded esophagectomy. J Surg Oncol. 1994;57:157–163.
thoracic esophagus for palliation of esophageal carcinoma. 14. Altorki NK, Girardi L, Skinner DB. En bloc esophagectomy
J Thorac Cardiovasc Surg. 1975;70:836–851. improves survival for stage III esophageal cancer. J Thorac Car-
4. Orringer MB, Sloan H. Esophagectomy without thoracotomy. diovasc Surg. 1997;114:948–955.
J Thorac Cardiovasc Surg. 1978;76:643–654. 15. Akiyama H, Tsurumaru M, Udagawa H, et al. Radical lymph
5. Orringer MB. Transhiatal esophagectomy. In: Kaiser LR, Jamie- node dissection for cancer of the thoracic esophagus. Ann Surg.
son GG, eds. Operative Thoracic Surgery. 5th ed. New York, NY: 1994;220:364–372
Hodder Arnold, Oxford University Press; 2006:397–412. 16. Hagen JA, Peters JH, DeMeester TR. Superiority of extended en
6. Orringer MB, Marshall B, Chang AC, et al. Two thousand tran- bloc esophagogastrectomy for carcinoma of the lower esophagus
shiatal esophagectomies:Changing trends, lessons learned. Ann and cardia. J Thorac Cardiovasc Surg. 1993;106:850–858.
Surg. 2007;246:363–372. 17. Bolton JS, Sardi A, Bowen JC, et al. Transhiatal and transthoracic
7. Bosset JF, Gignoux M, Triboulet JP, et al. Chemoradiotherapy esophagectomy: A comparative study. J Surg Oncol. 1992;51:
followed by surgery compared with surgery alone in squamous- 249–253
cell cancer of the esophagus. N Engl J Med. 1997;337: 18. Gluch L, Smith RC, Bambach CP, et al. Comparison of outcomes
161–167. following transhiatal or Ivor Lewis esophagectomy for esopha-
8. Walsh TN, Noonan N, Hollywood D, et al. A comparison of mul- geal carcinoma. World J Surg. 1999;23:271–275.
timodal therapy and surgery for esophageal adenocarcinoma. 19. Horstmann O, Verreet PR, Becker H, et al. Transhiatal oesophagec-
N Engl J Med. 1996;335:462–467. tomy compared with transthoracic resection and systematic
9. Tepper J, Krasna MJ, Niedzwiecki D, et al. Phase III trial of tri- lymphadenectomy for the treatment of oesophageal cancer. Eur
modality therapy with cisplatin, fluorouracil, radiotherapy, and J Surg. 1995;161:557–567.
surgery compared with surgery alone for esophageal cancer: 20. Skinner DB. En bloc resection for neoplasms of the esophagus
CALGB 9781. J Clin Oncol. 2008;26(7):1086–1092. and cardia. J Thorac Cardiovasc Surg. 1983;85:59–71.
10. Gebski V, Burmeister B, Smithers BM, et al. Survival benefits 21. Swisher SG, Deford L, Merriman KW, et al. Effect of operative
from neoadjuvant chemoradiotherapy or chemotherapy in volume on morbidity, mortality, and hospital use after esophagec-
oesophageal carcinoma: A meta-analysis. Lancet Oncol. 2007;8: tomy for cancer. J Thorac Cardiovasc Surg. 2000;119:1126–
226–234. 1132.
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LWBK1254-ch20_p217-234.indd 234 19/02/14 10:05 AM
21 Ivor Lewis
Esophagectomy
Christopher J. Mutrie, Christopher R. Morse, and Douglas J. Mathisen
Introduction
Treatment of esophageal carcinoma is aimed at cure of the neoplasm. However, relief
of dysphagia is an important secondary concern. An operation that removes the entire
tumor, with adequate margins, as well as the lymph node drainage offers the best chance
for cure. Studies have shown that neoadjuvant therapy may improve survival for
patients with squamous carcinoma of the esophagus and possibly adenocarcinoma of
the esophagus.1,5,25,34,36,39,41 As preoperative adjuvant therapy for carcinoma of the esopha-
gus increases in popularity, operative approaches that provide as much biologic and
staging information as possible allow better evaluation of the results of such treatment.
Location of the tumor, preference of the surgeon, body habitus, prior operations,
condition of the patient, and choice of esophageal substitute are all factors influencing
the choice of operation for carcinoma of the esophagus. Prior irradiation and irradiation
for other diseases are important considerations. The risk of complications after
esophagectomy is greatly increased if the dose of irradiation exceeded 50 Gy and was
given more than 1 year before the contemplated surgery. If this is the case, an anasto-
mosis outside the irradiated field so that one end of the anastomosis has not been
irradiated should be performed. Buttressing the anastomosis with additional tissue,
such as omentum or pedicled muscle, aids with healing and minimizes leaks.
The choice of incision is influenced by the ease of anastomosis and the ability to
mobilize the stomach and resect the esophagus. Tumors located in the middle third of
the esophagus have traditionally been removed by a combined laparotomy and right
thoracotomy—the Ivor Lewis approach.16
Indications
n The most common indication for an Ivor Lewis esophagectomy is middle-third
esophageal squamous or adenocarcinoma
n Esophageal disorders requiring removal of most of the esophagus
n Distal esophageal tumors with proximal extension above 35 cm
n High-grade dysplasia in Barrett’s esophagus with proximal extension above 35 cm
235
LWBK1254-ch21_p235-250.indd 235 20/02/14 10:36 PM

n Failed myotomy for achalasia with sigmoid esophagus requiring near-total

esophagectomy
Contraindications
Contraindications to an Ivor Lewis esophagectomy are relative and in some cases may
include prior thoracotomy, especially for inflammatory disease on the right side. Factors
to be considered include the nature of esophageal disease (benign vs. malignant), the
need for adequate longitudinal and radial margins, surgeon preference, patient factors,
and neoadjuvant treatment.
Careful evaluation of each patient is essential. Patients must be in reasonable medical
condition and must have adequate pulmonary function. Patients with forced expiratory
volume in 1 second of less than 1 L are probably not suitable candidates for this
approach. Smoking should be stopped, and aggressive measures to treat underlying
obstructive lung disease should be instituted. Careful evaluation for underlying cardiac
disease should be done in elderly and high-risk patients.
Radiologic Evaluation
Standard preoperative evaluation includes the following.
n Barium esophagography
n Computed tomography (CT) of the chest and upper abdomen
n For malignant esophageal tumors, esophagoscopy with endoscopic ultrasound to
assess depth of invasion and presence of enlarged lymph nodes30
Endoscopic Evaluation
Histologic diagnosis and determination of the true proximal and distal extent of the
tumor is best achieved through endoscopic evaluation. Direct visualization also allows
for checking of the presence of Barrett’s mucosa proximal to adenocarcinomas. The
proximal extent of the tumor and abnormal mucosa is critical in determining surgical
approach.
Endoscopy should be performed by the surgeon in all cases. It is particularly help-
ful in determining proximal extent of tumor. A 5-cm surgical margin is desirable for
carcinoma. Distal tumors with proximal involvement above 35 cm may be technically
difficult to resect from the left side. Tumor involvement of the esophagus between 30
and 35 cm can be approached from either the left side, utilizing a supra-aortic anasto-
mosis, or the more traditional Ivor Lewis approach.
In patients with adenocarcinoma arising in Barrett’s mucosa, it is important to
resect the tumor, with a 5-cm proximal margin and all of the Barrett’s mucosa. It is
helpful to identify the proximal extent of Barrett’s mucosa by endoscopically placing
the nasogastric tube just above the squamocolumnar junction or by performing endoscopy
intraoperatively to identify the location. Tumors extending above 30 cm may involve
either the left main stem bronchus or the trachea and should be evaluated with bron-
choscopy by the surgeon.
A combined thoracoscopy–laparoscopy, where peritoneal or pleural seeding, lymph
node involvement, and local extent of tumor can all be assessed offers the potential for
minimally invasive surgical staging of esophageal cancer and is an adjunct similar to
that associated with mediastinoscopy for lung cancer.14,20 Pretreatment staging is neces-
sary to better evaluate response to neoadjuvant therapy and should include esophageal
ultrasound, CT scan, PET scan, and brain MRI.
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Chapter 21 Ivor Lewis Esophagectomy 237
Open Ivor Lewis Esophagectomy
Surgery
Abdominal Phase
Positioning
With the patient in the supine position, an upper midline abdominal incision is made
(Fig. 21.1). The abdomen is explored. If liver metastases or unresectable retroperitoneal
nodes are found, resection should be abandoned, and palliation of dysphagia should be
achieved by other means. Endoscopically placed covered esophageal stents or irradia-
tion have successfully been used.8,32
Technique
n If the tumor is resectable, the left triangular ligament of the liver is divided.
n The lesser sac is entered through the greater omentum, preserving the gastroepiploic
artery.
n The omentum is separated from the transverse colon, and care taken to preserve the
gastroepiploic artery. If possible, omentum along the greater curvature is saved for
later use to cover the anastomosis. Excess bulk of omentum can be removed to facil-
itate transport into the chest. By elevating the greater curvature of the stomach, while
preserving the gastroepiploic artery, the surgeon can easily divide the short gastric
vessels (Fig. 21.2).
n The gastrohepatic ligament is divided taking care to preserve the right gastric artery.
n The left gastric artery and vein are isolated and doubly suture-ligated at their origin
Part III: Techniques and Approaches for

with lymph nodes taken from this area with the specimen.
n The hiatus and distal esophagus are dissected. Enlarging the hiatus from the right
chest is difficult and more easily achieved through the laparotomy incision.
Anterior
axillary line
Scapula
Fifth rib
removed
7
Figure 21.1 Standard incisions for an Ivor Lewis esophagectomy. An upper midline abdominal incision is used to mobilize the stomach.
A right thoracotomy is used to resect the esophagus and do the esophagogastric anastomosis.
LWBK1254-ch21_p235-250.indd 237 20/02/14 10:36 PM

Figure 21.2 The omentum is sepa-

rated from the transverse colon and
care taken to preserve the gastroepi-
ploic artery. If possible, omentum
along the greater curvature is saved
for later use to cover the anastomo-
sis. Excess bulk of omentum can be
removed to facilitate transport into
the chest.
n Maximal mobility of the stomach can be achieved with a Kocher maneuver.

n A pyloroplasty or pyloromyotomy is often done at the surgeon’s discretion.
n It is helpful to identify the point of transection of the stomach and clear the greater
and lesser curvature in the abdomen. At this point, the final diameter of the new
conduit must be determined; there are arguments in favor of a wider conduit and in
favor of a narrow conduit. No objective data exist in terms of the ideal diameter of
the new conduit. One argument in favor of a narrow conduit (3 to 4 cm in diameter)
is that it may lead to less acid reflux.
n A feeding jejunostomy is inserted in most patients, especially high-risk or nutrition-
ally depleted patients.
It is helpful to accomplish as much dissection of the lower esophagus as possible
from the abdomen. This dissection facilitates the intrathoracic dissection of the lower
esophagus, which can be difficult through a high right thoracotomy. An attempt should
be made to advance the stomach and omentum into the posterior omentum before clos-
ing the abdomen to facilitate retrieval of the conduit from the chest.
Thoracic Phase
Positioning
The patient is then placed in the left lateral decubitus position. A double-lumen
endotracheal tube is used allowing the lung to collapse and exposing the esophagus for
dissection and anastomosis.
Technique
A standard posterolateral right thoracotomy is performed. The serratus muscle is spared,
and the chest is entered through the fourth or the fifth interspace. After the lung is
examined for abnormalities, it is deflated and retracted anteriorly.
n The azygos vein is divided.
n The esophagus is dissected from the vertebral body to the pericardium. All
paraesophageal nodes, including subcarinal nodes, are included in the specimen.
Dissection is continued to the apex of the chest.
LWBK1254-ch21_p235-250.indd 238 20/02/14 10:36 PM

n The stomach is then pulled into the chest and divided. It is done only after all of
the intrathoracic dissection has been completed to avoid any confusion about orien-
tation of the stomach.
n Care must be taken to avoid pulling too much of the stomach into the chest. Redun-
dant gastric conduit above the diaphragm will fall into the costophrenic gutter, cre-
ating an S-loop and cause delayed emptying of the stomach.
n Pulling the stomach too tightly into the chest may also lead to impingement of the
stomach at the level of the hiatus and cause delayed emptying as well as compres-
sion of the gastroepiploic vessels.
n It is best to grasp the omentum near the stomach to avoid tearing the gastroepiploic
vessels.
Anastomotic Technique
Sweet35 published his initial experience with surgical management of carcinoma of the
esophagus in 141 patients in 1947. Operating in an era without sophisticated postop-
erative monitoring devices, mechanical ventilation, or broad-spectrum antibiotics, his
results were remarkable: An operative mortality of 15%, anastomotic leaks in 1.4% of
patients, and overall 5-year survival of 11%. These results served as a standard for many
years. The low incidence of leaks and operative mortality was related to the attention
to detail and the reliability of the anastomotic technique.
n Churchill and Sweet6 warned of factors predisposing to anastomotic leak-namely the
lack of an esophageal serosal layer and the segmental blood supply of the esophagus.
n Churchill and Sweet emphasized the importance of preserving the esophageal and
gastric blood supply; gentle handling of the tissues, interrupted sutures, avoiding
crushing clamps, cutting with a knife or other sharp instrument, and firm but gentle
tying of sutures to avoid cutting tissues.
The traditional anastomotic technique is as follows.

n A 2-cm diameter circle is scored on the surface of the stomach (Fig. 21.3A). The
defect created should be 2 cm away from the stapled edge of the stomach to avoid
a compromised blood supply.
n Submucosal vessels are identified and individually ligated with fine silk sutures.
n Interrupted mattress sutures of fine suture (4-0 silk) are used to construct the back
row of the anastomosis (Fig. 21.3B). Corner stitches are placed first, with the remain-
ing sutures placed evenly between them. The sutures on the stomach include the
seromuscular layers. The esophageal sutures should be deep enough to include both
the longitudinal and circular muscular layers of the esophagus.
n The esophagus is opened sharply from one corner stitch to the other. The circular
button of the stomach is removed (Fig. 21.3B).
n The inner layer is completed with simple sutures, including just the mucosa of the
esophagus and all layers of the stomach (Fig. 21.3C).
n The knots are on the inside, allowing inversion or turning in of mucosa of both the
stomach and the esophagus. This step is accomplished for the entire circumference
of the anastomosis (Fig. 21.3D).
n A nasogastric tube is passed into the stomach under direct vision before a single
Connell stitch is placed for closure of the final opening. Healing of the inverted
mucosa is important in preventing leakage, and the location of the knots on the lumi-
nal side minimizes foreign-body reaction with the actual tissues of the anastomosis.
n The outer row is completed using horizontal mattress sutures as described for the
back row of the outer layer (Fig. 21.3E).
n The omentum, mobilized with the stomach, is placed over the anastomosis anteriorly
to provide an additional layer of coverage. In order to avoid tension on the anasto-
mosis when the patient is upright, several sutures are placed between the stomach
and the mediastinal pleura.
n Sutures are also placed between the stomach and the diaphragmatic hiatus to prevent
herniation of abdominal contents.
LWBK1254-ch21_p235-250.indd 239 20/02/14 10:36 PM

A B C
D E
Figure 21.3 Surgical technique. A: The serosa of the stomach has been scored, and the vessels have been ligated. The back row
of sutures has been completed. B: The button of stomach has been removed, and the anterior wall of the esophagus has been
opened. C: The back row of the inner layer is completed, and the esophagus is transected. D: Knots on the inside allow inversion of
the mucosa. E: The outer row is completed using horizontal mattress sutures.
In accordance with Dr. Churchill and Sweet’s teachings, trauma to the tissues is
avoided as much as possible. Once the first stitch is placed and tied, traction on it
permits placement of the next without the need of instrumental grasping of the mucosa.
The surgeon ties the sutures by positioning the index finger cephalad to the anastomo-
sis and lifting the stomach to the esophagus. This avoids pulling down on the fixed and
more fragile esophagus.
A nasogastric tube passed through the anastomosis for a short time decompresses
the stomach and avoids distention of the suture line. Gentle, periodic irrigation of the
tube ensures its patency. Temporary gastric decompression more than compensates for
any potentially deleterious effect of the intraluminal foreign body lying against the
suture line for a short period.
Complications
Experience with this technique from the Massachusetts General Hospital in a consecu-
tive series of 104 patients was reported.22 There were three postoperative deaths (2.9%),
all attributable to pneumonia and respiratory failure. Five patients developed anasto-
motic stricture requiring dilation 3 to 6 weeks postoperatively. Dysphagia resolved after
one to three dilations. Delayed anastomotic stricture was not present in this group of
patients. All patients underwent a postoperative barium swallow. There were no
LWBK1254-ch21_p235-250.indd 240 20/02/14 10:36 PM

anastomotic leaks, even of the localized type. The reliability of this precise, two-layer
anastomotic technique has been reported by others as well.7
Anastomotic Leaks
Aggressive management of anastomotic leaks is required if fatalities are to be avoided.
n If the leak is small and contained or well drained by the chest tube, the patient
should take nothing by mouth; antibiotic therapy and nutritional support should be
continued, and the contrast study should be repeated 1 week later.
n CT is performed to identify any undrained collections.
n Small, undrained collections can be drained by percutaneous ultrasound-guided
catheters.
The presence of a massive leak warrants urgent intervention. If the leak is related
to necrosis of the stomach, the stomach should be resected to viable tissue, returned
to the abdomen, and a cervical esophagostomy should be done. Reconstruction of
the gastrointestinal tract can be performed at a later date. Local repair in the presence
of gross contamination of the pleural cavity can be expected to fail in most cases.
n If local repair is attempted, devitalized tissue should be debrided and the repair
should be buttressed with healthy tissue. Omentum, chest wall muscles (serratus,
pectoralis), or pedicled intercostal muscle can all be used.
n The lung should be decorticated, and wide drainage of the pleural cavity should be
provided.
n Cervical esophagostomy may be appropriate if concern exists about the repair. The
esophagostomy can be constructed in such a way that reanastomosis can be done
between the divided ends of the esophagus in the neck, avoiding more complicated
reconstructive methods.10
n Alternatively if preservation of the conduit is desired and the anastomosis is
otherwise intact, a long T-tube can be placed through the defect, brought out

through the chest wall with pedicled muscle wrapped around the T-tube fistula.
Drains should be placed in close proximity to T-tube.
Delayed Gastric Emptying
The two main reasons for delayed gastric emptying after an Ivor Lewis esophagectomy
are the following.
n Obstruction at the hiatus
n Redundant intrathoracic stomach lying in the posterior costophrenic gutter
These problems are best avoided by an adequate drainage procedure at the time of
operation, with the surgeon enlarging the hiatus, not pulling the stomach too tightly
into the chest, and avoiding excess stomach in the chest.
Pyloric obstruction may also cause delayed gastric emptying. When a drainage pro-
cedure has been done, pyloric obstruction usually resolves with time. Metoclopramide
may be useful. Endoscopy and cautious balloon dilation of the pylorus can be tried.
Failure of conservative management requires reoperation and an adequate drainage pro-
cedure. Obstruction at the level of the hiatus usually demands reexploration and
enlargement of the hiatus. This procedure is often difficult, and great care must be taken
to avoid injury to the blood supply of the stomach.
Mortality
Advances in anesthesia, perioperative care, monitoring, and enteral and parenteral nutri-
tion have resulted in a dramatic decrease of 50% over 10 years in overall postoperative
mortality. In addition, there was a significantly lower hospital mortality rate for resec-
tions performed with curative intent versus those with palliative intent (mean, 11% vs.
19%, respectively).24 The hospital mortality rate was nearly identical whether or not
the anastomosis was located in the neck if the procedure involved a thoracotomy of
LWBK1254-ch21_p235-250.indd 241 20/02/14 10:36 PM

any type. Many institutions have reported operative mortality rates near or below 5%
for either transthoracic or transhiatal resection.3,29,37,38
Survival
Despite the theoretical advantages of an en bloc dissection and full lymphadenectomy,
studies comparing these procedures with transhiatal esophagectomy show no difference
in overall survival between these two approaches for esophageal carcinoma. Shahian
et al.31 demonstrated no statistically significant difference in survival for all patients who
underwent transthoracic versus extrathoracic esophagectomy for carcinoma (median,
14.1 vs. 12.6 months; p = 0.48), regardless of whether patients had stage I or stage III
disease. In the review by Müller, only tumor stage at time of operation was a significant
determinant of long-term survival. There was no significant difference in survival accord-
ing to extent of surgery or type of resection.
Results
The greatest immediate concern is the fate of the intrathoracic anastomosis. It is
undoubtedly this concern that has led to the popularity of the transhiatal esophagec-
tomy, which places the anastomosis in the cervical area.28 We and others have shown
that attention to technical details of the anastomosis leads to a very low incidence of
leaks and subsequent mortality, stressing the importance of how the anastomosis is
done rather than where it is done.
Transhiatal esophagectomy has become the popular alternative to Ivor Lewis
esophagectomy. No direct randomized series have compared the two procedures. Müller
et al.24 reviewed all published reports of surgical therapy of esophageal carcinoma from
1980 to 1988 (a summary of 59 published reports) and drew some conclusions about
the two procedures. Others have compared the two procedures in a retrospective fash-
ion within a single institution and provide some important insights into the relative
merits of the two procedures.3,17
In most reports, the risk of anastomotic leak from a cervical anastomosis is higher than
that reported for an intrathoracic anastomosis.24 In patients experiencing leaks, however,
morbidity and mortality related to the leak itself are lower if the anastomosis is in the
neck rather than in the chest. This finding is borne out in the Müller review. The anasto-
motic leak rate was 11% for intrathoracic anastomosis compared with 19% for cervical
anastomosis. However, the mortality rate for an intrathoracic anastomotic leak was three
times higher than that for a cervical anastomotic leak (69% vs. 29%, respectively).
Cervical anastomotic leak rates for transhiatal esophagectomy without thoracotomy
have been reported to be as low as 6% to 8% for operations performed for carcinoma
of the intrathoracic esophagus,28 and leak rates from 0% to 2% have been reported for
intrathoracic anastomosis.9,22,38 Even within the same institution and with the same
surgeons, cervical anastomosis is associated with a higher incidence of leaks. This find-
ing is confirmed by a report from the Lahey Clinic, with 15.4% leak for cervical anas-
tomosis but 1.8% for intrathoracic anastomosis.31
Respiratory insufficiency and atelectasis occur more commonly after transthoracic
esophagectomy, but the incidence of pneumonia is similar. Transhiatal esophagectomy
is associated with a high incidence of recurrent nerve paresis or palsy (6% to 24%),
but this is very uncommon after transthoracic esophagectomy. Chylothorax, posterior
membranous tracheal tears, and increased blood loss are all more frequent after tran-
shiatal esophagectomy. Most reports have not demonstrated the superiority of one sur-
gery over another and view the procedures as alternative choices.17,31
In a recent presentation at the American Surgical Association annual meeting, a
national database of over 15,000 esophagectomies was evaluated. The primary com-
parison was between patients having an intrathoracic anastomosis versus a cervical
anastomosis. The interesting findings of this study were that the patients with the
intrathoracic anastomosis fared markedly better in terms of length of stay, mortality, and
hospital charges. Another interesting finding was that the leak rate was about 10% in
LWBK1254-ch21_p235-250.indd 242 20/02/14 10:36 PM

each group, but overall morbidity and mortality still favored the intrathoracic anasto-
mosis group.11 This data compare favorably with the recent series by Luketich et al.18
where they compared ∼500 consecutive neck anastomosis to ∼500 intrathoracic anasto-
mosis and found better outcomes with the intrathoracic anastomosis as well So, it does
appear that over the last decade or so, we are seeing an increasing number of surgeons
choose the Ivor Lewis approach with morbidity that is quite favorable compared with
cervical anastomosis reports.
Late Functional Results

Although little information has been reported about late functional results after an Ivor
Lewis esophagectomy, the Mayo clinic did report early and late functional results in
100 patients.12 A pyloromyotomy (39 patients) or pyloroplasty (56 patients) was done
in 95 patients. Early functional results were excellent, with development of dysphagia
and gastroesophageal reflux in only 3% and 1% of patients, respectively. The mean
follow-up of patients was 2.3 years. Late dysphagia occurred in 40 patients; in 5 patients
it was related to anastomotic recurrence and in 35 to benign anastomotic narrowing,
requiring dilation. Dilation (range, 1 to 22 dilations; mean, 3.4 dilations) relieved symp-
toms in all 35 patients with benign stenosis. Delayed presentation of reflux occurred in
14% of patients and dumping in 5%. All patients with reflux or dumping were treated
successfully by standard medical therapy. Postoperative weight loss (median, 15.7 kg)
occurred in 62% of patients. The authors believed that weight loss was multifactorial
and not necessarily related to the procedure itself.
Conclusion
Ivor Lewis esophagectomy remains an excellent procedure for resection of the middle

third of the esophagus with good long-term functional results. Proper patient selection,
adequate preoperative preparation of the patient, attention to technical details of the
operation, and diligent postoperative care allow this procedure to be performed safely
with acceptable morbidity and mortality rates. A reliable anastomotic technique should
be implemented to avoid intrathoracic anastomotic leaks, the source of greatest morbid-
ity and mortality. Ivor Lewis esophagectomy offers potential advantages of wider, more
complete resection for better staging information, lower local recurrence rates, and pos-
sibly improved survival as compared with transhiatal esophagectomy.
Minimally Invasive Esophageal Resection

More recently, in an effort to limit the physiologic stress and possibly reduce the
morbidity associated with open esophagectomy, minimally invasive surgical
approaches to esophagectomy have been developed.21 The dramatic improvement in
laparoscopic technology since its introduction in 1991 has witnessed an associated
evolution in the complexity of laparoscopic technology. Complex esophageal disor-
ders, including achalasia and giant paraesophageal hernia, are being successfully
treated laparoscopically. Watson et al.40 reported a minimally invasive Ivor Lewis
technique in 1999 with their description of a laparoscopically constructed gastric
conduit followed by thoracoscopic esophagectomy with construction of an intratho-
racic esophagogastric anastomosis.
Concerns in minimally invasive esophagectomy include the amount of nodal clear-
ance achieved, the complexity of the procedure, and the ability to achieve a measur-
able impact on mortality. Early data reporting the outcomes of minimally invasive
esophagectomy challenge these concerns. Recent studies have shown that minimally
invasive esophagectomy is associated with outcomes comparable with open
surgery.4,15,19,27,33 The minimally invasive Ivor Lewis esophagectomy is also described
in detail in chapter 24.
LWBK1254-ch21_p235-250.indd 243 20/02/14 10:36 PM

Minimally Invasive Ivor

Lewis Esophagectomy
Surgery
Abdominal Phase
Positioning
The patient is positioned supine and a double-lumen tube is placed for eventual lung
isolation. As with the open technique, on table esophagoscopy is performed to deter-
mine the location and extent of tumor involvement as well as to assess the stomach for
suitability as a gastric conduit.
n Five ports are placed in the abdomen for gastric mobilization (Fig. 21.4).
n The liver and peritoneal surfaces are inspected to rule out metastatic disease.
n The celiac and left gastric artery and vein lymph nodes are identified. Any suspicious
nodes are removed and sent for frozen section analysis.
Technique
Dissection begins with mobilization of the right crus and the lateral aspect of the
esophagus. The dissection is carried anteriorly and superiorly over the esophagus
toward the left crus. Division of the phrenoesophageal ligament is spared until the end
of the case in order to maintain pneumoperitoneum. A retroesophageal window is cre-
ated through dissection of the inferior aspect of the right crus.
n The lesser sac is then entered through cephalad retraction of the antrum of the stom-
ach taking care to preserve the right gastroepiploic artery.
Using ultrasonic shears (Autosonix, Covidien, Mansfield, MA; Harmonic Scalpel,
Johnson and Johnson, Piscataway, NJ) and the Ligasure device (Ligasure, Valleylab,
Figure 21.4 Five ports are placed in

the abdomen for gastric mobilization.
5 mm
12 mm
5 mm 10 mm 5 mm
LWBK1254-ch21_p235-250.indd 244 20/02/14 10:36 PM

oulder, CO), dissection is carried along the greater curvature of the stomach to the end
B
of the gastroepiploic arcade with division of the short gastric vessels. Once mobilization
of the greater curvature of the stomach is achieved, the retrogastric attachments are
exposed by lifting the fundus of the stomach toward the patient’s right shoulder.
n The fundus of the stomach is completely mobilized and the retrohepatic attachments
are divided sparing the left gastric artery and vein. Care must be taken when mobiliz-
ing the pyloroantral region of the stomach to avoid the gastroepiploic arcade or the
gastroduodenal artery.
n When the pylorus is able to reach the right crus of the diaphragm under no tension,
the pylorus is adequately mobilized.
n The left gastric artery and vein are divided with a vascular Endo GIA stapler (Auto-
suture, Covidien, Mansfield, MA) through the lesser curve.
The gastric tube is then created. The first staple line is placed on the lesser curve
with a vascular Endo GIA stapler through a midclavicular port. Care is taken to avoid
the gastric antrum. To aid in this step, the assistant grasps the tip of the fundus through
a left upper quadrant port and stretches it toward the spleen with a second grasper
placing downward retraction on the antral area. The staple line parallels the gastroepi-
ploic arcade. The stomach is then divided across the antrum with 4.8-mm Endo GIA
stapler loads aiming for the conduit to be 5 cm wide (Fig. 21.5).
n Holding sutures are placed on the superior and inferior aspects of the pylorus to hold
the pylorus on tension. Ultrasonic shears are used to open the pylorus.
n The pyloroplasty is then closed in Heineke-Mikulicz fashion using interrupted
sutures and covered with omentum.
A feeding jejunostomy is placed using a needle catheter kit (5-French needle cath-
eter, Compat Biosystems, Minneapolis, MN) in the left lower quadrant (Fig. 21.6).
n The ligament of Treitz is identified with cephalad retraction on the transverse colon
and a loop of jejunum is tacked to the abdominal wall 30 to 40 cm from the ligament

of Treitz using an Endo Stitch device.
n A needle and guidewire are placed into the jejunum under laparoscopic vision and
placement is confirmed with air insufflation and visible jejunal distention. The jeju-
num is then tacked to the abdominal wall using an endostitch device.
Lastly, the most superior portion of the gastric tube is stitched to the specimen.
This stitch maintains correct orientation of the gastric conduit as it is delivered into
the chest.
n The final step of the laparoscopic portion of the surgery is to divide the phre-
noesophageal membrane.
Figure 21.5 Creation of the gastric

tube. Care is taken to avoid the
gastric antrum. The assistant grasps
the tip of the fundus through a right
lower quadrant port and stretches it
toward the spleen with a second
grasper placing downward retraction
on the antral area. The staple line
parallels the gastroepiploic arcade.
LWBK1254-ch21_p235-250.indd 245 20/02/14 10:36 PM

Figure 21.6 Placement of feeding

jejunostomy. The ligament of Treitz is
identified with cephalad retraction on
the transverse colon and a loop of
jejunum is tacked to the abdominal
wall 30 to 40 cm from the ligament of
Treitz using an endostitch device.
Thoracic Phase
Positioning
The patient is then placed in the left lateral decubitus position for esophageal mobiliza-
tion and creation of the anastomosis. The primary surgeon stands facing the patient’s
back. As in the abdomen, five ports are used (Fig. 21.7).
n A 10-mm port is placed in the seventh intercostal space anterior to the midaxillary
line.
n A 10-mm port is placed at the eighth intercostal space, posterior to the posterior
axillary line as the working port.
n A 10-mm port is placed in the anterior axillary line at the fourth intercostal space
allowing for retraction of the lung with a fan retractor to expose the esophagus.
n A 5-mm port is placed anterior to the tip of the scapula, used as a retraction port for
the surgeon.
n A final port is placed at the sixth rib, at the anterior axillary line for suction and for
creation of the anastomosis.
Technique
The gastroesophageal junction is exposed by placement of a retraction stitch placed
through the chest wall at the level of the diaphragm insertion and passed through the
central tendon of the diaphragm.
Figure 21.7 Placement of thoraco-

scopic ports. The patient is then
placed in the left lateral decubitus
position for esophageal mobilization
and creation of the anastomosis. The
primary surgeon stands facing the
patient’s back. As in the abdomen,
five ports are used. The fifth port is
not shown in this figure.
LWBK1254-ch21_p235-250.indd 246 20/02/14 10:36 PM

The inferior pulmonary ligament is divided and the inferior pulmonary vein is
retracted anteriorly allowing the dissection to be carried along the pericardium
exposing the subcarinal lymph node packet. Care must be taken during mobilization
of the subcarinal nodes to avoid the posterior membranous wall of the right main stem
bronchus.
n Both the right and left main stem bronchi should be clearly identified with complete
dissection of the subcarinal space.
n The mediastinal pleura is then opened along the hilum to the level of the azygos
vein and above the azygos vein.
n The azygos is then divided with a vascular load of the Endo GIA stapler.
n The pleura overlying the esophagus is opened carefully, avoiding injury to the tho-
racic duct and underlying aorta. Any tissue suspicious for branches of the thoracic
duct is clipped prior to division.
n The lateral dissection is carried from the azygos vein to the gastroesophageal junc-
tion. The deep margin is the contralateral pleura.
With complete esophageal mobilization, the specimen is brought into the chest with
the attached gastric conduit. As with the traditional Ivor Lewis approach, care must be
taken to avoid bringing redundant gastric conduit into the chest. Redundant conduit in
the chest is a source of poor gastric emptying owing to the fold of conduit created.
Similarly, spiraling of the conduit should be avoided as the conduit is brought into the
chest. As dissection progresses above the azygos vein, it is important to stay on the wall
of the esophagus to avoid injury to the recurrent laryngeal nerve. Once the esophagus
is completely mobilized in the thoracic cavity, it is brought out through enlarging the
inferior lateral port to 3 cm. A wound protector is used during removal of the tumor
and assists in retraction of the wound. The esophagus is transected with Endo Shears
(Fig. 21.8). The anastomosis is performed as follows.
n The anvil of a 28-mm EEA stapler is placed in the proximal esophagus and two
purse-string sutures are placed and tied to secure the anvil in position and pull in

any mucosal defects.
n The gastric conduit is then pulled to the apex of the chest and ultrasonic shears are
used to open the tip of the gastric conduit along the staple line.
n The EEA stapler is placed through the posteroinferior port and positioned in
the conduit.
n The stapler is brought out through the greater curve of the gastric conduit to join the
anvil.
n Once it is determined that there is no redundant conduit within the chest and there
is no twisting of the conduit, the tip of the stapler and anvil are docked and the
stapler fired at approximately the level of the azygos vein (Fig. 21.9).
Figure 21.8 Division of the esophagus

with Endo Shears.
LWBK1254-ch21_p235-250.indd 247 20/02/14 10:36 PM

Figure 21.9 Creation of the anastomosis. Once it is determined

that there is no redundant conduit within the chest and there is
no twisting of the conduit, the tip of the stapler and anvil are
docked and the stapler fired at approximately the level of the
azygos vein.
n The excess gastric conduit, through which the gastrostomy for the EEA stapler was
made, is trimmed with a linear stapler.
n A 28-French chest tube and Jackson-Pratt drain are placed near the anastomosis and
the space between the conduit and the right crus of the diaphragm is closed with a
single stitch.
Results
In the literature, two case series and several case reports characterize the results of this
innovative procedure. One of the first large series came from the University of Pitts-
burgh.2 With 50 patients, the reported median ICU stay was 1 day and the median
hospital stay was 7 days. The mortality rate was 6% and an anastomotic leak occurred
in 6%. The initial oncologic outcomes regarding negative surgical margins and lymph
node clearance were comparable to most open series. In a larger series update from the
University of Pittsburgh, Luketich reported on over 1,000 minimally invasive esophagec-
tomies. Within this group, they compared ∼500 cases performed with a neck anastomo-
sis (Mckeown approach23) to ∼500 cases performed with an intrathoracic anastomosis
(Ivor Lewis approach). In this series, the Ivor Lewis group fared better in terms of lower
mortality, had fewer anastomotic leaks, and had a 1% incidence of recurrent nerve
injuries. Therefore, the Ivor Lewis approach has become their favored approach for
routine gastroesophageal junction carcinomas.18 Kunisaki et al.,13 in a smaller series of
15 patients, observed an elevated leak rate of 13.3% with a long hospital stay of
30 days.2,13,26,40
Conclusion
The minimally invasive Ivor Lewis esophagectomy avoids a neck dissection and the
associated risk of recurrent laryngeal nerve injury and microaspiration seen in transhiatal
esophagectomy. Minimally invasive esophageal resection is technically feasible and can
be performed as safely as conventional esophagectomy. However, minimally invasive
LWBK1254-ch21_p235-250.indd 248 20/02/14 10:37 PM

esophageal surgery should be performed in centers with significant experience in open

esophagectomy and esophageal surgery and by surgeons who have experience in both
open esophagectomy and advanced laparoscopic and thoracoscopic procedures.
Recommended References and Readings 20. Luketich JD, Schauer P, Landreneau R, et al. Minimally invasive
surgical staging is superior to endoscopic ultrasound in detect-
1. Ajani JA, Walsh G, Komaki R, et al. Preoperative induction of ing lymph node metastases in esophageal cancer. J Thorac Car-
CPT-11 and cisplatin chemotherapy followed by chemoradio- diovasc Surg. 1997;114(5):817–821; discussion 821–833.
therapy in patients with locoregional carcinoma of the esopha- 21. Luketich JD, Nguyen NT, Weigel T, et al. Minimally invasive
gus or gastroesophageal junction. Cancer. 2004;100(11): approach to esophagectomy. JSLS 1998;2(3):243–247.
2347–2354. 22. Mathisen DJ, Grillo HC, Wilkins EW Jr, et al. Transthoracic
2. Bizekis C, Kent MS, Luketich JD, et al. Initial experience with esophagectomy: A safe approach to carcinoma of the esophagus.
minimally invasive Ivor Lewis esophagectomy. Ann Thorac Ann Thorac Surg. 1988;45(2):137–143.
Surg. 2006;82(2):402–406; discussion 406–407. 23. Mckeown KC. Total three-stage oesophagectomy for cancer of
3. Boyle MJ, Franceschi D, Livingstone AS. Transhiatal versus tran- the oesophagus. Br J Surg. 1976;63(4):259–262.
sthoracic esophagectomy: Complication and survival rates. Am 24. Müller JM, Erasmi H, Stelzner M, et al. Surgical therapy of
Surg. 1999;65(12):1137–1141. oesophageal carcinoma. Br J Surg. 1990;77(8):845–857.
4. Braghetto I, Csendes A, Cardemil G, et al. Open transthoracic or 25. Naunheim KS, Petruska PJ, Roy TS, et al. Multimodality therapy
transhiatal esophagectomy versus minimally invasive esophagec- for adenocarcinoma of the esophagus. Ann Thorac Surg. 1995;
tomy in terms of morbidity, mortality, and survival. Surg Endosc. 59(5):1085–1090.
2006;20(11):1681–1686. 26. Nguyen NT, Follette DM, Lemoine PH, et al. Minimally invasive
5. Carey RW, Hilgenberg AD, Wilkins EW Jr, et al. Long-term fol- Ivor Lewis esophagectomy. Ann Thorac Surg. 2001;72(2):593–
low-up of neoadjuvant chemotherapy with 5-fluorouracil and 596.
cisplatin with surgical resection and possible postoperative 27. Nguyen NT, Roberts P, Follette DM, et al. Thoracoscopic and
radiotherapy and/or chemotherapy in squamous cell carcinoma laparoscopic esophagectomy for benign and malignant disease:
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the esophagus and stomach. Ann Surg. 1942;115(6):897–920. 28. Orringer MB, Orringer JS. Esophagectomy without thoracotomy:
7. Ellis FH Jr, Gibb SP, Watkins E Jr. Esophagogastrectomy. A safe, A dangerous operation? J Thorac Cardiovasc Surg. 1983;85(1):72–
widely applicable, and expeditious form of palliation for 80.
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1983;198(4):531–540. benign and malignant conditions. Am J Surg. 2002;184(2):136–
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1997;38(1):127. 31. Shahian DM, Neptune WB, Ellis FH Jr, et al. Transthoracic ver-
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Lewis subtotal esophagectomy with two-field lymphadenec- long-term survival. Ann Thorac Surg. 1986;41(3):237–246.
tomy: Risk factors and management. J Am Coll Surg. 2002; 32. Siersema PD, Schrauwen SL, van Blankenstein M, et al. Self-
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12. King RM, Pairolero PC, Trastek VF, et al. Ivor Lewis esophagogastric junction. J Clin Oncol. 2009;27(6):851–856.
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functional results. Ann Thorac Surg. 1987;44(2):119–122. the stomach immediate and late results of treatment by resection
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tem. Surg Laparosc Endosc Percutan Tech. 2004;14(6):323–327. 36. Tepper J, Krasna MJ, Niedzwiecki D, et al. Phase III trial of tri-
14. Krasna MJ, Flowers JL, Attar S, et al. Combined thoracoscopic/ modality therapy with cisplatin, fluorouracil, radiotherapy, and
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Semin Surg Oncol. 1997;13(4):238–244. N Engl J Med. 1999;341:384.
18. Luketich JD, Pennathur A, Awais O, et al. Outcomes after mini- 40. Watson DI, Davies N, Jamieson GG. Totally endoscopic Ivor
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LWBK1254-ch21_p235-250.indd 250 20/02/14 10:37 PM
22 En Bloc Esophagectomy
Simon Law
Introduction
The concept of “en bloc” resection involves resecting the esophagus, together with its
fascial envelope to ensure a negative circumferential margin, as well as sufficient axial
margins proximally and distally. This envelope contains the lymphatics of potential spread
which are also removed. The propensity of esophageal cancer to spread submucosally
along the length of the esophagus dictates the removal of a long length of esophagus; for
squamous cell cancer, a proximal 10-cm margin should be the aim. It is less common for
esophageal cancer to spread distally across the gastroesophageal junction. For the lateral
circumferential resection margin, the anatomic location of the esophagus makes achieving
this a challenging goal because the organ is surrounded in the mediastinum by other
important, indispensable structures. For squamous cell cancers, which are often proxi-
mally located near the tracheobronchial tree, extending the lateral extent of resection is
limited by the trachea and bronchi. For adenocarcinomas, which are mostly located in the
lower esophagus and the gastroesophageal junction, extending the lateral extent of resec-
tion by the removal of bilateral pleurae, azygos vein, pericardium, and a cuff of diaphrag-
matic crura surrounding the esophagus is possible. It has to be explained that the original
term “en bloc” resection as coined by Skinner and DeMeester refers specifically to this
type of surgery for lower esophageal carcinoma, for which the procedure is most appropri-
ate. However the term is also loosely applied to any tumor resection that involves removal
of the tumor with its adjacent tissue “in one unbroken piece.” Another consideration about
en bloc resection is the extent of lymphadenectomy; as applied to lower esophageal cancer,
this involves lower mediastinal and upper abdominal lymphadenectomy around the celiac
axis. However, more “distant” nodes, such as those in the superior mediastinum and even
neck are not necessarily resected. Some surgeons, however, describe “en bloc” esophagec-
tomy together with extensive mediastinal and even cervical lymphadenectomy. The term
“en bloc” is therefore sometimes used interchangeably with extended lymphadenectomy.
The primary indication for surgical resection of esophageal cancer is for potential cure,
which can be achieved in patients whose tumors are confined to the esophageal wall and
when only limited local-regional disease is found. One should aim at maximizing the
chance of an R0 resection (macroscopic and microscopic clearance of proximal, distal,
and lateral margins), a parameter that has consistently been shown to be of major prog-
nostic significance.
251
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Increasingly neoadjuvant treatments including chemotherapy or chemoradiother-

apy are used to treat esophageal cancer. Consistently, these strategies have been shown
to result in a higher rate of R0 resection, and a pathologic complete response (in resected
surgical specimen) can be achieved in approximately 10% for chemotherapy alone, and
up to 30% for chemoradiotherapy. Although the benefits of neoadjuvant treatments over
surgical resection alone are not proven in randomized controlled trials and remain
controversial, these strategies are routinely used in many centers. In patients with
advanced staged disease where the chance of an R0 resection is lower such as c-T3/T4
disease or those with multiple local-regional nodal spread, these therapies will result
in significant downstaging in many patients, making a subsequent R0 resection possible.
Surgery and especially en bloc esophagectomy after radiotherapy can be difficult; postir-
radiation fibrosis often obscures tissue planes. It is also uncertain if adherence to adja-
cent structures is related to residual tumor infiltration or merely desmoplastic reaction.
This is especially important when minimally invasive surgical techniques are used.
How surgical resection should be integrated into programs of multimodality treatment
remains controversial and differs among institutions.
Accurate tumor staging should be performed to ensure maximal chance of R0 resection.
This usually involves computed tomography (CT) scan, endoscopic ultrasound (EUS) ±
fine-needle aspiration cytology of suspicious nodal metastases. Positron emission tom-
ography (PET) scan is becoming the standard investigation at many institutions; it pro-
vides additional information on suspicious lesions on EUS and CT scans, especially of
distant lesions. Postneoadjuvant staging is notoriously inaccurate. Tissue planes between
the tumor and the adjacent structures are still best assessed by EUS, though accuracy
decreases substantially after radiation.
Physiologic assessments are important to exclude patients for surgery, and optimi-
zation of cardiopulmonary function is of particular importance. Factors often cited as
being predictive of morbidity and mortality after esophagectomy include advanced age,
poor performance status, nutritional depletion and weight loss, more proximally located
tumor, poor pulmonary function, cirrhosis, and abnormal cardiac evaluation. Patients
with squamous cell cancers are more likely to be malnourished, have high alcohol
intake, be smokers, and have more impairment of pulmonary and hepatic functions.
Patients with adenocarcinomas on the other hand are more likely to be overweight and
are more at risk from cardiovascular diseases.
Preoperative assessments include a detailed history and clinical physical examina-
tion, simple blood profiles, chest radiograph, electrocardiogram, and pulmonary spirom-
etry. More detailed cardiac workup, including echocardiography, myocardial perfusion
scans, or angiograms, are selectively applied when specific indications exist. Cirrhosis
is not an absolute contraindication to esophagectomy, although the presence of esopha-
geal varices usually contraindicates surgery.
In general, limited improvement can be made to a patient’s physiologic status.
However the following measures should be instituted.
n Cessation of smoking and alcohol intake
n Incentive spirometry and chest physiotherapy
n Optimization of bronchodilator therapy in patients with asthma or significant chronic
obstructive airway disease
n Consideration of coronary revascularization with angioplasty and coronary stenting in
the presence of significant coronary ischemia. Antithrombotic medications, such as
aspirin and clopidogrel, are often indicated after coronary intervention for a period of
time. In such patients, it may be prudent to treat them with neoadjuvant therapy, so
that time is not lost in waiting for an optimal time for surgery after coronary stenting
n In patients with high-grade esophageal tumor stenosis, a fine-bore nasogastric tube
can be placed for nutritional support while workup is performed, and is preferable
over parenteral nutrition, gastrostomy, or jejunostomy feeding
LWBK1254-ch22_p251-262.indd 252 19/02/14 5:36 PM

Chapter 22 En Bloc Esophagectomy 253
n Diabetic control should be optimized

n Immediate preoperative preparations include prophylactic antibiotics to be given at
anesthesia induction and deep vein thrombosis prophylaxis. Bowel preparation is
not necessary, unless a colonic interposition is intended
Surgery
Many factors need consideration in choosing the approach to surgical resection. These
include the following.
n The location of the intended anastomosis, whether it should be in the thorax or the
neck
n The route of reconstruction: Conduit placed in the thoracic cavity or to the neck via the
posterior mediastinum, retrosternal, or subcutaneous route
n The conduit used: Stomach, jejunum, or colon
The following description refers to the standard combined abdominal right thoracic
approach for “en bloc” resection with lower mediastinal and upper abdominal lymph
adenectomy using the stomach as the conduit with an intrathoracic esophagogastros-
tomy. Variations in the technique are briefly illustrated.
Positioning and Anesthetic Technique

The patient is first placed in the supine position for the abdominal part of the surgery.
To prepare for the subsequent right thoracotomy, a double-lumen endotracheal tube is
usually placed. This, however, can be placed after the abdominal phase of the operation
to lessen the duration of airway trauma in using this relatively large endotracheal tube.
At the author’s institution, it is routine practice to place a single-lumen endotracheal
tube, and during the thoracotomy phase, a right bronchial blocker is placed. This results

in less airway trauma and the more flexible tube allows better exposure of areas behind
the trachea and also around the left main bronchus. In the thoracic phase of surgery,

the patient is placed in a full lateral decubitus position with the right arm approxi-
mately at a right angle at the shoulder.
Operating Technique: Abdominal Phase

A midline or a bilateral subcostal incision is made. The author prefers the latter because
it gives improved exposure to the upper abdomen especially in obese patients. The
stomach is mobilized together with celiac trifurcation lymphadenectomy via the follow-
ing steps.
n The gastrocolic omentum is taken off the greater curvature of the stomach, preserving
the right gastroepiploic vessels and arcades. Complete omentum resection is not
necessary. Division of the gastrocolic omentum can be carried out just outside the
right gastroepiploic vessels. The left crus is exposed when the short gastric vessels
are divided and the fundus mobilized medially (Fig. 22.1). The phrenoesophageal
membrane is detached, and the abdominal esophagus and cardia can be freed on the
left side.
n The gastrohepatic ligament is then detached from the liver and from the portal struc-
tures. Dissection from the right side toward the esophageal hiatus frees the right crus,
and dissection anterior to the esophagus will meet the already dissected plane from
the left. The anterior vagus nerve can be divided at this point. The esophagus is thus
freed on both sides as well as anteriorly. A sling placed around the lower esophagus,
such as a Penrose or latex drain, may help later dissection by providing retraction.
n For a tumor of the distal esophagus located at the hiatal opening, especially for a
transmural T3/T4 tumor, a cuff of diaphragmatic crura can be removed together with
the tumor. When a cuff of muscle from the esophageal hiatus is removed, both pleu-
ral cavities are likely to be entered, but this is of no serious consequence.
LWBK1254-ch22_p251-262.indd 253 19/02/14 5:36 PM

Figure 22.1 Figure showing detach

ment of the gastrocolic omentum off
the stomach. It is not necessary to
perform a total omentectomy. Division
of the gastrocolic ligament a short
distance from the right gastroepiploic
arcade is sufficient. This is the most
important blood supply to the gastric
conduit. The left gastroepiploic artery
is ligated near the inferior pole of the
spleen. Blue arrow, right gastroep
iploic arcade; Black arrow, inferior
pole of spleen where the left gastro
epiploic artery will be found.
n The stomach is then reflected upward and dissection is begun at the celiac trifurca-
tion (Fig. 22.2). Using fine electrocautery, dissection is performed along the anterior
aspect of the common hepatic artery. Lymphadenectomy can then proceed laterally
toward the hepatoduodenal ligament. It is sufficient to remove nodes along the ante-
rior surface of the common hepatic artery. Medially toward the origin of the left
gastric artery at the celiac axis, the left gastric artery and coronary vein require liga-
tion (Fig. 22.3). The origin of the left gastric artery is identified separately as it comes
off the celiac axis and it is doubly ligated and cut between ligatures (Fig. 22.4). Fur-
ther dissection toward the left will clear the lymphatic tissues on the splenic artery.
The areolar tissue superior to the common hepatic artery and splenic artery is there-
fore cleared en bloc with the abdominal esophagus toward the hiatus.
n Continued dissection upward can be carried out through the esophageal hiatus
along the front of the aorta. Areolar tissues are freed from the aorta and remain
attached to the resected specimen. The cardia and the abdominal esophagus are thus
freed totally.
n On the lesser curvature the right gastric vessels are divided at the angular incisura. One
linear stapler is used to transect the stomach from this point upward toward the fundus.
This is the first of a series of staplers used to transect the stomach to make a narrow
gastric conduit. The application of one stapler at this stage of the operation will make
the subsequent use of further staplers during the thoracic phase easier (Fig. 22.5).
Figure 22.2 Figure showing the celiac

axis to be dissected. CV, coronary
vein; LGA, left gastric artery; LN,
enlarged lymph node next to left
LGA gastric artery; HLN, enlarged hepatic
artery lymph node; PAN, pancreas.
LN
CV
HLN
PAN
LWBK1254-ch22_p251-262.indd 254 19/02/14 5:37 PM

Figure 22.3 Origin of coronary vein

dissected and about to be ligated.
Hepatic artery exposed. CV, coronary
vein; HA, hepatic artery.
CV
HA
Figure 22.4 Ligation of left gastric

artery at its origin; hepatic artery
lymph node already taken off the
anterior surface of hepatic artery.
LGA, left gastric artery; HA, hepatic
artery; HAN, hepatic artery lymph
node; ST, stomach.
HAN
HA

LGA ST

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). A linear stapler is used to
partially transect the stomach from this point
upward toward the fundus. This makes the
subsequent transection of the stomach
during the thoracic phase easier. Broken
arrow: Pyloroplasty site; small blue arrow:
Point at which the right gastric artery has
been divided; large blue arrow: Pointing
at the linear staple transection line. This
forms the first stapled line to transect the
stomach; this will be completed in the
thoracic cavity.
LWBK1254-ch22_p251-262.indd 255 19/02/14 5:37 PM

n A Heineke–Mikulicz pyloroplasty is then performed although some surgeons would

forgo this step. A Kocher maneuver is not mandatory, provided the stomach is of
sufficient length. However, this maneuver is easily performed and does have the
advantage of straightening the “axis” of the pyloroduodenal region when the stomach
is brought up to the right thoracic cavity. After careful hemostasis, the abdomen is
closed. Abdominal drains are not required.
Operating Technique: Thoracic Phase

n A posterolateral thoracotomy through the fifth intercostal space is usually per-
formed; the serratus anterior can be spared. Alternatively, an anterolateral thora-
cotomy can also be done with sparing of the latissimus dorsi. The author prefers
the latter. A controlled fracture of sixth rib posteriorly eases distraction of the rib
space. Two rib spreaders placed at right angles to each other are used to open up
the rib space.
n The arch of the azygos vein as it crosses the esophagus is divided and transfixed.
The right bronchial artery, which can be quite sizable, runs just beneath the vein. It
can be preserved if desired.
n For conventional “en bloc” esophagectomy, superior mediastinal nodal dissection is
not generally performed for a lower esophageal adenocarcinoma. The superior medi-
astinal segment of the esophagus can be mobilized close to its wall. The mediastinal
pleura is opened on the back of the trachea. The esophagus is freed from the back
of the trachea anteriorly and posteriorly from the spine; it can be slung with a tape
to ease later dissection. One should avoid cautery in front of the esophagus to avoid
tracheal injury. Dissection is carried out to near the apex.
n The inferior pulmonary ligament is divided with electrocautery to the root of the
inferior pulmonary vein. Dissection is then continued on the posterior surface of
the pericardium. The right main bronchus is identified and lymph nodes and con-
nective tissue inferior to it are taken together with the esophagus. Further dissection
will lead to the infracarinal lymph node package. The infracarinal dissection is fol-
lowed toward the left to expose the left main bronchus and the lymph nodes and
fatty tissues inferior to its edge. Sharp dissection with careful hemostasis is essential
to avoid thermal injury to the membranous parts of the bronchi.
n The mediastinal pleura is incised along the anterior aspect of the length of the
azygos vein from above downward. Some surgeons remove the whole length of the
azygos vein and its branches. The posterior limit of dissection can be defined using
the vein as a guide. When the point just above the hiatus is reached, the dissection
plane deepens onto the surface of the aorta. Anteriorly within the areola tissue
between the azygos vein and the surface of the aorta is the thoracic duct, which
is identified, isolated, and ligated (Fig. 22.6). When the dissection reaches the
esophagus anteriorly, the thoracic duct, the areolar connective tissue, and the con-
nective tissue on the aorta are removed en bloc with the esophagus. This resection
continues from below upward, until the previous dissection plane from anteriorly
on the left main bronchus is met. The limits of the lymph node dissection extend
inferiorly to the crura of the diaphragm, anterior on the pericardium, right main
bronchus, apically at the tracheal bifurcation, and posteriorly from the left main
bronchus along the length of the descending aorta. Further dissection upward
should meet the previously slung upper esophagus so that the whole intrathoracic
esophagus is freed. In “classical en bloc” esophagectomy, the pleura on the left
side can be resected with the esophagus, so that the left lung is exposed; a cuff of
pericardium attached to the primary tumor can also be removed to improve lateral
tumor clearance. The author feels that unless the pericardium or azygos vein are
obviously involved, these structures could be spared. The subaortic nodes could
be removed at this point just above the left main bronchus, taking care not to dam-
age the left recurrent laryngeal nerve medially, and the left pulmonary artery on
the deep limit of dissection (Fig. 22.7).
LWBK1254-ch22_p251-262.indd 256 19/02/14 5:37 PM

Figure 22.6 The thoracic duct is

ligated together with the loose con
nective tissue on the aortic surface.
It lies within the tissue in between
the azygos vein and the surface of
the aorta. Ligation of the thoracic
duct lessens the chance of chylotho
rax. The figure shows the beginning
TD
of dissection of the periaortic tissue
proximally, which contains the tho
racic duct. TD, thoracic duct ligated
AO within the areolar tissue on the aorta;
AO, aorta; AV, azygos vein.
AV
n After esophageal mobilization and mediastinal nodal dissection, the gastric tube is
delivered up through the diaphragmatic hiatus into the right chest. The gastric conduit
can be tailored by starting transection at a chosen point of the fundus downward toward
the already fired stapler from the distal lesser curvature during the abdominal phase of
the operation. Usually, two to three more linear staplers are necessary (Fig. 22.8).
n A Satinsky clamp is then applied across the supra-aortic segment of the esophagus
near the apex of the thoracic cavity. The esophagus is divided distal to the clamp.
The esophagus with the tumor is removed, and the gastric tube is placed in the
mediastinum ready for anastomosis.

n The anastomosis can be constructed using a handsewn method or stapling technique.
The authors prefer the former, which has a similar incidence of anastomotic leakage

but a lower stricture rate compared with using circular stapler. The tip of the gastric
conduit is removed, and the anastomosis made with a fine absorbable monofilament
suture (4-0 polyglyconate) using a one-layer continuous method. The apex of the
linear stapled line can be incorporated into the anastomosis (Figs. 22.9 and 22.10).
n If a circular stapler is used, the esophageal stump can be prepared in a standard
manner by using a purse-string device before placing the anvil. Transoral placement
Figure 22.7 The esophagus has been

dissected away. At the end of dissec
tion, the tracheal bifurcation nodes, the
bronchial nodes are all removed. The
pericardium and the aortic surface are
bared; the subaortic nodes are also
TRA removed. The nodal tissues are all
AA taken en bloc with the esophagus. ES,
esophagus; TRA, trachea; RMB, right
main bronchus; LMB, left main bron
ES chus; PC, pericardium; AO, aorta; AV,
RMB
LMB azygos vein; AA, aortic arch.
AO PC
AV
LWBK1254-ch22_p251-262.indd 257 19/02/14 5:37 PM

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
ES intended line of transection toward
the lesser curvature of the stomach
distally to complete making a narrow
GC gastric tube. GC, gastric conduit; ES,
esophagus.
Figure 22.9 The beginning of the

anastomosis between the esophagus
and the gastric conduit using a hand
sewn method at the apex of the
thoracic cavity. ES, esophagus; GC,
gastric conduit.
ES
GC
Figure 22.10 Completion of the anas

tomosis. Note the tip of the linear
stapled line is incorporated into the
hand-sewn anastomosis forming a
T-junction. ANS, anastomosis; ES,
esophagus; GC, gastric conduit.
ANS
ES
GC
LWBK1254-ch22_p251-262.indd 258 19/02/14 5:37 PM

of the anvil is also possible with an ORVil EEA stapler (Covidien Surgical) for a
double-stapling technique.
n Before the linear staplers are used to transect the stomach, a point on the lesser
curvature can be chosen to make a gastrotomy; the shaft of the circular stapler can
be introduced into the stomach toward a point chosen at the fundus. The central rod
of the shaft is advanced through the stomach and then engaged with the anvil and
fired. The lesser curvature of the stomach can then be resected using more linear
staplers, completing the transection by joining the first stapled line distally.
n After hemostasis, the thoracotomy is closed with a 24-French chest drain.
The appropriate selection of surgical procedure, its meticulous execution, and periop-
erative care have causal relationship with morbidity and mortality. For most patients,
a standardized clinical pathway is helpful.
n Most patients have endotracheal tube extubation in the recovery room, unless the
surgery has been prolonged, complicated, or performed in high-risk patients.
n Epidural analgesia is the most important in postoperative pain relief. It is continued
for the first 4 to 5 days after surgery, and can be replaced by patient-controlled anal-
gesia or oral medications. Adequate pain control is essential to lessen the chance of
pulmonary complications.
n The nasogastric tube is removed after 3 to 4 days. The tube is mainly used to avoid
gastric distension in the early postoperative period; output is usually minimal. Early
tube removal reduces discomfort and facilitates coughing efforts.
n All patients have a bronchoscopic examination on the first postoperative day to
check for recurrent laryngeal nerve injury, although this is unusual in the absence
of superior mediastinal or cervical lymphadenectomy. Fiber optic bronchoscopic
sputum suction is used liberally for sputum retention. Frequent need of broncho-

scopic toilet is an indication of tracheostomy. Judicious use of intravenous fluid is
also important to avoid overhydration and pulmonary edema.

n Chest physiotherapy is instituted and early ambulation encouraged. Deep vein
thrombosis prophylaxis is continued.
n The chest drain is removed on day 4 to 5 postoperatively, unless output is excessive.
n Liquid by mouth is started on postoperative day 4 to 5; this is gently advanced to
the 7th postoperative day. After a contrast swallow confirms absence of anastomotic
leak, a soft diet with porridge is started. Oral intake is gradually increased. Jejunos-
tomy feeding is not routinely practiced by the author. Early oral alimentation is
successful in most patients, and most do not need supplementary nutritional sup-
port. Should oral intake is delayed, such as when anastomotic leak occurs, endo-
scopic placement of a nasoduodenal tube for feeding will suffice.
Complications
Medical complications after esophagectomy are mostly cardiopulmonary in nature.
Arrhythmia, usually in the form of atrial fibrillation and supraventricular tachycardia,
may occur in up to 25% of patients. Although its occurrence is usually benign in itself,
it should trigger a careful search for underlying causes—surgical sepsis and pulmonary
complications being most common. Sputum retention and atelectasis are also common;
proactive pulmonary support should be instituted to prevent progression to pneumonia.
Many surgical complications could occur which may include the following:
n Conduit ischemia: Gross ischemia of the conduit usually presents early, within the
first 2 to 3 days after operation. Sepsis is obvious but in the early stage signs may be
subtle, which could simply be unexplained tachycardia, atrial arrhythmia, or poor
arterial oxygenation. It is important to treat this complication expeditiously so that
LWBK1254-ch22_p251-262.indd 259 19/02/14 5:37 PM

further deterioration does not occur. A high index of suspicion is required. A low
threshold of performing endoscopy on the patient is recommended to examine the
state of the conduit and anastomosis whenever there are signs of deterioration. Gross
ischemia dictates taking down of the conduit, adequate drainage, and staged recon-
struction later, once sepsis is under control. In selected cases with ischemia limited
to a small portion of the gastric conduit, when the patient is hemodynamically stable
with minimal sepsis, and when an adequate length of stomach remains after resec-
tion of the ischemic portion, immediate reanastomosis is an option.
n Anastomotic leak: Clinically apparent thoracic anastomotic leaks usually occur
within the first week. Signs of sepsis or excessive output from the chest drain, which
may be turbid in color, lead to diagnosis. The location and magnitude of the leak can
be visualized by a water-soluble contrast study. A carefully performed flexible endo-
scopic examination is also helpful. For small contained leaks, CT-guided drainage of
pockets of collection may suffice. In septic patients with a sizable leak, exploration
is warranted. Direct repair is seldom possible or effective; drainage is the key. Injec-
tion of fibrin glue or placement of intraluminal stents is increasingly used to treat
leaks; sealing of the leak allows early control of sepsis and resumption of oral
alimentation. The stent can be removed afterward, depending on the severity of the
leak in the first place. Usually 4 to 6 weeks will suffice for adequate healing.
n Chylothorax: Persistently high output from the chest tube, often more than a liter a
day, should prompt the search for chylous leak. A milk challenge via a nasogastric
tube or by mouth, looking at the color change of the drain effluent into a milky fluid,
is diagnostic. Other biochemical parameters that could be looked at include triglyc-
eride level and the presence of chylomicrons in the drain output after milk challenge.
After the diagnosis is confirmed, low-output chylothorax (less than 1 L/day) could be
treated by a short period of nothing by mouth (nil per os) with total parenteral nutri-
tion, or a diet with midchain triglyceride. Early surgical re-exploration, however, has
a higher chance of success and prevents deterioration related to constant loss of lym-
phocytes and proteins from the effluent fluid. A preoperative lymphangiogram may
help locate the site of chylous leak. If uncertain, mass ligation of lymphatic tissue
near the diaphragmatic hiatus via thoracic re-exploration may be successful.
n Malrotation of the gastric conduit: This may result in ischemia of the stomach or
outlet obstruction. Early surgical exploration is the key.
n Diaphragmatic herniation: A widened diaphragmatic hiatus, especially after crural
resection, may lead to herniation of bowel into the thoracic cavity. Most commonly,
this involves the transverse colon. An abnormal shadow on the chest radiograph
should prompt further investigations. Again, early re-exploration with reduction of
hernia and closure of the hiatus around the gastric conduit is indicated.
n Recurrent laryngeal nerve injury: When unilateral, recurrent laryngeal nerve injury
results in hoarseness of voice, poor cough effort, and increased chance of aspiration.
When it is bilateral, airway compromise is the rule and tracheostomy and delayed
feeding are required. Long-term quality of life is also affected.
n Tracheobronchial injury should be rare and is mostly recognized at the time of sur-
gery; primary repair with or without reinforcing tissue (such as muscle flaps) is
indicated.
Results
Mortality after en bloc esophagectomy should be rare (<5%) when carried out in high-
volume expert centers. With a high-risk population and extensive surgery with many
potential pitfalls, morbidity can still be substantial; the total complication rate after en
bloc esophagectomy still approaches 40%. The most common of which are sputum
retention, atelectasis, pneumonia, and atrial arrhythmia. Anastomotic leakage remains
not an uncommon problem, although with appropriate and aggressive treatment, death
from this complication should be infrequent. Local disease control is superior with
LWBK1254-ch22_p251-262.indd 260 19/02/14 5:37 PM

extended lymphadenectomy compared with less extensive surgery or nonoperative

treatments such as chemoradiation; reported local recurrence within the area of dissec-
tion can be as low as 1%. Achieving better long-term survival remains a less easily
accomplished goal; at present 5-year survival rates of 37% to 52% are reported in series
of en bloc resection. In randomized trial comparing extended transthoracic resection
and transhiatal resection with limited lymphadenectomy, the more extended surgery
led to a trend of better 5-year survival in type I lower esophageal adenocarcinoma (51%
vs. 37%), especially in those with limited nodal burden (one to eight positive nodes)
(64% vs. 23%). Carefully selected patients treated by combination of multimodality
treatment strategies and en bloc resection with extended lymphadenectomy may lead
to even longer survival.
Conclusions
n En bloc esophagectomy aims at complete resection of the fascial envelope of the
esophagus. This is most suitable for lower esophageal cancer where the circumfer-
ential margin can be extended, and lower mediastinal and upper abdominal lym-
phadenectomy are carried out.
n Commonly, this is performed with an abdominal and right thoracic approach. An
intrathoracic esophagogastrostomy with either a handsewn method or stapled tech-
nique is employed.
n Proper preoperative evaluation of disease stage (to maximize the chance of an R0
resection) and physiologic status is essential for a good outcome.
n Meticulous application of surgical technique minimizes the chance of surgical
complications.
n Perioperative care should be proactive and aggressive. Complications are diagnosed
early and treatment instituted.
n Good outcome can be achieved with hospital mortality rate of less than 2% in expert
centers.

Recommended References and Readings 7. Omloo JM, Lagarde SM, Hulscher JB, et al. Extended transtho-
racic resection compared with limited transhiatal resection for
1. Altorki N, Kent M, Ferrara C, et al. Three-field lymph node dis- adenocarcinoma of the mid/distal esophagus: Five-year sur-
section for squamous cell and adenocarcinoma of the esophagus. vival of a randomized clinical trial. Ann Surg. 2007;246(6):992–
Ann Surg. 2002;236(2):177–183. 1000.
2. Hagen JA, DeMeester SR, Peters JH, et al. Curative resection for 8. Peyre CG, Hagen JA, DeMeester SR, et al. The number of lymph
esophageal adenocarcinoma: Analysis of 100 en bloc esophagec- nodes removed predicts survival in esophageal cancer: An inter-
tomies. Ann Surg. 2001;234(4):520–530. national study on the impact of extent of surgical resection. Ann
3. Law S. Esophagectomy without mortality: What can surgeons Surg. 2008;248(4):549–556.
do? J Gastrointest Surg. 2010;14(Suppl 1):S101–S107. 9. Rizk NP, Ishwaran H, Rice TW, et al. Optimum lymphadenec-
4. Law S, Fok M, Chu KM, et al. Comparison of hand-sewn and tomy for esophageal cancer. Ann Surg. 2010;251(1):46–50.
stapled esophagogastric anastomosis after esophageal resection 10. Rizzetto C, DeMeester SR, Hagen JA, et al. En bloc esophagec-
for cancer: A prospective randomized controlled trial. Ann Surg. tomy reduces local recurrence and improves survival compared
1997;226(2):169–173. with transhiatal resection after neoadjuvant therapy for esopha-
5. Law S, Wong KH, Kwok KF, et al. Predictive factors for postop- geal adenocarcinoma. J Thorac Cardiovasc Surg. 2008;135(6):
erative pulmonary complications and mortality after esophagec- 1228–1236.
tomy for cancer. Ann Surg. 2004;240(5):791–800. 11. Tachibana M, Kinugasa S, Yoshimura H, et al. En-bloc esophagec-
6. Murthy SC, Law S, Whooley BP, et al. Atrial fibrillation after tomy for esophageal cancer. Am J Surg. 2004;188(3):254–260.
esophagectomy is a marker for postoperative morbidity and mor-
tality. J Thorac Cardiovasc Surg. 2003;126(4):1162–1167.
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LWBK1254-ch22_p251-262.indd 262 19/02/14 5:37 PM
23 Left Thoracoabdominal
Exposure for Esophagectomy
and Complex Hiatus
Pathology
Sudish C. Murthy
Introduction
Esophagectomy through a left thoracotomy approach was described over 60 years ago.1
It ushered in a new era of transmediastinal placement of the gastric conduit and dem-
onstrated the safety of an intrathoracic anastomosis. Up until this time, an extrathoracic
passage (subcutaneous) was used to facilitate transfer of the gastric conduit to the neck
for anastomosis to the cervical esophagus.2 This nonorthotopic reconstruction eventu-
ally became relegated to a bypass-type procedure once the left thoracoabdominal
approach became popular.
Esophagectomy through a left thoracotomy remained a standard approach for the
ensuing 30 years until supplanted by other techniques.3–5 By the late 1970s, Ivor Lewis
and McKeown procedures proved more appropriate for midesophageal squamous cell
cancer resections, and transhiatal (blunt) esophagectomy became the favored approach
for the then, less common, adenocarcinoma of the distal esophagus.
Current trends suggest the overall incidence of esophageal cancer is dramatically
increasing, and there has been a marked shift in the frequencies of histologic subtypes
in the United States. Adenocarcinoma of the distal esophagus and gastroesophageal
junction (GEJ) is now the predominant cancer.6 When considering operations for esopha-
geal cancer, optimal exposure of the distal esophagus and gastric cardia is critical, because
this will be the location of the cancer in the majority of patients. Moreover, since N1
lymph node involvement is a likely early characteristic of the disease, exposure of the
esophageal hiatus and distal posterior mediastinum for lymphadenectomy must be con-
sidered an important component of any operation for adenocarcinoma of the esopha-
gus.7 To achieve optimum exposure of the hiatus and posterior mediastinum for
resection of esophageal cancer, there is no better procedure than the left thoracoab-
dominal approach.8
263
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To date, no randomized studies exist that advocate which of several esophageal

resection techniques provide the most complete resection for cancer nor do any propose
what technique may have the best cancer-related outcomes.9,10 Little question remains,
however, that the less extensive open operation (i.e. transhiatal esophagectomy) has
fewer morbidities than any approach utilizing a thoracotomy. Yet, this must be balanced
by the possibility of an increased locoregional cancer recurrence rate after transhiatal
resection.11 More recently, minimally invasive esophagectomy techniques have been
developed off transhiatal, McKeown, and Ivor Lewis platforms.12,13 The clear advantages
of less pain and expedited recovery are apparent, though efficacy as cancer operations,
when compared with open procedures, still needs to be clearly determined. However,
several recent series of minimally invasive operations, including an abstract presented
of a prospective, multi-institutional study (Eastern Cooperative Oncology Group Study
E2202) that included 16 institutions, demonstrated that morbidity and mortality were
acceptable, and the median nodal counts were ≥20 for this operation.13–15
If one simply abides by the basic tenants of cancer surgery—(1) optimal exposure of the
cancer field, (2) complete resection that includes radial margins, (3) extensive locore-
gional lymphadenectomy for accurate staging and possible benefit, and (4) ease of
reconstruction—left thoracoabdominal esophagectomy with cervical esophagogastric
anastomosis still remains relevant today. Morbidity of the approach can be reduced by
careful preoperative patient selection, meticulous surgical technique, and early recogni-
tion and management of evolving postoperative problems.
Perhaps the greatest utility of the left thoracoabdominal approach arises in the reop-
erative benign disease setting and for difficult to repair perforations. The wide exposure
of the pathology is an advantage for these complex operations. The more recent practice
of placing synthetic or biosynthetic mesh to repair large hiatal hernias has created dif-
ficulty in sparing the esophagus when reoperations are indicated, and for cases where
there has been mesh erosion into the esophagus itself, there is no safer exposure for
esophagectomy than the left thoracoabdominal approach. Moreover, when salvage of
the esophagus is attempted following a distal esophageal perforation, a left thoracotomy
incision can be extended to a thoracoabdominal approach for perforations straddling
the hiatus to ensure an adequate primary repair.
Contraindications to a left thoracoabdominal approach are few, but clearly, prior
left thoracotomy (for lung resection or empyema) would make this exposure more chal-
lenging. Repair of the radial diaphragmatic incision is, in part, dependent upon a nor-
mally compliant diaphragm. Any prior left-sided operation can compromise this and
complicate diaphragm repair during closure. Candidates for this approach should also
be able to tolerate single-lung ventilation, as this greatly enhances the exposure.
The left thoracoabdominal/left neck approach for esophagectomy is principally a
cancer operation (Fig. 23.1) though given the explosive increase in the number hiatal
hernia operations performed and their failure rates, it should be considered an important
approach for reoperative GEJ surgery. Moreover, for the morbidly obese patient with
resectable esophageal cancer, left thoracoabdominal/left neck approach may be techni-
cally easier than one requiring laparotomy. Due to the location of the aortic arch, a high
left-sided intrathoracic anastomosis cannot be created, as in the Ivor Lewis approach.
Consequently, a cervical anastomosis is favored for this technique. Of course, when
utilized during repair of esophageal perforation, though no anastomosis will be required,
the exposure allows for access for G-tube and J-tube placement.
A left thoracoabdominal/left neck approach for distal esophageal and GEJ adeno-
carcinoma provides excellent exposure to the tumor bed, allows en bloc resection of
regional lymph nodes (N1) and celiac trunk disease (M1A), and permits the entire pro-
cedure to be completed with a single sterile preparation and draping. In addition, it affords
the surgeon the opportunity to identify peritoneal carcinomatosis and unresectable
LWBK1254-ch23_p263-272.indd 264 20/02/14 10:37 PM

Chapter 23 Left Thoracoabdominal Exposure for Esophagectomy and Complex Hiatus Pathology 265
Figure 23.1 Operative plan for resec-

tion of adenocarcinoma of the distal
esophagus/gastroesophageal junction
with cervical anastomosis.
abdominal disease prior to a commitment to extension of the incision into the left
thorax. Finally, significant splenic capsular injury is extremely rare because of the supe-

rior access to the short gastric arcade.
Because the left thoracoabdominal/left neck procedure is performed infrequently, the
orientation of abdominal, thoracic, and cervical structures is less familiar to the sur-
geon, and an appreciation of the anatomic relationships from the left lateral view must
be gained. Structures close or to the right of the midline (i.e., duodenum and thoracic
duct) are more difficult to access. Protracted ipsilateral lung collapse may be required
to complete the mediastinotomy (for cancer operations). Of importance is the morbidity
associated with division of the costal arch and circumferential dissection of the left
diaphragm. This morbidity can be significant, and accordingly, specific attention to
incision closure at the conclusion of the case is warranted.
Given that the appropriate assessment of surgical candidacy has taken place, all
patients undergo a standard bowel preparation the day before surgery. Epidural analge-
sia is favored. Standard support lines include: Left-sided double lumen endotracheal
tube, nasogastric tube, right internal jugular central venous access, right radial arterial
line, and bladder catheter. Patients are positioned in a modified right lateral decubitus
position with the abdomen and pelvis rotated back (cork-screwed) toward the table (Fig.
23.2). The sterile prep is extended beyond the midline anteriorly from neck to groin,
and posteriorly, to the spine. Regardless of intention of the procedure (benign or malig-
nant indication), the entire left arm is included within the field as is the left neck to
allow for possible left neck anastomosis. Until cervical exposure is needed during the
case, the left arm is draped across the patient’s body and supported on an arm board.
Important musculoskeletal landmarks are the left sternocleidomastoid muscle, scapular
tip, costal margin, umbilicus, and anterior iliac spine.
LWBK1254-ch23_p263-272.indd 265 20/02/14 10:37 PM

Figure 23.2 Patient position for

left thoracoabdominal and neck
incisions. The patient’s pelvis is
rotated slightly back toward the
table to allow better exposure of
the abdomen. The left arm is
draped within the sterile field and
can be repositioned throughout
the operation.
Surgery
Thoracoabdominal Incision
The thoracoabdominal incision generally extends from two fingerbreadths below the
scapula tip along the seventh interspace, across the costal margin, and obliquely toward
the umbilicus (Fig. 23.3). The oblique abdominal incision, beginning at the costal arch,
is made first. External and internal oblique muscles are divided, and the lateral aspect
of the rectus muscle and sheath are incised. The left inferior epigastric vascular pedicle
is seldom encountered and usually borders the most medial extent of the abdominal
incision. Manual palpation of abdominal viscera is used to determine resectability for
cancer cases. Specifically, peritoneal carcinomatosis, as well as liver, porta hepatis,
duodenum, pancreatic, and gross celiac involvement would end the procedure after an
enteral feeding access (J-tube) was placed. If no contraindications to proceeding are
encountered, the incision is extended posteriorly and superiorly across the costal mar-
gin and along the seventh interspace toward the scapular tip. Lower slips of serratus
muscle are generally divided in the direction of their fibers, and the anterior aspect of
the latissimus dorsi muscle is incised depending upon the posterior and superior extent
of the incision.
To connect the thoracotomy and oblique laparotomy, the costal margin and the
diaphragm must be divided. The costal arch is cut sharply, usually between the seventh
and eighth ribs. Beginning at this location, the diaphragm is circumferentially divided
posteriorly for 8 to 10 cm. A 2-cm margin of diaphragm should be left attached to the
chest wall for diaphragm closure at the conclusion of the case. The ribs are distracted
in the standard fashion, and a standard abdominal retractor is used. The GEJ should be
in the center of the operative field.
Mobilization of the proximal stomach is much easier, since the short gastric arcade
is more superficial and approached laterally. For cancer operations, an abdominal lymph
adenectomy is far easier to complete (Fig. 23.4). Mobilization of the duodenum (Kocher
maneuver) and gastric conduit drainage (pyloromyotomy or pyloroplasty) will initially
seem more awkward because of the unfamiliarity with the exposure, but can, nonethe-
less, be fully completed.
LWBK1254-ch23_p263-272.indd 266 20/02/14 10:37 PM

Figure 23.3 Lateral view of the completed

thoracoabdominal incision. The inferior
aspect of the incision is opened first, and a
thorough assessment of the abdominal
cavity is undertaken. If advanced disease is
not discovered, the incision is extended
upward in a posterior-lateral fashion, and
the costal margin is divided.
Despite the use of preoperative chemoradiotherapy for locally advanced cancer

cases, dense fibrosis at the hiatus is rarely problematic, even in obese patients. A
circumferential cuff of diaphragm can easily be included en bloc. For cancers of the

gastric cardia or fundus, or if the stomach were deemed an unsuitable conduit for any
reason, and a distal esophagectomy and total gastrectomy would be preferred, this expo-
sure is ideal. The Roux-en-Y limb is easily harvested, passed in a retrocolic fashion,
brought through the hiatus, and anastomosed to the distal esophagus at the level of the
inferior pulmonary vein without much fanfare.
For en bloc cancer operations, the mediastinal portion of the procedure begins by
widely opening the left mediastinal pleura and fully dividing the inferior pulmonary
ligament. Posteriorly, the dissection continues over the aortic adventitia to the right,
Figure 23.4 Exposure of the celiac axis

through the left thoracoabdominal
incision.
LWBK1254-ch23_p263-272.indd 267 20/02/14 10:37 PM

Figure 23.5 En bloc mobilization of the thoracic

esophagus can be performed through the
thoracoabdominal approach.
toward the spine and lower portion of the azygos vein. The right pleural space is fre-
quently opened (especially for cancer operations). Anteriorly, the mediastinal tissues
are dissected off the inferior aspect of the pericardium. After these two tissue planes
have been established, the en bloc dissection continues cephalad toward the subcarinal
region (Fig. 23.5). A Penrose drain can be used to encircle the specimen and provide
countertraction. Because of its right-sided location, it may be difficult to identify the
thoracic duct. Inclusion of the duct during the resection is often by chance, and atten-
tion must be taken to carefully clip or ligate any tissues remaining adjacent to the aorta
to prevent postoperative chylothorax. Care must also be taken to avoid injury of the
azygos vein, as repair from the left side is difficult.
For benign cases, the mediastinal dissection is often the easiest portion. Control of
the esophagus here is often performed first, and then the esophagus is followed back
toward the hiatus. For spontaneous perforation cases (Boerhaave’s syndrome), the usual
location of the injury is just above the GEJ on the left side of the esophagus. Extension
of the left thoracotomy across the costal arch and into the abdomen should be consid-
ered for injuries that extend inferiorly because access from the left thorax may not be
adequate.
For reoperative hiatal hernia repair, esophagectomy should be considered the fall-
back option when the distal esophagus or proximal stomach is felt to be unsalvageable.
This commonly occurs in the setting of a multiple reoperative case or if some prosthetic
was used to reconstruct the hiatus on the initial repair attempt. Irreparable esophageal
injury is often the norm for these types of cases, and accordingly, salvage esophagec-
tomy must be discussed with patients as a possible outcome.
When esophagectomy is planned for cancer cases, the mediastinotomy is termi-
nated after evacuation of the subcarinal lymph node packet. Cautery injury of the left
main stem bronchus and left pulmonary artery are risks during this aspect of the pro-
cedure. Several aortoesophageal collaterals are typically encountered and require surgi-
cal control. Above the level of the carina, the esophagus is bluntly dissected off the
airway and spine up toward the neck.
LWBK1254-ch23_p263-272.indd 268 20/02/14 10:37 PM

Figure 23.6 Left neck exposure of

the esophagus for cervical anas-
tomosis if indicated.
Exposure of the cervical esophagus is more challenging than from a standard supine
approach. The orientation makes it difficult to use self-retaining retractors, so assistants
are relied upon to manually expose the region. A standard oblique incision is made
along the anterior border of the sternocleidomastoid muscle (Fig. 23.6). The platysma
is incised, and the sternocleidomastoid muscle is mobilized and displaced primarily
posteriorly. The omohyoid muscle is then divided and the carotid sheath structures
carefully mobilized laterally. A useful anatomic landmark is the middle thyroid vein,

which is often bowstrung across the field and requires division. Access to the cervical
spine is then facilitated. To properly dissect the tracheoesophageal groove, the spine
must be first identified and the cervical esophagus initially approached posteriorly.
Isolating the cervical esophagus from the trachea is left as the final maneuver. Circum-
ferentially controlling the esophagus in the superior mediastinum (working back up to
the cervical esophagus) reduces the frequency of both right and left recurrent laryngeal
nerve injury.
With the cervical esophagus encircled, blunt esophagectomy techniques are used
to fully dissect the thoracic esophagus above the aortic arch. The rest of the esophagec-
tomy is performed in the standard fashion given the indication.
A modified Collard anastomosis (Figs. 23.7 and 23.8) is used to re-establish ali-
mentary tract continuity.16 Once again, more lateral exposure can be slightly disorient-
ing, but the anastomosis is constructed identically to that performed with the patient
supine. When finished, the anastomosis is returned orthotopically and repositioned in
the superior mediastinum. Gentle traction on the conduit at the hiatus will aid in
straightening the stomach out, delivering the anastomosis to the superior mediastinum
(Fig. 23.9).
Incision Closure
After the neck incision is generously lavaged with warm saline, a two-layer, interrupted
suture closure is preferred for the cervical incision. The platysma and dermis are closed
separately with absorbable suture. The interrupted technique allows for partial opening
of the cervical incision for drainage of leak or infection (5% to 10%). A Silastic closed
suction drain is placed into the superior mediastinum through the cervical incision.
Closure of the thoracoabdominal incision begins with repair of the diaphragm. This
is routinely conducted with interrupted, large gauge (#1), polyglactin suture. The repair
is made significantly easier if 2 cm of diaphragm was left on the chest wall as the sewing
LWBK1254-ch23_p263-272.indd 269 20/02/14 10:38 PM

Figure 23.7 Hybrid cervical anas-

tomosis. The posterior aspect of
the anastomosis is completed with
a 45-mm linear stapler-cutter.
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 medi-
astinum, and the conduit is gently
straightened.
LWBK1254-ch23_p263-272.indd 270 20/02/14 10:38 PM

cuff. Interrupted #2 polyglactin suture is used to coapt the thoracotomy with a

figure-of-eight suture placed across the costal margin defect (into the cartilage edges)
for realignment purposes. Occasionally, a small segment of cartilage is removed to allow
for better reapproximation of the arch. The diaphragm is tacked at the costal margin
repair site to fortify the closure. Chest and abdominal wall muscles, as well as abdom-
inal fascia, are repaired in layers with continuous absorbable suturing techniques. The
skin and subcutaneous closure is routine.
There is no question that the magnitude of the procedure leads to a more complicated
postoperative course. It should be remembered that this procedure, in combination with
induction chemoradiation therapy, is principally reserved for fit patients with locally
advanced malignancy and with limited, if any, other effective treatment options. Those
patients with perforation or GEJ mesh erosion/hiatal hernia repair failure may have
infectious disease issues that will require attention. Regardless, the vast majority of
patients will require intensive care early postoperatively, if for nothing else than to
ensure adequacy of pain control.
Complications
For esophagectomy patients, cervical infection, with or without anastomotic leak,
occurs in 5% to 10% of patients. Early identification reduces its impact. Treatment
usually requires only reopening the cervical incision and widely draining the space.
The majority of anastomotic fistulas heal within 2 weeks. A short course of broad-
spectrum antibiotics is useful to treat the accompanying cellulitis.

Approximately 5% of patients will develop chylothorax requiring a reintervention.
These are defined by early high-volume output (>1,000 mL/day) or chylothorax that
fails to resolve after 2 weeks, despite complete bowel rest and total parenteral nutrition.
Percutaneous identification and embolization of chylous leak is the standard therapy at
our institution.17,18 Reoperation and thoracic duct ligation, performed through the right
chest, is reserved for treatment failures.
Costal arch dehiscence usually occurs in the setting of a deep surgical site infection.
Though the prevalence is rare, operative debridement, wide drainage, and postoperative
vacuum dressings are indicated. Uncomplicated costal margin “clicks” are managed
expectantly.
To reduce the chance of early gastric distention and herniation of the conduit into
the left chest, patients are maintained solely on tube feeds for 4 weeks. Oral intake is
gradually advanced, and separation from tube feeds occurs between 6 and 8 weeks.
Conclusions
The left thoracoabdominal/left neck approach provides exceptional exposure for opera-
tions centered at the esophageal hiatus. For cancer indications, a complete two-field
lymph node dissection is easy to complete; en bloc esophagectomy can be performed
without patient repositioning. An emerging population of patients with failed hiatal
hernia repairs or complicated esophageal perforations might also benefit from this type
of surgical access whether esophagectomy is ultimately indicated or not. The orienta-
tion will seem awkward at first, but rapidly becomes appreciated and embraced.
LWBK1254-ch23_p263-272.indd 271 20/02/14 10:38 PM

Recommended References and Readings 11. Hulscher JB, van Sandick JW, Tijssen JG, et al. The recurrence
pattern of esophageal carcinoma after transhiatal resection. J Am
1. Sweet R. Surgical management of carcinoma of the midthoracic Coll Surg. 2000;191:143–148.
esophagus: Preliminary report. N Engl J Med. 1945;233:1. 12. Mamidanna R, Bottle A, Aylin P, et al. Short-term outcomes fol-
2. Kirschner M. Eines neues Verfahren der Osophagoplastik. Arch lowing open versus minimally invasive esophagectomy for can-
Klin Chir. 1920;114:606. cer in England: A population-based national study. Ann Surg.
3. Lewis I. The surgical treatment of carcinoma of the oesophagus 2012;255(2):197–203.
with special reference to a new operation for growths of the 13. Luketich JD, Pennathur A, Awais O, et al. Outcomes after mini-
middle third. Br J Surg. 1946;34:18. mally invasive esophagectomy: Review of over 1000 patients.
4. McKeown K. Total three-stage oesophagectomy for cancer of the Ann Surg. 2012;256(1):95–103.
oesophagus. Br J Surg. 1976;63:259–262. 14. Luketich J, Pennathur A, Catalano PJ, et al. Results of a phase II
5. Orringer M, Sloan H. Esophagectomy without thoracotomy. multicenter study of minimally invasive esophagectomy (East-
J Thorac Cardiovasc Surg. 1978;76:643–654. ern Cooperative Oncology Group Study E2202). J Clin Oncol.
6. Pohl H, Welch HG. The role of overdiagnosis and reclassification (Meeting Abstracts) 2009;27:4516.
in the marked increase of esophageal adenocarcinoma inci- 15. Berger AC, Bloomenthal A, Weksler B, et al. Oncologic efficacy
dence. J Natl Cancer Inst. 2005;97(2):142–146. is not compromised, and may be improved with minimally inva-
7. Murthy SC. Left thoracoabdominal esophagectomy. In: Pearson sive esophagectomy. J Am Coll Surg. 2011;212:560–566; discus-
FG, Patterson GA, Cooper JD, Deslauriers J, Lerut A, Luketich sion 566-568.
JD, Rice TW, eds. Thoracic & Esophageal Surgery. New York, 16. Ercan S, Rice TW, Murthy SC, et al. Does esophagogastric anas-
NY: Churchill Livingston Inc., Elsevier Health Sciences; 2008:53. tomotic technique influence the outcome of patients with
8. Ginsberg R. Left thoracoabdominal cervical approach. In: esophageal cancer? J Thorac Cardiovasc Surg. 2005;129:
Pearson FG, ed. Esophageal Surgery, 2nd ed. Philadelphia, PA: 623–631.
Churchill Livingstone; 2002:809–817. 17. Boffa DJ, Sands MJ, Rice TW, et al. A critical evaluation of a
9. Hagen J, Peters J, DeMeester T. Superiority of extended en bloc percutaneous diagnostic and treatment strategy for chylothorax
esophagogastrectomy for carcinoma of the lower esophagus and after thoracic surgery. Eur J Cardiothorac Surg. 2008;33(3):
cardia. J Thorac Cardiovasc Surg. 1993;106:850–858. 435–439.
10. Goldfaden D, Orringer MB, Appelman HD, et al. Adenocarcinoma 18. Cope C, Kaiser LR. Management of unremitting chylothorax by
of the distal esophagus and gastric cardia: Comparison of results percutaneous embolization and blockage of retroperitoneal lym-
of transhiatal esophagectomy and thoracoabdominal esophagogas- phatic vessels in 42 patients. J Vasc Interv Radiol. 2002;13(11):
trectomy. J Thorac Cardiovasc Surg. 1983;91:242–247. 1139–1148.
LWBK1254-ch23_p263-272.indd 272 20/02/14 10:38 PM

24 Minimally Invasive Ivor
Lewis Esophagectomy
Rachit D. Shah, Ryan M. Levy, and James D. Luketich
Introduction
Over the last three decades in North America, the incidence of adenocarcinoma of the
esophagus has risen faster than the incidence of any other solid organ malignancy.1
Surgical resection is the best curative therapy for patients with invasive resectable
esophageal cancer. Recently endoscopic mucosal resection (EMR) has had encouraging
results for subsets of patients with Barrett’s esophagus (BE) and high-grade dysplasia
(HGD) and in select patients with T1a tumors. However, until recently, most surgical
candidates with resectable esophageal cancers underwent esophagectomy, performed by
an open technique with the transhiatal approach or transthoracic approaches, such as
the Ivor Lewis approach, being most commonly used. The survival from either approach
has been similar in prospective randomized studies.2,3 According to the Medicare data-
base, complications from these open resections remain high with operative mortality
ranging from 8% in high-volume centers to 23% in low-volume centers.4
In an attempt to decrease the morbidity and mortality of open esophagectomy, we
adopted and have continued to refine a minimally invasive approach.5–9 We reported
our initial experience of 77 minimally invasive esophagectomies (MIEs) in 2000, fol-
lowed by our growing experience of 222 MIEs in 2003.5,6 In 2011, we reported a large
series of over 1,000 MIEs, and currently are approaching the 2,000 mark, with mortality
rates in the 1% range.8 In a recent prospective study of 17 centers experienced in
minimally invasive esophageal surgery, MIE was associated with a 2% mortality rate
and offered a safe and oncologically equivalent alternative to open esophagectomy.9
Many hybrid approaches have been reported in the pursuit of the ideal minimally
invasive esophagectomy, but the main techniques include laparoscopic transhiatal
esophagectomy, laparoscopic–thoracoscopic 3-hole (McKeown) esophagectomy, and
laparoscopic–thoracoscopic (Ivor Lewis) esophagectomy. The approach is usually a mat-
ter of surgeon preference but on occasion is dictated by the location of the tumor. For
the majority of distal esophageal tumors or gastroesophageal junction (GEJ) tumors, an
273
LWBK1254-ch24_p273-288.indd 273 21/02/14 4:06 PM

Ivor Lewis approach allows good exposure and adequate margins. At the present time,
we prefer the minimally invasive Ivor Lewis esophagectomy for most patients with
esophageal adenocarcinoma, due to the predominant localization of esophageal adeno-
carcinoma at the GEJ or distal esophagus. Ivor Lewis MIE is also adequate for most
esophageal squamous cell carcinomas in the mid- or distal esophagus. Ivor Lewis MIE
may not be ideal for upper third or midesophageal cancers with significant proximal
extension because resection with adequate margins may be difficult to obtain. In these
cases, a modified McKeown MIE (3-hole) may be a good alternative. Esophagectomy
may also be performed for patients with BE with HGD. In patients with HGD or early-
stage tumors confined to the mucosa (T1a), satisfactory results have been reported with
EMR with or without mucosal ablation (e.g. photodynamic therapy, radiofrequency
ablation) when used under selected circumstances (e.g., well-circumscribed, well-dif-
ferentiated tumors with no angiolymphatic invasion). It is important to note, however,
that there have been only short- to intermediate-term outcomes reported thus far. In a
well-known study, Ell et al.10 reported the updated results of EMR (with photodynamic
therapy in 49%) for 100 highly selected patients with T1 intramucosal cancer (from 667
patients referred for early adenocarcinoma or HGD). The selection criteria for inclusion
in their study included no angiolymphatic invasion, and histologic grades G1 and G2
(well differentiated and moderately differentiated, respectively) arising from BE. The
lateral margins of resection were positive in 34% of patients, and could not be assessed
in 33%. During a median 33-month follow-up, recurrent or metachronous lesions were
detected in 11% of patients.10 While EMR in combination with ablation may offer
several immediate benefits to the patient, there are several concerns.
1. Even in Ell’s experience,10 a large number of patients were screened and excluded
from this approach, and only ideal candidates were chosen.
2. Even in experienced hands, positive margins are present in up to 34% of patients,
with another 33% of patients with indeterminate margins due to cautery artifact,
leaving only 33% with pathologically confirmed clear margins.10,11
3. Subsquamous BE remains at risk for progression to adenocarcinoma, and continued
surveillance endoscopy is required.
4. When EMR is performed for early-stage tumors confined to the mucosa, incomplete
nodal resection is a concern.
The rate of lymph node metastasis for T1a and T1b lesions is up to 7% and 27%,
respectively,11 thus even when a negative margin is obtained in T1a tumors, a defined sub-
set will fail this approach. Moreover, HGD is often multifocal and there is a high rate of
occult carcinoma in patients who undergo resection for the preoperative diagnosis of HGD.12,13
Therefore, we continue to offer MIE for multifocal HGD and early-stage adenocarcinoma.
Patients with localized esophageal carcinoma and adequate cardiopulmonary reserve
can be offered an MIE. Patients with locally advanced tumors and no distant metastasis
on positron emission tomography (PET) scan who have a favorable response to neoad-
juvant chemotherapy with or without concurrent radiation are also candidates for MIE.
In the planning phase, detailed clinical and pathologic data should be obtained and
reviewed by an experienced center. In our center, all patients undergo an upper endos-
copy and a biopsy to confirm presence of esophageal cancer, its proximal and distal
extent, and the suitability of stomach as a gastric conduit. Other preoperative studies
include endoscopic ultrasonography (EUS) and positron emission tomography–computed
tomography (PET–CT) scans for proper clinical staging. Many patients also require a
stress test to assess underlying coronary artery disease. We perform pulmonary function
tests on patients with a heavy smoking history or known chronic obstructive pulmonary
disease to stratify their risk of respiratory complications. All patients undergo a bowel
preparation the day before surgery. Subcutaneous heparin and intravenous antibiotics
are administered on induction of general anesthesia.
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Chapter 24 Minimally Invasive Ivor Lewis Esophagectomy 275
Surgery
Patient Positioning
n A double-lumen endotracheal tube is placed and its location is confirmed with a
pediatric endoscope. The bronchial cuff (blue) is deflated during the abdominal por-
tion of the procedure to minimize the risk of left main stem ischemic injury. If the
tumor is localized to the upper esophagus or midesophagus, we routinely perform
an initial bronchoscopy with a single-lumen endotracheal tube.
n We start the operation by performing an on-table endoscopy to confirm preoperative
findings and ensure that the stomach is suitable as a gastric conduit. This defines the
exact location of tumor and proximal extent of BE.
n The patient is placed supine and positioned slightly toward the right edge of the
table. A footboard is placed to prevent the patient from slipping during steep reverse
Trendelenburg positioning.
Laparoscopic Phase
Port Placement/Staging
n The surgeon operates from the right side of the table and the assistant is on the left
side. Six abdominal ports are placed, five as depicted in Figure 24.1 and a right lower
costal margin port for the Mediflex liver retractor (Mediflex surgical products, Islan-
dia, NY). The peritoneal surface, omentum and the liver are thoroughly inspected
during the initial laparoscopic staging to rule out any occult metastasis. If there is a
suspicion for liver metastasis on preoperative imaging, an intraoperative liver ultra-
sound may be performed. The suitability of the stomach for use as a conduit is also
assessed laparoscopically.

n The patient is placed in a steep reverse Trendelenburg position and the abdomen is
insufflated using 10 to 15 mm Hg carbon dioxide insufflation.
Figure 24.1 Laparoscopic port placement.
The 10-mm port is placed first in the right
midabdomen using open Hasson trocar
insertion technique. An additional 5/11-mm
port (not shown) is placed in the right lower
quadrant that is helpful for retraction during
pyloroplasty and gastric tube creation.
LWBK1254-ch24_p273-288.indd 275 21/02/14 4:06 PM

Figure 24.2 Laparoscopic staging,

with opening of the gastrohepatic
ligament and evaluation of left
gastric/celiac lymph nodes.
n Next, the gastrohepatic ligament is opened using ultrasonic energy. Dissection is car-
ried along the left gastric vessels. A formal left gastric and celiac lymph node dis-
section is done, and any suspicious nodes are dissected and sent for frozen-section
analysis (Fig. 24.2).
n Once assured that minimal nodal disease is present and the tumor appears com-
pletely resectable, then we proceed to crural dissection and complete mobilization
of the lower esophagus.
n Esophageal mobilization is performed at the level of the diaphragmatic crura. The
right crus is separated from the esophagus; dissection is carried anteriorly and cepha-
lad to free the left crus and the gastric fundus (Figs. 24.3 and 24.4). The esophagus
is mobilized circumferentially at the hiatus from the preaortic tissue plane posteri-
orly to the pericardium anteriorly and from right to left pleura.
n At this point, provided there is no metastatic disease, bulky adenopathy, or evidence
of a T4 tumor, one can proceed with esophagectomy.
n If at this point, a decision is made to delay the MIE and give neoadjuvant therapy,
consideration can be given to some vascular conditioning, such as dividing the left
gastric artery and vein and the short gastrics. However, we have noted when opera-
tion is delayed and a significant amount of periesophageal and gastric dissection
have been done, this can lead to significant dense scar tissue and adhesions at the
time of definitive resection.
Mobilization of the Stomach

n The medial border of the right crus is dissected inferiorly toward the decussation of
the crura. A retroesophageal window is created. Additional mobilization of the lesser
curve along the left gastric vascular pedicle is performed.
LWBK1254-ch24_p273-288.indd 276 21/02/14 4:06 PM

Figure 24.3 Laparoscopic staging

(continued). The right crus is separated
from the esophageal wall/fat pad and
the decussation of the crura is identi-
fied. Resectability along these tissue
planes and along the left crus is con-
firmed before proceeding to left gastric
vascular pedicle ligation and division.
n The superior portion of the greater curve is mobilized, starting at the level where the
last gastroepiploic arcade vessel enters the gastric wall, and proceeds cephalad along
the greater curve. Care is taken to avoid direct handling of the conduit portion of the
stomach. We try to grasp areas that will be resected as opposed to handling
the neoesophagus proper. Short gastric vessels are divided up to the left crus. We
use autosonic shears or the Ligasure device (Covidien Surgical, Mansfield, MA).
n The lesser sac is entered below the gastric antrum, preserving the right gastroepiploic
arcade. The attachments to the transverse colon are mobilized to fully free the greater
curve. This completes the antropyloric mobilization.

n The fundus is rotated toward the patient’s right side and all retrogastric attach-
ments in the lesser sac are taken down toward the lesser curve until the left gastric
vessels are seen. This retrogastric dissection is carried posteriorly toward the
pylorus. The degree of Kocher maneuver that is needed is up to the judgment of
the surgeon. In general, we free up the antrum and pylorus and free the first por-
tion of the duodenum from the gall bladder. Once the pylorus is mobilized enough
to be lifted and reach the right crus without any tension, the mobilization is
usually sufficient.
Figure 24.4 Division of highest short

gastric vessels and dissection along
the greater curve of the stomach.
LWBK1254-ch24_p273-288.indd 277 21/02/14 4:06 PM

n The left gastric vessels are skeletonized and divided at the take off from the celiac
artery with a vascular load of the Endo GIA stapler. Care is taken to maximize
lymph node yield by sweeping all lymph nodes and fatty tissue up to the specimen
side.
Creation of Gastric Conduit

n The first assistant stretches the gastric fundus by holding it along the line of the
short gastrics and gently pulling it above the upper pole of the spleen. The gastric
antrum is pulled toward the right lower quadrant from the additional 5/11-mm
port (Fig. 24.5). This stretches the stomach to some degree, leading to a longer
conduit as staple loads are applied and minimizes the risk of spiralling of the
gastric tube.
n The vascular tissue along the lesser curve is divided above the level of the right
gastric artery with a vascular load (tan load, three rows of staples [tri-staple technol-
ogy] of height 2 mm, 2.5 mm, and 3 mm) of an Endo GIA stapler (Covidien Surgical).
Next, sequential firing of Endo GIA purple loads (three rows of staples; height 3 mm,
3.5 mm, 4 mm) is performed across the antrum and toward the fundus trying to keep
the staple line parallel to the line of the short gastrics with a distance of 2.5 to 3 cm
between the staple line and the short gastric vessels.
n An unusually thick antrum may require that one chooses a greater staple height (e.g.,
the black Endo GIA loads, staple height 4 mm, 4.5 mm, 5 mm) to get an adequate staple
line integrity. Generally, even when there is a thick antrum, the final stapler firings
across the thinner fundus can be reduced to the purple loads with 3 mm, 3.5 mm, and
4 mm tri-staple heights (Fig. 24.6).
n The gastric tube is generally created before completion of other abominal steps to
provide time to assess the viability of the gastric tube as a conduit before bringing it
into the chest.
n Recently, we have added an omental flap on all cases where preoperative radiation
therapy was used.14 This can be performed by sparing two or three of the omental
Figure 24.5 Creation of the gastric

conduit. The first stapler along the
lesser curve is a vascular Endo
GIA stapler after which the thick
Gentle
antrum is divided as described in
traction
the text. The antrum and the
fundus are pulled in opposite
directions to provide adequate Creation of
tension during the gastric conduit gastric tube
creation. 3 cm
Divided left
gastric artery
Division
Surgical parallel to
specimen greater
curvature
Gentle
traction
LWBK1254-ch24_p273-288.indd 278 21/02/14 4:06 PM

Figure 24.6 Completed gastric conduit

with an intact right gastroepiploic
arcade and an intact right gastric artery.
arcades that leave the gastroepiploic arcade in a perpendicular fashion. We then care-
fully follow these arcades out toward the free omentum for a distance of 10 cm or
more, thus creating 2- to 3-cm wide, 10 cm or more long vascularized omental pedi-
cle (Fig. 24.7).
Creation of Pyloroplasty
n Stay sutures (2-0 Surgidac; Covidien Surgical) are placed at the superior and inferior
edges of the pylorus to help with retraction. With experience, the pylorus can be
readily identified by gentle touching of the grasper across the surface, and
one can feel the “bump” of the thickened muscle. Frequently, one can also visualize

the small veins of Mayo from each edge of the stomach at the pyloric location. The
pylorus is oriented with traction on the stay sutures longitudinally so that the upper
stitch is at the 12 o’clock position and the lower stitich is at the 6 o’clock position.
The anterior wall is opened transversely with ultrasonic energy. It is important to
ensure that the pyloric muscle is completely divided.
n The pylorus is then closed in a Heineke–Mikulicz fashion using 2-0 Surgidac inter-
rupted sutures with the Endostitch device (Covidien Surgical). Usually, four to six
sutures are required (Fig. 24.8).
n At the end of the abdominal portion, a flap of omentum is mobilized and brought
over the pyloroplasty. It is secured over the pyloroplasty with one or two interrupted
sutures of 2-0 Surgidac using the Endostitch.
Placement of Feeding Jejunostomy

n A 10-French jejunostomy catheter is placed in the left lower quadrant using the
Seldinger technique.
Figure 24.7 Creation of a flap of

omental pedicle.
LWBK1254-ch24_p273-288.indd 279 21/02/14 4:07 PM

A B
C D
Figure 24.8 Creation of pyloroplasty (A and B) and vertical closure (C and D) in a Heineke–Mikulicz fashion.
n The camera is switched to the 5/12-mm right upper quadrant port. The omentum
and the transverse colon are elevated into the upper abdomen and the ligament of
Treitz is identified. Approximately 30 to 40 cm distal to the ligament of Treitz, a
mobile loop of jejunum is identified, and a site on the left abdominal wall is identi-
fied for tube placement. The 5/11-mm right lower quadrant port is the surgeon’s
right-hand port for jejunostomy tube creation. The jejunum is sutured to the abdom-
inal wall along the antimesenteric border (Fig. 24.9).
n A feeding jejunostomy tube (J-tube) kit needle is inserted into the bowel lumen just
distal to the tacking suture in a Witzel fashion. Air insufflation is performed to con-
firm intraluminal placement. The guidewire is advanced over the needle into the
lumen and carefully guided downstream under laparoscopic vision, and the dilator
sheath complex is introduced over the wire. The wire and dilator are removed, and
the J-tube is introduced and the peel-away housing removed.
n After placing the tube into the jejunum under direct vision and placing one or two
Witzel-type 2-0 Surgidac Endostitches, the jejunum is tacked to the abdominal wall
using a single 2-0 Endostitch placed in a triangular fashion to completely bury the J-tube
between the peritoneum and the jejunum. An antitorsion stitch is placed ∼3 cm distally,
securing the jejunum to the anterior abdominal wall (Fig. 24.9).
LWBK1254-ch24_p273-288.indd 280 21/02/14 4:07 PM

Figure 24.9 Placement of a

10-French needle jejunostomy
30 cm distal to catheter and an antitorsion stitch
Ligament of Treitz 3 to 4 cm distally along the
antimesenteric border.
One additional
suture placed into
peritoneal wall
Final Abdominal Steps

n The most superior edge of the gastric conduit along the greater curve is sutured to
the specimen along the staple line by the lesser curve with a horizontal mattress
suture. This helps with the proper orientation of the conduit during delivery into
the chest (Fig. 24.10).
n If the esophageal hiatus is generous, a 0-Surgidac Endostitch is placed to reapproxi-
mate the crura to prevent herniation of the conduit and other organs into the chest.

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.
LWBK1254-ch24_p273-288.indd 281 21/02/14 4:07 PM

Figure 24.11 Thoracoscopic port

placement. (Reprinted from Tsai
WS, Levy RM, Luketich JD.
Technique of minimally invasive
Ivor Lewis esophagectomy.
Operative Techniques in Thoracic
and Cardiovascular Surgery.
2009;14:176–192, Copyright (2009),
with permission from Elsevier.)
n The pyloroplasty site is covered with a patch of omentum, as described above.

n If an omental pedicle was created, we suture the free end of this near the fundic tip
to facilitate entry into the chest in an atraumatic fashion.
Thoracoscopic Phase
Thoracoscopic Port Placement

n Before turning the patient in the left lateral decubitus position, a nasogastric (NG)
tube is advanced into the midesophagus. Appropriate placement of the double-lumen
endotracheal tube placed at the beginning of the procedure is confirmed after turning
the patient. Five ports are placed for thoracoscopic esophageal mobilization and
anastomosis (Fig. 24.11). The surgeon works from the right side of the table while
the first assistant stands on the lower left side. The first assistant manages the cam-
era and the suction. The second assistant stands on the left upper side and controls
lung retraction.
n A 10-mm camera port is placed above the costophrenic angle, usually in the eighth
or ninth intercostal space along the anterior axillary line. The goal is to have this
port just above the diaphragm.
n The surgeon’s working port is a 10-mm port, usually one intercostal space below the
camera port, generally at the eighth or ninth intercostal space, in line with the tip
of the scapula and at least one hand’s breadth away from the camera port.
n Another 10-mm port is placed anteriorly in the fourth intercostal space. A fan-shaped
lung retractor is placed through this port.
n A 5-mm port is placed just posterior and inferior to the tip of the scapula and is
surgeon’s left-hand port used for retraction.
n An additional 5-mm port is placed in the sixth intercostal space along the anterior
axillary line for suction by the first assistant.
Thoracoscopic Esophageal Mobilization

n A stitch is placed in the central tendon of the diaphragm, at the dome, to pull the
diaphragm anteroinferiorly. We bring this stitch out low, near the costophrenic junc-
tion to allow the downward retraction of the diaphragm.
n Mobilization is begun by dividing the inferior pulmonary ligament, and the medias-
tinal pleura is incised along the edge of the lung, anterior to the esophagus, up to
the level of the azygos vein (Fig. 24.12). The azygos vein is mobilized and divided
with an Endo GIA vascular stapler load.
n Further anterior esophageal mobilization is started inferiorly along the pericardium,
retracting the esophagus posteriorly. This plane is carried cephalad, identifying the
inferior pulmonary vein, then the inferior extent of the bronchus intermedius, up to
the right main stem bronchus, and the carina. At this point, we try to resect all nodes
LWBK1254-ch24_p273-288.indd 282 21/02/14 4:07 PM

Figure 24.12 Thoracoscopic esophageal

mobilization. The lung is retracted anteriorly
and the pleura along the esophagus is
excised. The subcarinal lymph nodes are
excised en bloc along with the specimen.
and keep on a plane near these structures, but taking care not to apply energy to

these areas, in particular to the posterior membranous airway structures.
n As the carina is approached, there are always one or two large bronchial arteries and
branches to the subcarinal lymph node packet must be carefully divided with a
coagulating energy device. As we reach this point, we are also sweeping the nodal
packet off of the pericardium between the “v” formed by the bronchus intermedius
and the left main bronchus. This dissection plane is carried down the left main stem
bronchus. Subcarinal lymph nodes are removed en bloc with the specimen. Above
the azygos vein, the dissection is kept on the esophagus.
n The vagus nerve is divided just above the azygos vein and reflected anteriorly, avoid-
ing excess traction on the vagus nerve as you dissect superiorly to avoid injury to
the recurrent laryngeal nerve.
n The posterior esophageal mobilization is begun by retracting the distal esophagus
anteriorly and incising the pleura over the posterior esophageal groove anterior to
the thoracic duct. Endoclips are used liberally along the aortoesophageal branches
and lymphatic tributaries. This dissection is carried cephalad above the level of the
azygos vein. Care must be taken with the posterior plane of dissection to avoid injury
to the aorta and the thoracic duct. We generally do not resect the thoracic duct or
the azygos vein, although occasionally we have done this if a large node is adherent
in this location.
n The specimen with the attached gastric conduit is pulled into the chest taking care
to preserve proper orientation of the conduit. The divided, gastric end of the speci-
men is used as a handle to lift the specimen and complete division of the posterior
attachments in the mediastinum. Clips are used liberally in this area.
n A 5-cm access incision is made one or two interspaces above the surgeon’s working
port. A wound protector is placed.
n The esophagus is transected using Endoshears (Covidien Surgical) above the azygos
vein as the NG tube is slowly pulled back. The exact point of transection may be
varied based on the proximal extent of the tumor and the presence of BE. Also,
LWBK1254-ch24_p273-288.indd 283 21/02/14 4:07 PM

consideration to the length of the new conduit should be given prior to this step.
The specimen is removed through the access incision, opened and grossly examined
by the surgeon, and sent for frozen-section analysis of the resection margins.
Creation of Esophagogastric Anastomosis

n The anvil of a 28-mm end-to-end anastomosis (EEA) stapler is sutured into the prox-
imal esophagus. We prefer to secure this with two purse-string sutures using 2-0
Surgidac Endostitches. The first suture is used to secure the anvil. The second suture
is used to ensure that all edges are circumferentially pulled around the anvil.
n The gastric conduit is pulled up into the chest, maintaining its orientation. The lesser
curve staple line should be facing the camera. A gastrotomy is created at the tip of
the conduit, opening to the right of the staple line. The lubricated EEA stapler is
placed through the minithoracotomy and into the conduit. The conduit should be
pulled onto the stapler like a sock is pulled onto a foot.
n The tip of the EEA point pierces the new conduit, is brought out along the greater
curve of the conduit, and is carefully docked into the anvil that is sutured into the
esophagus (Fig. 24.13). The exact location of this site on the posterior wall of the
neoesophagus for the anastomosis is based on several considerations.
1. Do you have a nice, healthy neoesophagus that will easily reach the transection
point of the esophagus? If not, you may want to consider leaving some extra length
to the remaining proximal esophagus.
2. Was there any concern over the actual gastric margin, and do you need to poten-
tially resect additional conduit to achieve an adequate margin? This is not seen
often, but with cardia extension, it can be an issue.
3. What was the viability of the gastric conduit tip? Was there any duskiness? If so,
you may want to have the EEA point exit several centimeters lower on the conduit
and allow more of the proximal conduit to be resected.
n Once the exit point of the EEA tip is decided, the point of the EEA is brought out of
the posterior conduit and docked with the anvil under direct vision. The esophagus
Figure 24.13 Creation of the esophagogastric

anastomosis. The anvil is secured in the
proximal esophagus with two purse-string
sutures. The EEA stapler is introduced into
the conduit via a gastrostomy and is docked
with the anvil keeping the conduit aligned
with the lesser curve staple line facing the
camera.
LWBK1254-ch24_p273-288.indd 284 21/02/14 4:07 PM

Figure 24.14 The gastrotomy is closed

with an Endo GIA stapler and this part
of the stomach is sent as final gastric
margin. Care is taken not to encroach
this staple line too close to the circu-
Esophagus lar EEA staple line. A JP drain is left in
the esophageal bed posterior to the
Gastric tube anastomosis.
Excess stomach
trimmed and closed
and conduit are carefully approximated as you screw down on the EEA slowly bring-
ing the anvil and proximal esophagus toward the stapler to remove any slack proxi-
mally. Care is taken not to place undue tension on the anvil as you tighten the EEA,
as it is possible to actually pull the anvil out of the proximal purse-string sutures if
careful observation is not done.

n The tightening continues slowly allowing the EEA to drag up the conduit, and dock-
ing is completed as you visualize the “green” mark on the EEA device. As this dock-
ing occurs, everyone must be paying attention to avoid an incomplete ring due to
tension, or having fat or another structure get into the plane of the EEA rings.
n Finally, the EEA stapler is fired, creating an end-of-proximal-esophagus to side-of-
gastric-conduit anastomosis. The EEA rings are inspected grossly by the surgeon to
ensure that they are complete rings and then sent for permanent pathology.
n The gastrotomy through which the EEA stapler was placed is excised with the Endo
GIA stapler; generally we use the purple loads as described above (Fig. 24.14). It is
important not to transect this excess portion of the gastric tube too close to the EEA
staple line. This is sent for analysis as the final gastric margin.
Final Thoracoscopic Steps

n If an omental flap was created during the abdominal dissection, it is wrapped around
the anastomosis and secured in place with interrupted sutures.
n The chest cavity is irrigated with several liters of warm antibiotic irrigation solution
to remove any saliva or gastric contents spilled during the anastomotic steps.
n The conduit is secured to the crus of the diaphragm with a single 2-0 Surgidac stitch
to prevent potential herniation of conduit through the esophageal hiatus. A final
schematic of the reconstruction is shown in Figure 24.15.
n The NG tube is pushed down across the anastomosis under direct vision and is
positioned in the middle of the gastric conduit above the pylorus.
n A Jackson-Pratt (JP) drain is placed in the esophageal bed, posteriorly behind the
conduit and next to the anastomosis and exited out the lateral chest wall near the
costophrenic recess.
n A 28-French chest tube is placed through the camera port and is positioned posteri-
orly going toward the apex of the chest.
LWBK1254-ch24_p273-288.indd 285 21/02/14 4:07 PM

Figure 24.15 Completed recon-

struction.
Left crus
Right crus
Pyloroplasty
n At the end of the procedure, the patient is placed in a supine position, and the mouth
and nasopharynx are cleared of all saliva and secretions that may have built up dur-
ing the case. This must be done before the balloon in the tracheal portion of the
double-lumen tube is deflated to avoid aspiration of gastric contents and saliva. A
single-lumen endotracheal tube is placed and thorough bronchoscopy is performed
to clear the secretions and check for any airway injuries.
The patient is transferred to the intensive care unit (ICU) for overnight observation. The
NG tube is kept on low, intermittent suction. Patients are given intravenous narcotics
for pain control and are encouraged to participate in aggressive pulmonary toilet.
Aggressive pulmonary toilet bronchoscopy is performed as needed. The NG tube is
typically removed on the second postoperative day and slow, trickle-rate tube feeds
(20 mL/hr) are begun via the jejunostomy tube. The Foley catheter is also removed on
postoperative day 2. A barium study is performed on the third or fourth postoperative
day provided the patient has a good cough and is able to clear secretions. If the contrast
study is negative for leak, a small amount of oral intake is allowed. We allow 1 to 2 oz
an hour of a clear oral liquid diet, which is advanced to 3 to 4 oz per hour over 2 days.
The chest tube is removed when output is low (<200 mL/day) and the JP drain is
slightly pulled back before discharge. The patients are discharged on an oral diet regi-
ment of up to 4 oz per hour maximum of full liquid diet. Jejunostomy tube feeds are
typically cycled on at night from 3 pm to 9 am at approximately 100 mL per hour, but
may vary based on the type of tube feeds and the caloric needs and weight of the
patient. Patients return to the clinic 10 to 14 days after discharge, if the chest x-ray is
clear and there is no drainage from the JP drain, it is removed. If the patient is taking
4 to 6 oz per hour of a full liquid diet at this point, we remove the jejunostomy tube
and advance the oral diet.
LWBK1254-ch24_p273-288.indd 286 21/02/14 4:07 PM

T able 2 4 . 1 Comparison of Postoperative Adverse Outcomes after Elective MIE with

Either a Cervical (MIE-Neck) or Intrathoracic (MIE-Chest) Anastomosis
MIE-Neck MIE-Chest Total
Major Morbidity n = 481 (48%) n = 530 (52%) n = 1011 p-value
Vocal fold paresis/paralysis 37 (8) 5 (1) 42 (4) <0.001
Empyema 31 (6) 28 (5) 59 (6) 0.431
Acute respiratory distress syndrome 18 (4) 8 (2) 26 (3) 0.026
Myocardial infarction 9 (2) 11 (2) 20 (2) 0.809
Congestive heart failure 20 (4) 10 (2) 30 (3) 0.033
Anastomotic leak requiring surgery 26 (5) 23 (4) 49 (5) 0.439
Gastric tube necrosis 15 (3) 9 (2) 24 (2) 0.140
Mortality at 30 days 12 (2.5) 5 (0.9) 17(1.7) 0.083
From Luketich JD, Pennathur A, Awais O, et al. Outcomes after minimally invasive esophagectomy: Review of over 1000 patients.
Ann Surg. 2012;256(1):95–103, used with permission.
Complications
Recently, we published our results in more 1,000 patients who underwent MIE.8 Patients
were stratified by surgical approach, and perioperative outcomes were analyzed. The
primary end point studied was 30-day mortality. A McKeown-type, 3-incision MIE was
performed in 481 patients (48%) and an Ivor Lewis MIE in 530 patients (52%). In this
largest series to date on minimally invasive Ivor Lewis esophagectomy, we reported a
median ICU stay of 1 day and a median hospital stay of 8 days.8 The mortality rate after
Ivor Lewis MIE was 0.9%, and rate of anastomotic leak requiring surgery was observed
at 4%. The median number of lymph nodes resected was 21. The overall operative
mortality in this series of 1,011 patients was 1.68%. In comparing the experience with
our prior series, the mortality rate had decreased from 1.4% from previous series to

0.9% with an Ivor Lewis MIE.6,8 The rate of major perioperative morbidity also
decreased (Table 24.1). Notably, the incidence of vocal cord paralysis was significantly
lower with the Ivor Lewis approach (1%) compared with the McKeown, 3-incision
technique (8%). The low rate of leaks from the Ivor Lewis chest anastomosis was also
of note, with less than half of these requiring any operative intervention. Generally, if
we see a small leak, with no sepsis, and good drainage out the JP drain, we do not
intervene other than a short course of antibiotics, EGD with gentle dilations, and mon-
itoring. If the patient is stable, some of these can be monitored after discharge as well.
For small leaks that go right to the drain, we allow the patient to continue sips of clear
liquid during this time.
Results
In our series of over 1,000 patients who underwent MIE, the oncologic resection (negative
surgical margins and lymph node harvest) was comparable with most open series and
compared favorably with our previously published series on minimally invasive 3-hole
esophagectomy.6,8 At a median follow-up of 20 months, the stage-specific survival for
patients undergoing MIE was comparable with previously published open series. More-
over, we recently conducted a multicenter study with 17 centers in the United States
performing MIE in a controlled, prospective fashion. This was coordinated through the
Eastern Cooperative Oncology Group (ECOG 2202) with participation of the Cancer and
Leukemia Group B (CALGB) and the American College of Surgeons Oncology Group
(ACOSOG). The initial results were presented in abstract form at the ASCO Annual
Meeting.9 Of note, even in this 17 center study, the early operative outcomes were
favorable, with a median of 19 lymph nodes resected per case, negative margins (R0
resections) in 96% of patients, median hospital length of stay of 9 days, an anastomotic
leak rate of 8.6%, and a mortality rate of 2%.9
LWBK1254-ch24_p273-288.indd 287 21/02/14 4:07 PM

Conclusions
It has been clearly demonstrated that minimally invasive esophageal resection is techni-
cally feasible and can be performed as safely as open esophagectomy by surgeons who
are experienced in both open and minimally invasive esophageal surgery. MIE should
be performed in centers with significant experience in open esophagectomy and by
surgeons who are well trained in advanced laparoscopic and thoracoscopic procedures.
Recommended References and Readings 8. Luketich JD, Pennathur A, Awais O, et al. Outcomes after mini-
mally invasive esophagectomy: review of over 1000 patients.
1. Blot WJ, McLaughlin JK. The changing epidemiology of esopha- Ann Surg. 2012;256:95–103.
geal cancer. Semin Oncol. 1999;26(15):2–8. 9. Luketich JD, Pennathur A, Catalano PJ, et al. Results of a phase
2. Hulscher JB, van Sandick JW, de Boer AG, et al. Extended tran- II multicenter study of minimally invasive esophagectomy (East-
sthoracic resection compared with limited transhiatal resection ern Cooperative Oncology Group Study E2202). J Clin Oncol.
for adenocarcinoma of the esophagus. N Engl J Med. 2002;347 2009;27:S15 (suppl; abstr 4516).
(21):1662–1669. 10. Ell C, May A, Pech O, et al. Curative endoscopic resection of
3. Omloo JM, Lagarde SM, Hulscher JB, et al. Extended transtho- early esophageal adenocarcinomas (Barrett’s cancer). Gastrointest
racic resection compared with limited transhiatal resection for Endosc. 2007;65:3–10.
adenocarcinoma of the mid/distal esophagus: Five-year survival 11. Pennathur A, Farkas A, Krasinskas AM, et al. Esophagectomy
of a randomized clinical trial. Ann Surg. 2007;246(6):992–1001. for T1 esophageal cancer: outcomes in 100 patients and implica-
4. Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume tions for endoscopic therapy. Ann Thorac Surg. 2009;87(4):1048–
and surgical mortality in the United States. N Engl J Med. 2002; 1054; discussion 1054–1055.
346:1128–1137. 12. Pennathur A, Landreneau RJ, Luketich JD. Surgical aspects of
5. Luketich JD, Schauer PR, Christie NA, et al. Minimally invasive the patient with high-grade dysplasia. Semin Thorac Cardiovasc
esophagectomy. Ann Thorac Surg. 2000;70(3):906–911; discussion Surg. 2005;17(4):326–332.
911–912. 13. Pennathur A, Gibson MK, Jobe BA, et al. Oesophageal carci-
6. Luketich JD, Alvelo-Rivera M, Buenaventura PO, et al. Mini- noma. Lancet. 2013;381(9864):400–412.
mally invasive esophagectomy: outcomes in 222 patients. Ann 14. Pennathur A, Awais O, Luketich JD. Technique of minimally
Surg. 2003;486–495. invasive Ivor Lewis esophagectomy. Ann Thorac Surg. 2010;
7. Bizekis G, Kent MS, Luketich JD, et al. Initial experience with 89(6):S2159–S2162.
minimally invasive Ivor Lewis esophagectomy. Ann Thorac
Surg. 2006;402–407.
LWBK1254-ch24_p273-288.indd 288 21/02/14 4:07 PM

25 Esophagectomy with
Substernal Pull-up
Jie Zhang, Haichuan Hu, and Haiquan Chen
Introduction
After resection of the esophagus, the alimentary tract is most commonly substituted
using the gastric conduit through the prevertebral route (also called the posterior medi-
astinal or native esophageal route) or the substernal route (also called the retrosternal
route). As scarce evidence is available, the surgeons’ experience and preference most
often determine the choice of route. Since Orringer and Sloan1 introduced the subster-
nal route in a gastric bypass surgery for palliation of esophageal carcinoma in 1975,
esophagectomy with substernal pull-up is now widely applied when a neck anastomosis
is to be performed and esophageal replacement is delayed for any reason. This proce-
dure is also highly recommended in patients whose R0 resection is questionable,
because substernal pull-up avoids infiltration of the conduit that may subsequently
occur due to locally recurrent neoplasia. This option also allows postoperative irradia-
tion to the tumor bed without causing damage to the conduit. In addition, substernal
pull-up allows delayed reconstruction and is always available in esophagectomy surgeries
regardless of whether a thoracotomy is performed.
Indications
n Patients for whom postoperative adjuvant therapy is indicated due to a locally
advanced tumor or because a complete (R0) resection in the native esophageal bed
is questionable.2
n Delayed reconstruction in patients with esophageal exclusion and cervical
esophagostomy.
n Previous posterior mediastinal surgery (for instance, repair of a thoracic esophageal
fistula).
289
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Relative Contraindications
n Young patients or patients with a benign esophageal lesion, in whom a cardiac sur-
gery may be required in the foreseeable future.
n Previous anterior mediastinal surgery.
Preoperative work-up begins with collection of a thorough medical and surgical history
and a physical examination. Patients with previous anterior mediastinal surgery are not
ideal for substernal reconstruction. If the patient has previously undergone partial gas-
tric resection, or has a condition that might preclude application of the gastric tube as
the replacement conduit, an alternate conduit (typically colon) must be prepared.
Systemic assessment of nutritional status and hepatic, renal, and cardiopulmonary
function are essential for perioperative treatment. Radiologic investigations, including a
barium swallow and a computed tomography (CT) scan, are performed to detect the
location, length, and extent of the local lesion. To improve the staging, an endoscopic
ultrasound (EUS), and a positron emission tomography (PET) scan may be complemen-
tary to determine the T, N, and M status. In some cases, we perform laparoscopic staging
to further evaluate the patient for possible immediate surgical resection versus neoadju-
vant treatment. Esophagogastroscopy must be performed to obtain a biopsy for histologic
diagnosis and ensure suitability of the gastric conduit as an esophageal replacement.
Surgery
Anatomy
The substernal route lies in the anterior mediastinal space between the sternum and the
pericardia and the large vessels. Gastric, colonic, and jejunal interposition can all be
achieved through the substernal route. Currently, there is a debate regarding whether recon-
struction using the stomach substernally results in a longer distance for the conduit to
travel. Limited cadaveric anatomic studies indicated that the prevertebral route was 2 to
3 cm shorter than the substernal route.3,4 In some instances, this has been used as an argu-
ment against the substernal pull-up procedure. However, we questioned whether the sub-
ject and reference selection in these studies was representative of that seen clinically in our
practice. Therefore, we examined patients who underwent surgery at our institution and
found that the substernal route was unexpectedly 2.8 cm shorter than the prevertebral route.5
Position and Incision

In this procedure, the patient should be placed in the supine position. The location of
the incision depends on the purpose of the surgery. Usually, a midline laparotomy inci-
sion and an oblique cervical incision are necessary for a substernal pull-up procedure
with an anastomosis at the neck. A laparoscopic approach is also considered appropri-
ate for experienced and well-trained surgeons.
Operative Technique
Here we describe the main surgical techniques when a gastric tube is formed as the
conduit to substitute for the esophagus.
n The stomach is isolated and the gastric conduit is constructed as described in other
chapters. Because a cervical anastomosis will be constructed, the conduit has to be
completed in the abdomen (Fig. 25.1). Different surgeons have recommended differ-
ing conduit diameters, ranging from as small as 2.5 to 3 cm in diameter to as large
as 6 to 8 cm.6–9 We prefer a gastric conduit approximately 4 to 6 cm in diameter for
LWBK1254-ch25_p289-296.indd 290 19/02/14 7:44 AM

Chapter 25 Esophagectomy with Substernal Pull-up 291
Figure 25.1 The gastric conduit can

be created with a stapler as
described in other chapters.
substernal pull-up because we believe an excessively narrow conduit might increase

the incidence of cervical anastomotic leaks (Fig. 25.2). Usually, a 30- to 35-cm long
conduit is long enough for substernal pull-up to reach the hypopharynx, though a
longer tube can be fashioned, if needed.
n An optional Kocher maneuver may give extra mobility to the conduit during the
gastric pull-up. In the authors’ practice, this procedure is not routinely performed,
and usually the complete Kocher maneuver is not necessary.
n We routinely perform a jejunostomy for an enteral feeding tube. We prefer jejunos-
tomy tube feeding over nasal tube feeding for the comfort of the patient. In addition,

we believe nasal tube feeding might increase the risk of aspiration.
Figure 25.2 A gastric conduit 4 to 6 cm in diameter is
recommended.
LWBK1254-ch25_p289-296.indd 291 19/02/14 7:44 AM

Figure 25.3 The cervical esophagus is

identified and dissected, while the left
recurrent laryngeal nerve should be
distinguished and protected.
n An oblique cervical incision is made anterior to the left sternocleidomastoid mus-

cle. The space between the carotid sheath and the trachea is dissected, and the
cervical esophagus is identified and dissociated from the carotid artery, internal
jugular vein, and the left side of the thyroid gland. It is important to distinguish
and protect the left recurrent laryngeal nerve, which lies in the tracheoesophageal
groove (Fig. 25.3).
In our practice, instead of removing the left sternoclavicular joint,10 we incise part
of the sternothyroid muscle inside the sternum, when needed, to expand the thoracic
inlet and decrease the pressure caused by muscle contraction, thus alleviating compres-
sion on the microvascular network in the gastric wall.
n After that, a space within the retrosternal mediastinum was created and widened
using a combination of blunt and sharp dissection under direct visualization, and
the width of the tunnel is expanded as much as possible (Fig. 25.4A to C).
n With combination of pushing and carefully pulling, the conduit can then be positioned
substernally (Fig. 25.5A to C). It can also be placed in a plastic bag, such as a laparo-
scopic camera bag, which is tied and guided cephalad by pulling on an umbilical tape.
n Fix the proximate portion of the gastric tube with the surrounding tissues at the neck
and the distal part with peritoneum under the diaphragm (Fig. 25.6). This procedure
is of great importance to avoiding twisting of the gastric conduit and postoperative
hernia.
n Anastomosis of the cervical esophagus may be performed with an end-to-end anas-
tomosis using a hand-sewn, double-layer technique. Cervical drainage is then placed.
Stapled anastomotic techniques have been described as well.
n The laparotomy incision and the cervical incision are closed, and some patients may
then be positioned in the left lateral decubitus position for a right thoracotomy, if
indicated.
n The esophagus is isolated from diaphragm to the thoracic inlet, and all lymph nodes
are dissected. Note: This step is optional and not performed in most palliative cases.
Most patients are extubated immediately in the operation room and transferred to ICU.
Postoperative management includes adequate pain control, intravenous fluid support,
prophylactic antibiotic, anticoagulants, antacids, and enteral nutrition. Enteral nutri-
tion through jejunostomy tube feeds begins 24 hours postoperatively. If no anastomotic
leak is identified and satisfactory gastric emptying is demonstrated, the nasogastric
LWBK1254-ch25_p289-296.indd 292 19/02/14 7:44 AM


B C
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.
tube can be removed and oral food or fluids can be taken, generally beginning on
postoperative day 5–7, based on the patient’s status. The patient is then allowed to
slowly progress with oral intake. Later, the cervical drainage tube can be removed if
the volume is limited and there is no sign of leak, generally around postoperative
day 7. When the patients are discharged, usually on day 7, they should be able to
manage several small meals of a soft diet every day. The jejunostomy tube is kept in
place and used for additional nutritional support till the patient’s first postoperative
follow-up.
An anastomotic leak should be immediately managed by open drainage. Drainage
should be assessed daily, and antibiotics should be considered if necessary. Assess-
ment of the upper mediastinum should be included in patients with a cervical leak
as it is not uncommon for the actual anastomosis to lie below the level of the tho-
racic inlet and leaks may not be completely drained by opening the cervical inci-
sion. An anastomotic stricture can be identified by delayed emptying in a barium
swallow test, and usually benign strictures can be treated effectively by repeated
endoscopic dilatation, though occasionally it might be difficult in an individual
whose substernal gastric conduit is curved in the tunnel.10 Usually, the substernal
pull-up procedure facilitates drainage for leaks and reoperation for anastomotic
stricture.11,12
LWBK1254-ch25_p289-296.indd 293 19/02/14 7:45 AM

A B
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 surround-
ing tissues. This photograph shows
the distal part, which is fixed to
peritoneum under the diaphragm.
LWBK1254-ch25_p289-296.indd 294 19/02/14 7:45 AM

Complications and Results

Anastomotic leak is considered one of the major postoperative complications of
esophagectomy and the reported incidence after esophagectomy with substernal pull-up
varies. Most retrospective studies on esophagectomy with a substernal pull-up have
examined esophagectomy performed for palliative purposes and the incidence of leak
reported ranged from 19% to 27%.13–16 In three randomized trials that compared sub-
sternal and prevertebral pull-up after transhiatal esophagectomy, the incidence of leak
was 10% to 20% in the substernal group and was not significantly different from the pre
vertebral group in any of the trials (Bartels et al.17 10% vs. 11%, p > 0.05; van Lanschot
et al.10 20% vs. 27%, p > 0.05; Khiria et al.18 16.7% vs. 16%, p > 0.05). From 2006
to 2009, 208 patients received esophagectomy with three-field lymph node dissection
in our center. In these patients, we retrospectively found that individuals who under-
went esophagectomy with a substernal approach had a higher leak incidence (29 leaks
in 109 patients; 27%) than those with a prevertebral approach (18 leaks in 99 patients;
18%). We further compared outcomes in 40 patients who underwent esophagectomy
with substernal pull-up from May 2007 to February 2008 with outcomes in 62 patients
who underwent esophagectomy with substernal pull-up from March 2008 to March
2009, after we made modifications to the procedure. We found that the incidence of
leaks could be reduced dramatically—from 8 leaks in 40 patients (20%) to 3 leaks in
62 patients (5%)—if the following aspects had been ensured: (1) Expanding the retros-
ternal tunnel as wide as possible; (2) Forming a 4- to 6-cm wide gastric tube; (3) Resect-
ing part of the sternothyroid muscle to expand the thoracic inlet and decrease the
pressure caused by muscle contraction; (4) Fixing the gastric tube to avoid twisting.19
In a meta-analysis comparing postoperative events after esophagectomy with sub-
sternal pull-up and esophagectomy with prevertebral pull-up, there were no signifi-
cant differences in the incidences of anastomotic stricture, cardiopulmonary
complications, or perioperative mortality, and no differences in the patients’ quality

of life (including assessment of reflux, dysphagia, delayed gastric emptying, and
dumping syndrome).20
In the past, substernal pull-up was usually adopted as an unwilling method of
choice after palliative esophagectomy.14 With modification to the surgical technique
and improved perioperative care, the procedure of esophagectomy with substernal pull-
up seems to give satisfying outcomes.19 Data for some outcomes, such as overall sur-
vival, is not yet sufficiently available. Although the choice between prevertebral and
substernal pull-up procedure after esophagectomy is still debated, substernal pull-up
should be considered in patients who cannot undergo reconstruction via the prever-
tebral route.
Conclusions
n Substernal pull-up is one option for esophageal reconstruction and an alternative
when the prevertebral route is unavailable.
n Substernal pull-up is recommended for patients when postoperative adjuvant radia-
tion therapy or delayed reconstruction is indicated, and in patients with previous
posterior mediastinal surgery.
n Substernal pull-up is relatively contraindicated in patients who may need cardiac
surgery in the future and patients with prior anterior mediastinal surgery.
n Preoperative planning should be based on the purpose of the surgery and the pos-
sible options.
n Key principles of the surgery technique are to maximize the thoracic inlet and
improve the local “microenvironment” of the esophagogastric anastomosis, which
can significantly improve the blood supply.
LWBK1254-ch25_p289-296.indd 295 19/02/14 7:45 AM

n The anastomotic complications mainly include anastomotic leak and stricture. With
modification to the surgical technique and improved perioperative care, substernal
pull-up may equal or even exceed prevertebral pull-up in terms of reducing morbid-
ity and mortality.
Acknowledgments
The authors thank Dr. Hong Hu, Dr. Yihua Sun, Dr. Xiaoyang Luo, and Dr. Ting Ye for
assistance in surgical photography. We also thank Dr. Hong Hu, Dr. Ting Ye, and Dr.
Bin Li for sharing their research data.
Recommended References and Readings 10. van Lanschot JJB, van Blankenstein M, Oei HY, Tilanus HW.
Randomized comparison of prevertebral and retrosternal gastric
1. Orringer MB, Sloan H. Substernal gastric bypass of excluded tube reconstruction after resection of oesophageal carcinoma.
thoracic esophagus for palliation of esophageal carcinoma. Br J Surg. 1999;86:102–108.
J Thorac Cardiovasc Surg. 1975;70:836–851. 11. Urschel JD. Does the interponat affect outcome after esophagec-
2. Siewert JR. Eingriffe am Oesophagus. In: Breitner B, ed. Chirur- tomy for cancer? Dis Esophagus. 2001;14:124–130.
gische Operationslehre. Munich: Urban und Schwarzenberg; 12. Horvath OP, Lukacs L, Cseke L. Complications following esopha-
1989:9–67. geal surgery. Recent Results Cancer Res. 2000;155:161–173.
3. Coral RP, Constant-Neto M, Silva IS, et al. Comparative ana- 13. Orringer MB. Substernal gastric bypass of the excluded esophagus
tomical study of the anterior and posterior mediastinum as —results of an ill-advised operation. Surgery. 1984;96:467–470.
access routes after esophagectomy. Dis Esophagus. 2003;16: 14. Kunisaki C, Makino H, Otsuka Y, et al. Appropriate routes of
236–238. reconstruction following transthoracic esophagectomy. Hepato-
4. Ngan SYK, Wong J. Lengths of Different Routes for Esophageal gastroenterology. 2007;54:1997–2002.
Replacement. J Thorac Cardiovasc Surg. 1986;91:790–792. 15. Lee Y, Fujita H, Yamana H, et al.. Factors affecting leakage
5. Chen HQ, Lu JJ, Zhou JH, et al. Anterior versus posterior routes following esophageal anastomosis. Surg Today. 1994;24:24–29.
of reconstruction after esophagectomy: A comparative anatomic 16. Orringer MB, Marshall B, Chang AC, et al. Two thousand tran-
study. Ann Thorac Surg. 2009;87:400–404. shiatal esophagectomies—changing trends, lessons learned. Ann
6. Ferguson MK. Thoracic Surgery Atlas. Philadelphia, PA: Saunders Surg. 2007;246:363–374.
Press; 2007. 17. Bartels H, Thorban S, Siewert JR. Anterior versus posterior
7. Hölscher AH. Surgery techniques: Conduit preparation and reconstruction after transhiatal esophagectomy—a randomized
route of reconstruction. In: Jobe BA, Thomas CR, Hunter JG, eds. controlled trial. Br J Surg. 1993;80:1141–1144.
Esophageal Cancer Principles and Practice. New York, NY: 18. Khiria LS, Pal S, Peush S, et al. Impact on outcome of the route
Demos Medical Publishing; 2009: 535–548. of conduit transposition after transhiatal oesophagectomy: A
8. Postlethwait RW. Surgery of the Esophagus. East Norwalk: randomized controlled trial. Dig Liver Dis. 2009;41:711–716.
Appleton-Century-Crofts; 1986. 19. Hu H, Ye T, Zhang Y, et al.. Modifications in retrosternal recon-
9. Yekebas EF, Chernousov AF, Broering DC, et al. Blunt transhiatal struction after oesophagogastrectomy may reduce the incidence of
subtotal esophagectomy with gastroplasty and cervical anasto- anastomotic leakage. Eur J Cardiothorac Surg. 2012;42(2):359–363.
mosis. In: Izbicki JR, Broering DC, Yekebas EF, et al. eds. Surgery 20. Urschel JD, Urschel DM, Miller JD, et al. A meta-analysis of
of the Esophagus : Textbook and Atlas of Surgical Practice. randomized controlled trials of route of reconstruction after
Springer Press; 2009: 109–155. esophagectomy for cancer. Am J Surg. 2001;182:470–475.
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26 Merendino Jejunal
Interposition
Attila Dubecz and Hubert J. Stein
Introduction
The modified Merendino procedure is the limited resection of the distal esophagus and
gastroesophageal junction (GEJ) with regional lymphadenectomy and reconstruction
with an interposed pedicled isoperistaltic jejunal segment. Merendino and Dillard first
introduced this operation in 1955 as an antireflux procedure. They showed that the
interposition of a 15-cm isoperistaltic jejunal segment acts as a substitute for the lower
esophageal sphincter protecting against gastroesophageal reflux after resection of the
esophagogastric junction. The use of mechanical anastomotic staplers has made this
procedure simple and safe and extended its indication to the treatment of various
benign and malignant lesions involving the distal esophagus and the gastric cardia.
Indications
The Merendino procedure can be employed when a limited resection of the distal
esophagus and the GEJ is required.
These include the following.
n Caustic nondilatable strictures of the distal esophagus
n Revisional surgery after multiple failed antireflux procedures
n Benign and semimalignant tumors at the esophagogastric junction
n Early adenocarcinoma of the distal esophagus or GEJ
In this chapter, we describe the patient selection and operative steps of the Mer-
endino operation for early adenocarcinoma of the distal esophagus and GEJ in detail;
nevertheless, most of the surgical technique is applicable to the other indications as well.
There are several proposed advantages specific to the Merendino procedure when compared
with other competing procedures (total esophagectomy and endoscopic mucosal resection
[EMR]) for treating early adenocarcinoma of the distal esophagus and the gastric cardia.
297
Potential advantages are as follows:

n An oncologically adequate organ-preserving approach with low morbidity and mor-
tality and superior long-term quality of life as compared with total esophagectomy.
n Full-thickness resection of the cancerous lesion with adequate tumor-free margins
versus endoscopic resections in a piecemeal fashion.
n Removal of the entire esophageal segment with intestinal metaplasia to avoid recur-
rences and the need for life-long surveillance as seen after EMR.
n Regional en bloc lymphadenectomy providing locoregional control in patients with
submucosal adenocarcinoma (T1b); these patients have a >20% chance of lymph node
metastases.
n Combines esophageal reconstruction with an antireflux procedure controlling the
underlying, usually severe reflux disease.
Evaluation of the patient with suspected early esophageal adenocarcinoma should
include extensive diagnostic work-up with systematic biopsies aided by high-resolution
endoscopy and endoscopic ultrasound to assess the depth of tumor invasion and the
possible presence of multicentric disease. In patients with early cancer limited to the
mucosa and without a multicentric tumor manifestation, an endoscopic mucosectomy
can be performed to confirm the depth of tumor invasion. If a complete tumor removal
(R0 situation) can be achieved, and the tumor is truly limited to the mucosa (T1a),
with an endoscopic ultrasound showing no suspicious lymph nodes and a PET scan
showing no evidence of distant metastasis, life-long close endoscopic surveillance
may be justified, provided the patient is able and willing to undergo this follow-up
and other unfavorable tumor characteristics are absent (e.g., angiolymphatic invasion,
poor differentiation, ulceration, size >2 cm). All other patients including patients with
intramucosal carcinoma with unfavorable tumor characteristics (as described above),
multicentric lesions, submucosal tumor invasion, R1-mucosal resections, or recur-
rence after endoscopic mucosectomy are candidates for limited surgical resection. A
computed tomography (CT) scan of the thorax and abdomen should be performed to
evaluate for distant metastatic spread or lymph nodes outside the field of resection.
Surgery
Surgical Considerations
The goal of the operation is the full-thickness removal of the entire esophageal segment with
Barrett’s mucosa and an additional en bloc regional lymphadenectomy. An antireflux proce-
dure should be added to treat the underlying gastroesophageal reflux disease (Fig. 26.1A, B).
Surgical Technique/Sequence of Operative Steps

Positioning
he patient is positioned supine in a slight reverse Trendelenburg position on the oper-
T
ating room table, and at the time of induction a single dose of a broad-spectrum anti-
biotic is administered. The patient’s chest and abdomen are prepared with an
antiseptic solution.
Exploration
he abdomen is entered via a generous bilateral subcostal incision. Although a midline
T
incision affords excellent exposure of the upper abdomen as well, we prefer a transverse
incision as this provides a wider exposure of the esophageal hiatus. The falciform liga-
ment is divided and retractors are placed on the abdominal wall. The abdomen is then
carefully explored to evaluate the extent of locoregional disease as well as the presence
of unexpected peritoneal or hepatic metastases. Furthermore, at this point, the adequacy
(length) of the jejunal mesentery for the intrathoracic pull-up should be assessed.
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Chapter 26 Merendino Jejunal Interposition 299
Figure 26.1 A: Limited resection

of the distal esophagus, esoph-
agogastric junction, and proximal
stomach. B: Reconstruction by
interposition of a pedicled isoperi-
staltic jejunal segment.
A B
Dissection of the Diaphragmatic Hiatus and the GEJ

irst, the greater curvature of the stomach is mobilized and the bursa omentalis is
F
entered by dividing the greater omentum from the colon through the avascular plane
using the electrocautery. Then, the gastrohepatic ligament at the lesser omentum is dis-
sected. Here, running beside the hepatic branch of the vagus nerve, a sizeable hepatic

branch of left gastric artery can be encountered in fewer than 5% of patients, which
may comprise the majority of arterial inflow to the left lateral segment of the liver. For
this reason, it should be preserved by ligating the minor branches providing the lesser
curvature of the stomach while conserving the main branch. Further dissection from
the right side toward the esophageal hiatus and the division of the gastrophrenic liga-
ment frees the right diaphragmatic crus. From the left side, the short gastric vessels are
divided, the left diaphragmatic crus is identified (Fig. 26.2). After circular dissection of
Figure 26.2 Complete dissection of the

distal esophagus and the diaphragmatic
crura.
Diaphragmatic
crura
LWBK1254-ch26_p297-306.indd 299 20/02/14 11:07 AM

Figure 26.3 Placement of the purse-

string clamp on the distal esophagus.
Esophagus
the abdominal esophagus, a Penrose drain is slung around the esophagus to provide
retraction for the further dissection. The vagal nerves can be divided at this point.
Preservation of the vagal nerves compromises lymphadenectomy and should thus only
be attempted in patients with mucosal cancer or high-grade neoplasia. The diaphrag-
matic hiatus is widely opened by incision of the left diaphragmatic crus. This provides
good access to the lower posterior mediastinum.
Transection of the Distal Esophagus

he distal esophagus should be transected above the most proximal margin of Barrett’s
T
mucosa under the guidance of intraoperative endoscopy to avoid residual intestinal
metaplasia. After a proximal placement of a purse-string clamp (Fig. 26.3), nonabsorb-
able monofilament purse-string sutures are placed with a straight needle and the
esophagus transected with a scissor. Frozen section analysis of the proximal margin is
performed if there is concern about an R1 resection. After removal of the purse-string
clamp, the proximal esophagus is gently dilated with two forceps allowing the easy
insertion of the anvil of the circular stapler.
The largest stapler that can be safely inserted into the proximal esophagus should
be selected to avoid anastomotic strictures associated with the smaller staplers. It is
important to avoid 21-mm diameter staplers as the stricturing can be difficult to man-
age. After the successful placement of the entire anvil into the proximal esophageal
lumen, the purse-string suture is securely tightened around it (Fig. 26.4).
Figure 26.4 Placement of the anvil of

the circular stapler into the esophageal
lumen and tying the purse-string
suture.
LWBK1254-ch26_p297-306.indd 300 20/02/14 11:07 AM

A B
Figure 26.5 A, B: Transection of the proximal stomach with the linear stapler.
En bloc Dissection of the Distal Esophagus and Gastric Cardia with

Mediastinal and Abdominal Lymphadenectomy
The hiatus is exposed with narrow deep retractors, and the distal esophagus and GEJ
along with the entire fatty tissue with the accompanying lymph nodes in the lower
posterior mediastinum up to the level of the tracheal bifurcation are dissected en bloc.
Abdominal lymphadenectomy comprises an en bloc removal of all lymphatic tissue
along the cardia, proximal two-thirds of the lesser curvature, fundus, and along the
common hepatic and splenic artery toward the celiac axis. After the left gastric artery
is transected at its origin, the entire lymphatic tissue around the artery is dissected with
the resection specimen.

Transection of the Proximal Stomach
he stomach is transected using linear staplers. The first GIA stapler is applied at the
T
proximal third of the lesser curvature proceeding toward the tip of the gastric fundus,
thus preserving the gastric antrum and the vast majority of the corpus. Usually two to
three linear staplers are necessary (Fig. 26.5A, B). The staple line is reinforced with
interrupted 3-0 absorbable sutures (Fig. 26.6).
Preparation of the isoperistaltic jejunal Conduit

econstruction is performed by a retrocolic and retrogastric interposition of a pedicled
R
isoperistaltic jejunal segment. The jejunal mesentery is examined for completeness of
Figure 26.6 Reinforcement of the

staple line with interrupted 3-0
absorbable sutures.
LWBK1254-ch26_p297-306.indd 301 20/02/14 11:07 AM

Figure 26.7 Preparation of the pedi-

cled isoperistaltic jejunal segment.
The jejunal mesentery is examined for
completeness of the vascular arcades
with transillumination by a strong
light from behind.
the vascular arcades with transillumination by a strong light from behind (Fig. 26.7).
Selection of a segment with a good single-vessel blood supply is essential. The mesen-
tery is divided, and the isolated jejunal segment is transposed retrocolically through
the transverse mesocolon to place it tension-free in juxtaposition to the esophagus
(Fig. 26.8). An end-to-end jejunojejunostomy is performed with a running monofilament
3-0 suture between the remaining ends of the small bowel. The length of the interposed
jejunal segment should be tailored to size of the defect between the esophagus and
stomach. A minimum length of 10 to 12 cm is, however, required to protect against
postoperative reflux. On the other hand, excess length of the interponate (interposition
graft) will result in kinking and dysphagia.
Reconstruction by Esophagojejunostomy and jejunogastrostomy

he esophagojejunostomy is performed in end-to-side (functional end-to-end) fashion
T
using a circular stapler with the entry point of the stapler through the proximal end of
the isoperistaltic jejunal segment (Fig. 26.9). The redundant proximal end of the inter-
ponate is then resected and closed with a linear stapler. A 4- to 5-cm segment of the
gastric staple line at the greater curvature is excised with the electrocautery for the
subsequent jejunogastrostomy. Mechanical pyloric dilation or a formal pyloromyotomy
is performed to avoid postoperative delayed gastric emptying (Fig. 26.10). The anasto-
mosis is performed in an end-to-end fashion using a single-layer of interrupted absorb-
able 3-0 sutures. Three additional interrupted absorbable 3-0 sutures are used to secure
the fundus to the diaphragm. These serve to recreate the angle of His (Figs. 26.11 and
Figure 26.8 Appearance of the pedi-

cled jejunal segment (interponate/
interposition graft) after completing
the jejunojejunostomy.
LWBK1254-ch26_p297-306.indd 302 20/02/14 11:07 AM

Figure 26.9 Reconstruction using the

Circular stapler
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 absorb-
able 3-0 sutures to secure the fundus
to the diaphragm.
LWBK1254-ch26_p297-306.indd 303 20/02/14 11:07 AM

Interponated jejunal segment Fundodiaphragmatic Figure 26.12 Completed reconstruc-

sutures tion with the isoperistaltic pedicled
jejunal segment.
Stomach
26.12). A 24-French chest tube is placed in left pleural cavity and connected to under-
water suction.
Keys to Success
n Good exposure at the hiatus
n Adequate lymphadenectomy
n Interponate (interposition graft) length: 10 to 15 cm with an adequate vessel for blood
supply
n Straight interposition: No redundancy, no tension
n Retrocolic and retrogastric route
n Isoperistaltic reconstruction
n Creation of the angle of His and fixation of the neofundus
n Pyloric dilation or pyloroplasty
Routine extubation in the recovery room is practiced at the authors’ institution. A
nasogastric tube, which is passed at the time of the procedure to aid the hiatal dissection,
is removed in the recovery room. The patient is kept NPO (nil per os, nothing by mouth)
for 2 to 3 days on intravenous fluids and parenteral analgesics. A routine meglumine
diatrizoate (Gastrografin) swallow is not performed. On the third or fourth postoperative
day, the patient is started on a clear liquid diet and is instructed to drink in an upright
position only. The patient is advanced to a regular diet as tolerated.
Complications
Complications that occur during the initial 24 hours are usually related to bleeding from
inadequate hemostasis or iatrogenic injury of the spleen during surgery. A resulting
anemia or hypotension could jeopardize the viability of the interponated jejunal segment.
Clinical suspicion of major hemorrhage (tachycardia and a significant drop in hemoglobin
in arterial blood gas) should prompt immediate re-exploration even in the absence of
large amounts of blood in the abdominal drainage. Respiratory complications (atelectasis,
pneumonia) due to poor cough effort or aspiration are the most common cause of morbid-
ity. Perioperative physiotherapy, early postoperative ambulation and adequate pain relief,
and returning to oral diet only if an upright position can be maintained are essential.
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Anastomotic Leakage
In patients with suspected anastomotic leakage, a CT scan with a water-soluble contrast
study and a careful endoscopic assessment are performed. If a leak occurs, oral intake
is limited. Early leaks with fulminant sepsis are usually due to necrosis of the inter-
ponated jejunal segment. Operative intervention and resection of the interponate is
mandatory. Smaller, contained leaks can be usually treated conservatively with NPO
(nil per os; nothing by mouth) measures, total parenteral nutrition, broad-spectrum
antibiotics, CT-guided drainage of the fluid collections, and in selected cases with the
implantation of self-expanding plastic stents.
Results
More than 100 Merendino procedures have been performed at the authors’ present and
previous institutions; approximately 80% of these operations have been for malignancy,
and 20% for benign disease. The median number of removed lymph nodes was 20.
Perioperative mortality was 0% and postoperative morbidity was 16%. All patients
with cancer underwent an R0 resection; there were no tumor recurrences. Barrett’s
metaplasia persisted in less than 5%, and postoperative reflux was present in less than
10% of the patients at the 1-year follow-up. Personal communications with other sur-
geons (Luketich J.D., personal communications) performing this operation indicate that
stricturing at the esophagojejunal and jejunal-gastric anastomoses can be severe in some
cases. In addition, others have reported significant stasis within the jejunal segment,
significant clinical dysphagia, and in some cases herniation of redundant jejunal inter-
posed segment with the resulting dysphagia.
Recommended References and Readings 4. Stein HJ, Feith M, Mueller J, et al. Limited resection for early

adenocarcinoma in Barrett’s esophagus. Ann Surg. 2000;232(6):
1. Merendino KA, Dillard DH. The concept of sphincter substitution 733–742.
by an interposed jejunal segment of anatomic and physiologic 5. Stein HJ, Hutter J, Feith M, et al. Limited surgical resection and
abnormalities at the esophagogastric junction; with special refer- jejunal interposition for early adenocarcinoma of the distal
ence to reflux esophagitis, cardiospasm and esophageal varices. esophagus. Semin Thorac Cardiovasc Surg. 2007;19(1):72–78.
Ann Surg. 1955;142(3):486–506. 6. Takeshita K, Saito N, Saeki I, et al. Proximal gastrectomy and
2. Gerzic ZB. Modification of the Merendino procedure. Dis Esopha- jejunal pouch interposition for the treatment of early cancer
gus. 1997;10(4):270–275. in the upper third of the stomach: Surgical techniques and
3. Stein HJ, Feith M. Surgical strategies for early esophageal adeno- evaluation of postoperative function. Surgery. 1997;121(3):
carcinoma. Best Pract Res Clin Gastroenterol. 2005;19(6):927–940. 278–286.
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27 Long Segment
Reconstruction
with Jejunum
Shanda H. Blackmon and Wayne L. Hofstetter
Introduction
Full length esophageal reconstruction using a pedicled jejunal flap augmented by cervi-
cal vascular microanastomosis (supercharged pedicled jejunum [SPJ]) represents a col-
lection of historically important contributions to surgical technique. Roux was the first
to report the use of jejunum as an esophageal substitute, but the first successful intratho-
racic esophagojejunostomy was performed by Reinhoff in 1942.1 Prior to this, anesthetic
techniques limiting the application of thoracic surgery only allowed for subcutaneous
reconstructions. Longmire and Ravitch reported the first successful use of a segment of
jejunum as a free graft to replace the esophagus by enclosing it in a skin tube with
sequential transposition in three patients.2 Reinhoff’s successful one-stage surgery
accomplished what Longmire and Ravitch previously aimed to achieve in their labora-
tory and clinical work. Harrison described the first reconstruction of the entire esopha-
gus with jejunum using a transpleural route in 1949 using the experiences of Roux,
Herzen, Yudin, and Reinhoff.3 In 1950, Robertson and Sarjeant first described construc-
tion of the substernal route.4 Merendino and Dillard expanded the use of jejunal inter-
position by describing the use of an isoperistaltic segment of jejunum to replace the
lower esophageal sphincter and protect the esophagus from acid-peptic injury in 1955.5
Androsov and a group of engineers in Moscow successfully used metal clips to perform
microvascular anastomoses between the internal mammary vessels to an interposed
segment of intestine in 11 patients in 1956.6 Seidenberg performed the first free jejunal
interposition with a microvascular anastomosis to replace the cervical esophagus. 7
Kasai suggested an alternative means for supplying blood to a short segment of jejunum
based on a long pedicle to reconstruct the cervical esophagus.8 The utility of small
bowel for esophageal reconstruction was confirmed with publications by Allison,
Wooler, and Gunning, who reported 3-year follow-up of most patients having normal
nutritional intake and work capacity.9 Ascioti reported the first large series of pedicled
jejunal interposition to replace the entire esophagus in cancer patients by using the
“supercharging” technique.10
307
Indications
Patients who have acquired long segment esophageal discontinuity and lack stomach as
a viable replacement conduit primarily have two options for reconstruction: jejunum
and colon. The jejunum is uniquely suitable for esophageal reconstruction because it is
relatively abundant, does not require a formal preparation, has similar luminal size com-
pared with esophagus, and does not undergo senescent lengthening like the colon does.
Contraindications
Typical contraindications include Crohn disease, radiation enteritis, portal hyperten-
sion, short bowel syndrome, extensive fibrous adhesions, and superior mesenteric artery
(SMA) syndrome. Patients who have unfavorable jejunal anatomy may require modifica-
tions to the standard approach or an alternative conduit.
The most important part of the surgery is planning and preparation. When a patient is
known to have an extensive disease that will preclude reconstruction with a stomach
conduit, the operating room, staff, and patients and their families need to be prepared.
The first step in planning the surgery is deciding which route will be taken for the small
bowel. There are two main routes for reconstruction with jejunum: Posterior mediasti-
nal and substernal. The posterior mediastinal route is frequently used when patients
have immediate reconstruction with any conduit and the substernal route is more often
used for delayed reconstruction due to scar tissue precluding the use of the posterior
mediastinum. Given below is a list of characteristics of each route (Fig. 27.1A,B).
Figure 27.1 A: Posterior mediastinal route for

supercharged jejunal conduit. B: Substernal
route for supercharged jejunal conduit.
A B
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Chapter 27 Long Segment Reconstruction With Jejunum 309
Posterior Mediastinal Route

n Already present if initial reconstruction
n More anatomic
n Potentially shorter route
Substernal Route
n Best option for delayed reconstruction
n Easier access to chest vessels
n Outside field for potential recurrence or radiation
n May be unavailable if a previous coronary artery bypass graft (CABG) was placed
n May empty better
Anatomy
The jejunum is a long, hollow organ that extends from the ligament of Treitz and trans-
verse mesocolon (superior and inferior duodenal recesses) to the ileum, which has an
indistinct boundary of transition. The mesentery serves as the sole attachment of this
organ to the body. The serosa, muscularis propria, and mucosa comprise the three lay-
ers of the jejunum wall. The muscularis propria, like the esophagus, has an outer lon-
gitudinal layer and an inner circular layer. The lumen is lined by folds that run
perpendicular to the longitudinal axis called valvulae conniventes.
The blood supply to the jejunum arises from the SMA. Jejunal branches arise from
the left side of this artery and the right side of the SMA provides branches to the ileum
and colon. There are one to five jejunal arteries.11
Positioning

Patients are placed in the supine position. The legs are prepared into the field in the
event that a saphenous vein graft harvest would be required. The head is turned slightly
to the right and a roll is placed beneath the shoulders. The neck is prepared into the
field. Slight modifications may need to be made for patients who have a tracheostomy
or who require esophageal diversion reversal.
Surgery
Dissection of the Jejunum

n Midline abdominal incision
n Lysis of adhesions if present
n Identification of the ligament of Treitz
n Transillumination and mobilization of the bowel mesentery
n Identification of the segmental blood supply to the jejunum
n Take down any feeding jejunostomy site
n Do not divide any of the branches of the small bowel until the neck and tunnel have
been prepared to minimize ischemia time
Preparing the Neck

Dissection of the Neck and Blood Supply/Partial manubriectomy and resection of the first rib
(Fig. 27.2)
n Make an incision anterior to the sternocleidomastoid muscle low on the neck extend-
ing onto the chest either at or to the left of the midline.
n Detach the sternocleidomastoid at the head of the clavicle.
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Internal mammary
artery and vein
Figure 27.2 Manubriectomy and dissection of donor vessels.
n Dissect around the left first rib ∼3 cm lateral of the sternal border.
n Divide the clavicle just lateral to the head and medial to the ligamentous attachments
of the clavicle to the first rib. Divide the first rib 3 cm lateral to the sternal border;
allow enough space to dissect the left internal mammary artery (LIMA) for micro
vascular augmentation of the jejunal flap.
n A hemimanubriectomy is performed angled to the left on top of the second rib. The
manubrium, the head of clavicle, and the proximal first rib are removed en bloc. Use
caution because the internal mammary artery will be located underneath the cartilagi-
nous portion of the ribs, about 1 cm from the sternal border.
n A rongeur is used to resect additional bone if needed, smooth the edges so that noth-
ing sharp will injure the bowel or mesentery.
n Prepare the recipient vessels for microvascular anastomosis. The LIMA is typically
an adequate artery, the left internal mammary vein (LIMV) may or may not be robust
enough for use. If not, consider using the jugular vein for mesenteric venous anasto-
mosis. A saphenous vein graft can be used to lengthen the artery or vein depending
on the position of the conduit and recipient mesenteric vessels.
Creating the Tunnel for the Conduit
Creation of the Substernal Tunnel

n From the abdomen, an incision is made on the anterior midline aspect of the diaphragm.
n Create a midline substernal tunnel while attempting to stay extrapleural. An intrap-
leural route may be necessary in some cases. Allow enough space for the conduit and
mesentery to pass unobstructed (approximately 5 cm diameter should be adequate).
The posterior mediastinal route is an alternative avenue for positioning of the jeju-
nal conduit depending on the individual patient’s anatomic circumstances and the
nature of the esophageal pathology being approached.
Selection and Division of Jejunal Branches

n One must choose the arcade based on transilluminated visualization of the mesenteric
vascular segmental anatomy and the length of bowel being considered for transposition.
n There will be anatomic variations and shortened mesenteries from scar tissue, but
the ideal jejunal arterial choice is depicted in Figure 27.3A, B.
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A B
Figure 27.3 A: Selection and division of jejunal branches. Typical branching pattern of proximal jejunum; mesenteric and jejunal cut points
are indicated. B: Divided jejunal branches prepared for anastomosis. Vessel loops are placed around recipient vessels for augmentation.

n The first branch of the jejunal blood supply provides blood to the proximal segment
beginning after the ligament of Treitz; this first segment with its blood supply is
typically left in situ for the Roux limb reconstruction.
n Perform all of the dissection before dividing any of the blood supply to the small
bowel to minimize ischemic time. Once the second arcade has been identified and
the remaining segments appear to be appropriate, the mesentery is divided a little
proximal to the second arcade to provide additional proximal bowel length for what
will become the monitoring flap.
n This second arcade will eventually be connected by a microvascular anastomosis to
the LIMA and LIMV or jugular vein.
n Open up the mesentery to allow lengthening of the flap (Fig. 27.3B)
n The mesentery between the third and fourth arcades can be divided only up to the
level of the bridging arteries. If the division of the mesentery is continued up to the
level of the bowel wall, the third arcade segment of bowel will die.
n The second and third jejunal branches to the SMA are tied off. It is the key to divide
the vessels as close to the SMA as possible so that collateral blood flow is maxi-
mized.
n The fourth arcade is left attached to the superior mesenteric artery (vascular
pedicle).
n The mesentery between the second and third arcades can be divided up to the level
of the bowel to allow the proximal jejunum to unfurl (Fig. 27.3A); this is a critical
step to establish a straight jejunal conduit. At this point the most proximal end of
the bowel is ischemic.
n Once the blood supply has been divided, the clock starts for ischemia time (do not
divide this segment until the tunnel has been created and the donor vessels have
been prepared).
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A B
Figure 27.4 A: Antecolic route. B: Retrocolic route.
n The blood supply to the small bowel is fairly brisk. Even after ligation of the proxi-
mal branches, it may not appear ischemic, making it unclear that vascular augmenta-
tion is actually necessary. Although the bowel may appear pink, over the ensuing
several days after the procedure, a significant amount of edema enters into the bowel
wall and mesentery, allowing for adequate venous drainage which is most critical
during this period.
Planning the Intra-abdominal Route for Jejunum
Plan A (Antecolic Tunneling of the Jejunal Segment) (Fig. 27.4A)

n Little preparation is needed for an antecolic route but measure the length needed.
n Plan for additional length with an antecolic route.
Plan B (Retrocolic Tunneling of the Jejunal Segment) (Fig. 27.4B)

n Transverse mesentery of the colon is transilluminated.
n Select a portion of the transverse colon mesentery away from the marginal artery of
Drummond and the middle colic artery and use Bovie electrocautery to create a
window at least twice the size of the small bowel such that it may pass through the
window without resistance.
n Once the jejunum has passed through the window and has been connected to the
new blood supply and the bowel anastomosis is complete, make sure the edge of
the mesentery is tacked to the edge of the jejunum to prevent herniation through the
transverse colon mesentery.
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Delivery of the Jejunum Through the Substernal Tunnel

n Prepare a large camera bag or an ultrasound probe cover.
n Ensure that the tunnel is large enough to allow for the bowel and mesentery and post-
operative edema.
n Bag is delivered through the tunnel, bottom to top.
n Trace the bowel back to the mesentery and place the untwisted segment of jejunum
into the bag, moisten the inside and outside of the bag. Feed the bag and jejunum
into the tunnel from below while placing gentle traction from above. Suction can be
placed inside the bag to facilitate delivery of the conduit if necessary.
Microvascular Anastomosis
n The vascular augmentation is performed prior to esophagojejunostomy.
n Operating microscope is used to prepare the recipient vessels.
n 2- to 4-mm coupler device is typically used to create the venous anastomosis.
n Saphenous vein grafts can be used to compensate for length issues.
n Venous anastomosis is performed prior to arterial anastomosis to lessen congestion.
n 9-0 nylon sutures are typically used for the arterial anastomosis with the aid of the
operating microscope.
Creation of the Indicator Flap

n The very distal segment of jejunum with its own mesenteric blood supply is external-
ized at the end of the case to serve as an indicator flap of bowel ischemia.
n Transilluminate to ensure that there is adequate blood supply to the indicator flap.
n Divide the jejunum and mesentery to create enough length to externalize.
n 3-0 silk ties or clips are used to tie off the connection in the distal mesentery to
provide length for the monitoring segment to pass outside the chest.
n Once the anastomosis is complete and the skin is closed, the monitoring flap should

exit from a small opening in the initial incision (Fig. 27.5).
n Be sure to open the segment of bowel so that it can drain secretions.
n This is resected to skin level at the bedside just prior to discharge.
Esophagojejunal Anastomosis
n We describe three anastomotic techniques available to connect the esophagus to the
proximal segment of jejunum.
n Stapled, functional end-to-end: This technique is also referred to as the modified
Collard or Orringer technique (Fig. 27.6). The proximal segment of esophagus is
Figure 27.5 Indicator flap.
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Figure 27.6 Functional end-to-end

stapled anastomosis.
positioned adjacent to the segment of jejunum in a side-by-side fashion. The tip

of the jejunum is closed with a stapler and the jejunum is passed behind the
esophagus. A tacking suture is used to hold the bowel in this position. An ente
rotomy 45 to 60 mm away from the terminal end of the bowel is created and Endo
GIA 60-mm (purple tristaple for Covidien or blue stapler for Ethicon) single stapler
ends are passed into the open end of the esophagus and the antimesenteric
enterotomy of the jejunum. By firing the stapler, a functional end-to-end anasto-
mosis is created. The “hood” is closed with interrupted absorbable sutures or
alternatively with a TA stapler if there is adequate residual lumen.
n Handsewn end-to-end anastomosis (either single layer or double layer): An inter-
rupted absorbable suture is typically used for this anastomosis.
n Stapled circular EEA device: The anvil is placed into the terminal end of the esopha-
gus and a purse-string 3-0 prolene suture is used to secure all layers of the esophageal
wall tightly around the anvil. The circular stapler is passed into the proximal open
end of jejunum and through the antimesenteric side of the bowel to join to the anvil.
Once the two devices are coupled and the stapler is fired, the rings are inspected
and the terminal end of the jejunum is closed with a longitudinal staple line.
n Beware: The defunctionalized limb that remains must be short; we have seen
blowouts of this staple line, and the limb may act as a pseudo-Zenker’s diver-
ticulum if left too large. For these reasons this is not the authors’ choice for
anastomotic technique.
n Care is taken not to disturb the vascular anastomosis while the anastomosis is being
performed.
Recreating Continuity in the Abdomen
Plan A: Creation of the Roux Anastomosis (Preferred)

n The bowel and the mesentery must be correctly oriented.
n An isoperistaltic anastomosis between the proximal jejunum and the downstream seg-
ment of jejunum is created in a side-to-side (functional end-to-side) stapled manner.
n Optimally, this anastomosis is made about 20 to 40 cm past the diaphragmatic tunnel
to lessen bilious passage toward the neck. The longer the segment, the less absorption
time and potential for more side effects.
n The afferent limb of jejunum is connected to the jejunal interposition.
Plan B: Jejunogastric Anastomosis

n The bowel must be oriented such that the mesentery is passing behind the stomach.
n A posterior-stapled EEA anastomosis can be made by placing an anvil into the
stomach and passing the EEA stapler through the terminal end of the small bowel
exiting from the antimesenteric side of the jejunum about 4 cm from the distal end.
LWBK1254-ch27_p307-316.indd 314 19/02/14 6:47 PM

n The ends of the circular stapler are connected (stapler sizes ranging from 25–29 mm)
and fired.
n Donuts are inspected for completeness.
n Do not forget to reconnect the ends of jejunum back together (stapled side-to-side,
functional end-to-end anastomosis).
Feeding Jejunostomy
n Tunnel the feeding tube through a very small hole through the left anterior side of
the bowel and cap the feeding tube.
n An antimesenteric portion of proximal jejunum is selected for placement.
n Place a 3-0 silk purse-string suture on the antimesenteric side of the jejunum.
n Use the Bovie electrocautery to make a hole through the center of the pursestring
n Place the feeding tube into the bowel lumen and tighten the pursestring.
n Use the Witzel procedure to place the tube or merely pexy the jejunum in four quad-
rants to the anterior abdominal wall (we do both to lessen drainage around the tube).
n Fix the tube to the outside of the abdomen.
Intraoperative and Postoperative Management

n Meticulous laparotomy and instrument count.
n Modifications in the event the patient has a tracheostomy.
n Securing lines and tubes to the abdomen is a key part of postoperative management
of these patients.
n We have found that an NGT is not necessary and may even cause problems
postoperatively
n Do not place drains directly on the anastomosis.
n Make sure the conduit is not redundant and is as straight as possible and avoid

pockets during creation of the anastomosis where food may pool.
n Make sure the patient is not placed on inotropic or vasoconstrictor drugs intra- or
postoperatively.
n Keep the operating and recovery rooms warm.
Complications
Fortunately, rarely, bowel ischemia is a dreaded complication. The monitoring flap cre-
ated intraoperatively serves as a constant indicator of the proximal jejunal perfusion
until discharge. Nonobstructive mesenteric ischemia (NOMI) is a well recognized but
infrequently encountered complication in under-resuscitated patients who have
advancement of tube feeding too early. We typically start feeds on day 3 and advance
slowly. When patients complain of abdominal pain, they should have the tube feedings
stopped and in severe cases, consideration for abdominal exploration to evaluate for
ischemia may be appropriate. In spite of possible lactic acidosis, their monitoring flaps
may continue to appear healthy, and the segment of bowel downstream to the tube
feeding may require investigation directly.
Other Potential Complications

n Bleeding
n Thrombosis of vessels
n Aspiration pneumonia
n Recurrent laryngeal nerve damage
n Stricture
n Dumping syndrome
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Results
From June 2000 to December 2010, 60 consecutive patients underwent esophageal replace-
ment with a supercharged pedicled jejunal (SPJ) interposition. A multi-institutional
database was used to evaluate patient characteristics, operative technique, and outcomes.
Of the 60 patients undergoing SCJ reconstruction, 73% (44) were males and the mean
age was 56 years (range, 28 to 76 years). SCJ reconstruction was used when stomach was
not available or considered an optimal replacement. Twenty-three patients (38.3%) had
the surgery performed to reverse esophageal discontinuity. Fifty-seven patients (95%)
had reconstruction for cancer. Substernal reconstruction was performed in 39 (65%)
patients. Roux-en-Y reconstruction of the jejunum was performed in 31 (52%) and
jejunogastric anastomosis was performed in 29 (48%) patients. Anastomotic leak
occurred in 19 patients (32%) and there were five cases (8%) of graft loss. Fifty patients
(83%) were able to return to an oral diet after jejunal reconstruction. Characteristic
postoperative manometric findings in several patients included segmental peristalsis as
is typical for in situ jejunum. Thirty-day or hospital mortality was 5% (three patients).
Ninety-day mortality was 10% (six patients). Median survival and the 5-year survival
were 28 months and 30%, respectively.12
Conclusions
The SPJ is a viable option for reconstruction of the esophagus when other options such
as the stomach or colon are not available. SPJ is uncommonly indicated and is more
complex and associated with significantly more morbidity and mortality than a gastric
pull-up, but in some cases this may be the best option for the patient in order to restore
the ability to take an oral diet.
Recommended References and Readings 7. Seidenberg B, Rosenak SS, Hurwitt ES, et al. Immediate recon-
struction of the cervical esophagus by a revascularized isolated
1. Reinhoff WF Jr. Intrathoracic esophagojejunostomy for lesions jejunal segment. Ann Surg. 1959;149(2):162–171.
of the upper third of the esophagus. South Med J. 1946;39:928– 8. Kasai M, Abo S, Makino K, et al. Reconstruction of the cervical
940. esophagus with a pedicled jejunal graft. Surg Gynecol Obstet.
2. Longmire WP Jr, Ravitch MM. A new method for constructing 1965;121:102–106.
an artificial esophagus. Ann Surg. 1946;123:819–834. 9. Allison PR, Wooler GH, Gunning AJ. Esophagojejunogastros-
3. Harrison AW. Transthoracic small bowel substitution in high tomy. J Thorac Surg. 1957;33:738–748.
stricture of the esophagus. J Thorac Surg. 1949;18:316–326. 10. Ascioti AJ, Hofstetter WL, Miller MJ, et al. Long-segment, super-
4. Robertson R, Sarjeant TR. Reconstruction of esophagus. J Thorac charged, pedicled jejunal flap for total esophageal reconstruction.
Surg. 1950;20:689–705. J Thorac Cardiovasc Surg. 2005;130(5):1391–1398.
5. Merendino KA, Dillard DH. The concept of sphincter substitu- 11. Michels NA, Siddharth P, Kornblith PL, et al. The variant blood
tion by an interposed jejunal segment for anatomic and physi- supply to the small and large intestines: Its import in regional
ologic abnormalities at the esophagogastric junction; with resections. J Int Coll Surg. 1963;39:127–170.
special reference to reflux esophagitis, cardiospasm and esopha- 12. Blackmon SH, Correa AM, Skoracki R, et al. Supercharged pedi-
geal varices. Ann Surg. 1955;142:486–506. cled jejunal interposition for esophageal replacement: A 10-year
6. Androsov PI. Blood supply of mobilized intestine used for an experience. Ann Thorac Surg. 2012;94:1104–1113.
artificial esophagus. Arch Surg. 1956;73:917–926.
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28 Colon Interposition
Thomas J. Watson and Christian G. Peyre
Introduction
The stomach is the most commonly utilized conduit for esophageal replacement. Based
on surgeon preference or the unavailability of the stomach, the colon may be chosen
for use in foregut reconstruction and is the next most frequent substitute. The colon is
well suited to the task, given its reliable blood supply, long length, and resistance to
acid injury. Colon interposition, however, is a technically demanding operation rewarded
by meticulous attention to detail and punished by minor mistakes in judgment that may
lead to disastrous consequences. The esophageal surgeon should be knowledgeable in
the principles underlying the use of the colon in esophageal replacement surgery,
including advantages and disadvantages relative to other options, patient selection and
preparation, technical aspects of colon mobilization and vascular assessment, routes of
transposition, anastomotic techniques, and perioperative management.
The colon possesses several advantages relative to the stomach when utilized in
foregut reconstruction. The interposed colonic segment separates the remaining esopha-
geal mucosa from acid-producing gastric mucosa and duodenal content, lowering the
potential for reflux-induced mucosal complications. The blood supply to the colon,
when mobilized appropriately, is generally quite robust and the incidence of ischemic
complications at the esophageal anastomosis, such as leaks or strictures, is quite low.
The colon possesses a reservoir function, allowing for a sizeable meal capacity. The dis-
tal colonic segment and residual stomach remain in the positive pressure environment
of the abdomen, helping to guard against reflux. In some individuals, the stomach is
not suitable or available for use as an esophageal substitute. In such cases, the colon
may serve the purpose quite well and can be anastomosed distally to the gastric antrum
or to a Roux limb of jejunum, if the antrum has been resected or there is a significant
gastric outlet obstruction. Finally, if the interposed colon becomes dilated or tortuous
over time, it often can be successfully revised.1,2
Disadvantages of the colon as an esophageal substitute are also apparent. The colon
must be free of significant pathology such as extensive diverticulosis, polyposis, or
malignancy, and must be adequately evaluated and prepared for use, as for elective
colon resection. Requiring three anastomoses (esophagocolonic, cologastric, and colo-
colonic), colonic interposition is inherently longer and more complex with a greater
degree of dissection compared with a gastric pull-up. The operation is technically chal-
lenging, especially in terms of preserving the arterial inflow and venous drainage of
the conduit. Seemingly minor mistakes in judgment or technique can have disastrous
317
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consequences with regard to maintenance of adequate vascularity. Leaks or strictures

can occur at any of the anastomoses, and bowel obstruction can occur if the colonic
mesentery is not adequately closed. Minimally invasive techniques for completion of
the operation have yet to be mastered. The colon is generally thought to be slower to
allow resumption of alimentation compared with the stomach. Finally, and of great
importance, colon interpositions can become dilated or tortuous when in place for
many years. Such redundancy can lead to problems with dysphagia, regurgitation, or
aspiration, though surgical remediation is often feasible.
Colon interposition is performed most frequently when the stomach is not suitable or
available for use as an esophageal substitute. Possible reasons include previous gastrec-
tomy, tumor involvement of the stomach, and synchronous gastric cancer. The general
indications for esophagectomy are similar to those described elsewhere in this text, and
include esophageal cancer, end-stage motility disorders, and stenoses that have not
responded to other treatments, and corrosive injury or trauma to the esophagus. The
surgeon’s preferences, the presence of nonmalignant disease, and whether a vagal-
sparing approach is being considered may also play a role in the decision to perform
colon interposition.3 Colon interposition is also indicated as a salvage operation neces-
sitated by failure of a previous esophageal substitute.
Mild diverticular disease is generally not a contraindication to the use of colon as
an esophageal replacement, though extensive diverticulosis, frank diverticulitis, or
inflammatory fibrosis may be. Similarly, the presence of a few colonic polyps, whether
hyperplastic or adenomatous, that can be removed before surgery does not preclude
colon interposition. The presence of extensive polyposis or malignancy, however, is an
absolute contraindication.
An assessment of the patient’s cardiopulmonary reserve is essential prior to any major
surgical undertaking such as esophagectomy. A thorough history should be obtained,
focusing on respiratory difficulties at rest or with exertion, exercise tolerance, chest
pain, or fatigability. In addition, any symptoms suggestive of possible colonic pathology,
such as diarrhea or constipation, or a history of inflammatory bowel disease, diverticu-
lar disease, colonic neoplasia, prior colon resection, or abdominal aortic disease should
be elicited.
Physical examination should concentrate on cardiopulmonary findings. When ques-
tions arise about coexistent cardiac or pulmonary disease based on the patient’s age,
comorbidities, physical signs or symptoms, formal physiologic testing should be pur-
sued. Pulmonary function testing, including expiratory flows, lung volumes and diffu-
sion capacity, can objectify the severity of concomitant obstructive or restrictive lung
disease. Lung function should be optimized through smoking cessation, bronchodilators,
expectorants, antibiotics, and pulmonary rehabilitation, as necessary. Cardiac imaging
and stress testing can elicit subtle changes in cardiac function suggestive of ischemia,
cardiomyopathy, or valvular heart disease. When coronary artery or valvular pathology
is deemed significant, interventions such as angioplasty, coronary stenting, or even
open heart surgery should be completed prior to elective esophageal surgery in an effort
to minimize perioperative risk at the time of esophagectomy.
One advantage of esophagectomy in the setting of benign disease compared to
malignancy is that surgery can often be delayed pending optimization of cardiopulmo-
nary issues, nutrition, or other comorbidities. While the patient and treating physicians
may feel a time pressure to treat an esophageal malignancy, end-stage benign esophageal
disorders tend to be fairly long-standing problems that can be temporized while a
thorough work-up is completed and risk factors addressed. Enteral or parenteral support
LWBK1254-ch28_p317-328.indd 318 19/02/14 7:52 AM

Chapter 28 Colon Interposition 319
may be pursued if a patient is unable to tolerate an adequate oral diet. While no abso-
lute thresholds exist for abandoning surgery due to pulmonary or cardiac compromise,
such objective information can often influence the surgeon in making a decision for or
against esophageal reconstruction and in the type of operation chosen.
When the colon is being considered as a potential esophageal substitute, colonos-
copy should be performed to evaluate the status of the colonic mucosa. Colonoscopy is
preferred to an air contrast barium enema because mucosal detail is better assessed and
polyps or masses can be biopsied or resected.
As the colon should be adequately prepared for colonoscopy as well as for subse-
quent surgery, the colonoscopy may be scheduled a day or two before foregut recon-
struction to allow both procedures following a single bowel prep. Our preferred regimen
is to admit the patient to the hospital 2 days before surgery for bowel prep, consisting
of 4 L of GoLYTELY (polyethylene glycol electrolyte solution; Braintree Laboratories
Inc., Braintree, Massachusetts) administered orally, followed by colonoscopy the day
before surgery along with oral neomycin and metronidazole.
Controversy exists regarding the necessity of routine preoperative mesenteric arte-
riography when colonic interposition is planned. As the successful use of colon is
dependent upon an adequate vasculature, the surgeon should have a low threshold
to perform such studies. When arteriography is performed, selective injections of the
celiac artery, superior mesenteric artery (SMA) and inferior mesenteric artery (IMA)
should be undertaken, including lateral views, and paying particular attention to any
anatomic aberrancy. When the left colon is to be utilized for interposition, the most
important angiographic finding is the status of the IMA, particularly at its origin,
which can be stenosed in elderly individuals or in those with peripheral vascular
disease. As the blood supply of a left colon interposition critically depends upon
adequate inflow from the IMA, a significant stenosis of this vessel is a contraindica-
tion to the use of the left colon for esophageal reconstruction.4 A right colon interpo-
sition, based on the middle colic branches of the SMA, can be used in this situation,
as it is not dependent upon IMA inflow. Other angiographic features thought impor-
tant to the successful use of left colon for interposition include a visible ascending

branch of the left colic artery, a well-defined anastomosis between the left colic and

middle colic systems (along the marginal artery of Drummond), and a single middle
colic trunk prior to division into right and left branches. Because of its more reliable
and predictable arterial inflow and venous outflow, not to mention its better size
match to the native esophagus, the left colon is generally preferred over the right
colon for esophageal replacement.
As patients undergoing foregut reconstruction frequently have undergone multiple
prior abdominal operations, mesenteric arteriography can help to define the resultant
vascular anatomy and ascertain that vessels supplying planned esophageal substitutes
are patent. In particular, prior operations involving the greater curvature of the stomach
may have disrupted the right gastroepiploic artery, critical to the blood supply of a
gastric pull-up, or the middle colic artery and marginal artery of Drummond, critical to
the blood supply of a colon interposition. Preoperative knowledge of such vascular
abnormalities can help the surgeon navigate the operation and save considerable time
and effort during the procedure.
Surgery
Choosing Short-segment or Long-segment Colon Interposition

Given the ability of the colon to reach either into the thorax or all of the way to the neck,
colonic interposition may be undertaken after resection of either short or long segments
of the esophagus. While the surgeon may want to preserve as much normally function-
ing esophagus as possible for certain indications, such as a nondilatable esophageal stric-
ture, resecting only a limited distal segment carries several concerns about subsequent
LWBK1254-ch28_p317-328.indd 319 19/02/14 7:52 AM

reconstruction. The esophageal anastomosis, whether it is to stomach, small intestine,

or colon, frequently must be intrathoracic in location after a limited distal esophagec-
tomy. Only if there is sufficient length of abdominal esophagus can the subsequent
anastomosis be placed in the abdominal compartment.
Three potential problems relate to placement of the anastomosis within the tho-
rax. First, a thoracotomy or thoracoabdominal incision is generally necessary and is
associated with significant pain, a poor cosmetic or functional outcome, and the
necessity for single-lung ventilation during surgery, as well as the additional operative
time necessary to open and close the incision and reposition the patient. While a
transhiatal stapled anastomosis using a circular stapling device, or a thoracoscopic
esophageal mobilization and anastomosis may obviate the need for a large thoracic
incision, such techniques may not be feasible, especially in the setting of a reoperative
procedure.
The second potential problem is that the consequences of an intrathoracic leak may
be more devastating than those resulting from a leak in the neck. Multiple surgical
series have reported higher morbidity and mortality associated with intrathoracic
esophageal leaks, leading to mediastinitis, empyema and systemic sepsis, although
these risks may be decreasing in recent years.5 Relative to near-total esophagectomy
with a cervical anastomosis, which can often be completed without a thoracic incision
and places the anastomosis near the thoracic inlet, resection of a limited segment of the
distal esophagus carries with it the potential morbidity of both the thoracic incision
and the intrathoracic anastomosis.
The third potential problem is reflux through the short colonic conduit, leading to
esophageal mucosal injury or heartburn. Anastomoses high in the chest or in the neck
appear to be less prone to subsequent reflux, though the length of the interposed
conduit may be an important determinant of the volume of refluxate as well.
In general, we avoid short-segment colonic interpositions and prefer near-total
esophagectomy with a cervical esophagocolonic anastomosis whenever possible. If the
length of colon available for interposition is a concern, an intrathoracic anastomosis is
preferably made high in the chest to minimize postoperative reflux.
Colon Conduit Preparation in Foregut Replacement

Both left and right colon interposition techniques have been described. In general, the
left colon is preferred because of the better predictability of its blood supply and the
better size match to the remnant esophagus. A successful outcome following colonic
interposition requires close teamwork between the surgeon and the anesthesiologist.
The maintenance of adequate mesenteric perfusion is critical to prevent ischemia of the
conduit. Vasopressors should be avoided and adequate blood pressure provided through
the use of intravenous fluid replacement and blood products, as indicated. This plan
should be clearly communicated and discussed with the anesthesia team prior to induc-
tion of general anesthesia, as well as with any new staff substituted throughout what
is often a prolonged procedure.
When the vagus nerves have been resected as part of an esophagectomy and colon
interposition is planned, the proximal three quarters of the stomach should be removed
to avoid problems with delayed gastric emptying that can result when the denervated
stomach is left intact. Typically the colon is anastomosed distally to the gastric antrum,
and a pyloric drainage procedure is added. If a vagal-sparing esophagectomy is
performed, the whole stomach may be left intact and gastric drainage avoided.
Left Colon Interposition

The term “left colon interposition” is a misnomer in that it refers to interposition of the
transverse colon, not the left colon. The name is derived from the fact that its blood
supply is based off of the ascending left colic artery, a branch of the IMA, and the left
colic vein, a tributary of the inferior mesenteric vein (IMV). The blood supply to the
conduit is dependent upon communication between these vessels and the marginal
LWBK1254-ch28_p317-328.indd 320 19/02/14 7:52 AM

Figure 28.1 Vascular anatomy of the colon.
arteries and veins originating from the middle colic circulation, the origins of which
get divided as part of the procedure (Fig. 28.1).
The operation is performed through an upper midline laparotomy incision and
commences by dissection and vascular isolation of the colon conduit prior to resection
of the esophagus and stomach. This sequence is chosen to allow for adequate time to

assess the perfusion of the prepared colon conduit before committing to its use. The

descending colon is mobilized laterally along the white line of Toldt from the splenic
flexure to the beginning of the sigmoid colon, as for a colectomy. Care should be taken
to prevent disruption of the colonic mesentery as well as to avoid the left ureter. The
ascending branch of the left colic artery is assessed by direct palpation. The right colon
is then mobilized in a similar fashion. The greater omentum is dissected from the trans-
verse colon, preserving the transverse mesocolon. The base of the left and transverse
mesocolon is next freed from the retroperitoneum, preventing inadvertent division of
the IMV in the region of the ligament of Treitz.
The middle colic artery and vein are identified by transillumination of the trans-
verse mesocolon and by direct palpation, then dissected near their origins from the
superior mesenteric artery and vein, respectively. This part of the operation is one of
the most challenging and important. It is critical to divide these vessels as near their
origins as possible, in order to preserve communications between the right and left
branches of the middle colic artery (as well as branches of the middle colic veins) and
any vascular arcades within the transverse mesocolon. Once these vessels have been
dissected, they are occluded with bulldog vascular clamps to allow assessment of colon
perfusion while the operation is progressing and prior to the irreversible step of vessel
transection.
The region of the distal transverse colon is then grasped and retracted cephalad,
demonstrating the tether point of the ascending left colic vessels (Fig. 28.2). This
portion of the colon typically reaches the level of the xiphoid process and is marked
with a suture along the antimesenteric border. Using an umbilical tape, the distance
between the xiphoid and the planned proximal anastomosis (typically within the left
neck) is measured, adding several additional centimeters of length to assure an adequate
reach. The umbilical tape is cut to this length and used to measure the distance proxi-
mally along the colon from the suture on the distal transverse colon, usually reaching
LWBK1254-ch28_p317-328.indd 321 19/02/14 7:52 AM

Figure 28.2 The colon is retracted

cephalad to note the tether point
of the ascending left colic vessels.
This point typically reaches the
xiphoid process and is marked
with a suture along the antimes-
enteric border. The distance
between this point (or xiphoid) and
the cervical esophageal remnant
is measured with an umbilical
tape, adding a few additional
centimeters of length.
a point at approximately the mid-ascending colon. The colon is marked with a second
suture at this point to denote the location for subsequent bowel division, defining what
will become the proximal end of the isoperistaltic colon conduit. Vascular contributions
to the colon conduit from the right colic and ileocolic vessels residing within the right
mesocolon are dissected and occluded with bulldog vascular clamps, as they will need
to be divided subsequently to allow interposition.
With the right-sided and middle colic vessels occluded with vascular clamps, the
colon is observed while the esophagogastrectomy is completed. Pulsations along the
marginal artery within the transverse mesocolon should be assessed frequently by pal-
pation. If doubt exists about the adequacy of arterial perfusion, a Doppler probe should
be utilized to assure the presence of triphasic flow. Despite the preoperative angio-
graphic findings, the adequacy of colon conduit perfusion is determined intraopera-
tively after all vessels planned for division are occluded. If the colon becomes ischemic,
the vascular clamps should be removed while options are considered for an alternate
form of foregut reconstruction. One possible solution in this scenario may be “super-
charging” the colon by microvascular anastomosis of the right or middle colic arteries
and veins to suitable vessels in the neck or upper thorax.6,7
Once the perfusion of the colon conduit is deemed adequate, the clamped vessels
are ligated and divided. The previously marked point of the ascending colon is also
divided using a cutting stapler, and the most proximal portion of the colon interposition
is advanced cephalad for subsequent anastomosis to the remnant esophagus (Fig. 28.3).
Delivery of the conduit to the neck may be accomplished by any of a number of meth-
ods. The authors prefer suturing one end of a Penrose drain to the staple line at the tip
of the conduit, and the other end to a 28-French chest tube that has been passed from
the neck through the chest into the abdomen. As the colon is drawn cephalad, care
must be taken to prevent torsion of the mesentery by maintaining it toward the right
side of the interposition. Most surgeons prefer to bring the conduit through the posterior
mediastinum when possible. If the posterior mediastinum is not suitable for passage of
LWBK1254-ch28_p317-328.indd 322 19/02/14 7:52 AM

Figure 28.3 The previously meas-

ured 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 isoperi-
staltic colon interposition. The
colon is marked with a second
suture at this region and subse-
quently divided with a cutting
stapler.
the colon to the neck, a substernal route can be used. Extreme care must be taken to

ensure no tension is placed on the vascular arcade. The vein is particularly vulnerable

to injury and once an injured major vessel is encountered, the colon conduit will likely
not be salvageable. In some cases of substernal routing, for this reason, we prefer to
open the sternum and do the pull-up under direct vision.
Esophagocolonic anastomosis may be accomplished by any of a number of tech-
niques. The authors prefer an end-to-end anastomosis, utilizing a single layer of inter-
rupted 4-0 monofilament suture with the knots tied on the inside, after excision of
staple lines from the remnant esophagus and colon conduit. The final few sutures con-
sist of modified Gambee stitches placed anteriorly with the knots on the outside.
Once the esophagocolonic anastomosis has been completed, the colon is withdrawn
inferiorly to straighten it. When brought through the posterior mediastinum, the colon
should be sutured to the hiatus anteriorly so as to prevent subsequent herniation of
viscera alongside it and to help prevent the development of subsequent redundancy of
the interposed colon segment. Similarly, colon brought through the retrosternal space
should be affixed to the diaphragm.
The colon is then divided just beyond the level chosen for the cologastric anasto-
mosis. Excess colon and loops in the colon conduit are not desirable and can lead to
functional emptying problems. An important technical detail is to preserve the entirety
of the mesocolon at the point of distal colon transection, so as not to disrupt the blood
supply to the interposed colon. Dissection of the mesentery should be adjacent to the
colon wall, and the colon transected without any division whatsoever of the mesocolon.
The cologastric anastomosis is then completed either with staplers or a hand-sewn
technique in a side-to-end fashion.
The remaining ends of the proximal right colon and distal left colon are then anas-
tomosed in a side-to-side or end-to-end fashion. The mesentery of these two portions
of colon ideally should be reapproximated so as to prevent internal herniation, though
such closure at times is not technically feasible.
LWBK1254-ch28_p317-328.indd 323 19/02/14 7:52 AM

Right Colon Interposition

The right colon also may be utilized for interposition. An issue of controversy is whether
the right colon conduit should be positioned in an isoperistaltic or antiperistaltic fash-
ion. A number of studies have confirmed that such interpositions typically empty by
gravity and are not peristaltic.8,9 Case reports, however, would suggest that an anti-
peristaltic conduit, over time, might propel a food bolus in a retrograde fashion. Most
surgeons, therefore, prefer to place the esophageal replacement conduit in an isoperi-
staltic fashion.
For an isoperistaltic right colon interposition based on the middle colic vessels, the
colon is mobilized from the hepatic flexure to beyond the cecum, including the distal
ileum. The ileocolic and right colic arteries are dissected at their bases and temporarily
occluded with vascular bulldog clamps, as described for left colon interposition. The
distance from xiphoid to the esophageal remnant is measured with an umbilical tape,
and that same distance then measured proximally from the mid-transverse colon to a
point typically within the distal ileum. Once adequate vascularity has been assured,
the ileum and previously clamped blood vessels are divided and the bowel delivered
proximally. After the esophagocolonic anastomosis has been completed, the transverse
colon is divided at an appropriate level to allow distal anastomosis to the remnant
stomach or a Roux limb of jejunum. The proximal end of the ileum and distal end of
transverse colon are then anastomosed, and the mesenteric defect closed, as per left
colon interposition.
Vagal-sparing Esophagectomy
The surgeon may choose to perform a vagal-sparing esophagectomy, particularly in
patients who undergo esophageal resection for nonmalignant conditions. The technical
details of the operation include making a small anterior gastrotomy along the gastric
cardia, mobilization and division of the cervical esophagus, passage of a vein stripper
of suitable size through the gastrotomy proximally to the cervical esophagus, fixation
of the cap of the vein stripper to the divided end of the esophagus by suture ligature,
and eversion of the esophagus out of the stomach. In the process, the esophagus is
stripped from its mediastinal divestments, commonly leaving a layer of longitudinal
esophageal muscle in situ. The dissection plane is typically quite easy to develop and
does not offer much resistance upon stripping. An umbilical tape is affixed to the
proximal tip of the esophagus being resected prior to eversion so as to allow passage
of the tape though the mediastinum. The vagal plexus and main trunks are left intact.
The esophagus is then divided near the GEJ. The resultant mediastinal tunnel must be
dilated to allow adequate space for passage of the esophageal replacement conduit.
Foley catheters with balloons inflated to progressively larger sizes (e.g., 30, 60, 90 mL)
can be used for this purpose. The umbilical tape within the mediastinum denotes the
proper plane for passage of the colon segment among the vagal fibers, which can be
somewhat web like. The operation can be performed via open laparotomy or, in expe-
rienced hands, using a laparoscopic or hand-assisted technique. The colon should be
passed up through the posterior mediastinum along the path established by the umbil-
ical tape. Anastomosis can then be performed proximally to the esophagus in the neck
and distally to the intact stomach. Important differences between the techniques of
colon interposition when performed following a vagal-sparing esophagectomy versus
after a standard esophagectomy are that a pyloroplasty is not necessary, as pyloric
innervation is preserved, and the proximal stomach is left intact.
Patients are admitted to the intensive care unit for initial postoperative observation. We
routinely place an epidural catheter before surgery to facilitate subsequent pain manage-
ment and pulmonary toilet. Intravenous fluid administration initially should be liberal
LWBK1254-ch28_p317-328.indd 324 19/02/14 7:52 AM

Figure 28.4 Computed tomography

image of a substernal colon
interposition.
to counter third-space losses and prevent intravascular volume depletion with resultant
mesenteric vasoconstriction. Vasopressor medications generally are avoided, as during
surgery. Parenteral antibiotics are administered for less than 24 hours. A nasocolonic
Salem sump tube is placed during surgery and kept on low continuous or intermittent
suction until the output is low and bowel function has returned, generally in the range
of 4 to 5 days. A feeding jejunostomy tube is placed during surgery, and tube feedings
are commenced starting on the third postoperative day. The feedings are advanced
slowly to the goal volume over a few days.
The utility of a postoperative contrast upper gastrointestinal radiographic study
(Fig. 28.4) is widely debated. The intent of such studies is to assess possible anasto-
motic leakage at either the esophagocolonic or cologastric anastomosis, as well as to
assess the adequacy of conduit drainage. While such studies, typically on the sixth or
seventh postoperative day, previously were our policy, we no longer utilize them rou-

tinely and have gone to the liberal use of flexible upper endoscopy instead. Our belief

is that endoscopy offers a more sensitive assessment of mucosal ischemia and anasto-
motic dehiscence than contrast radiography, which is associated with a high false neg-
ative rate for conduit and anastomotic complications.
Complications
Perioperative mortality has ranged from 2% to 10% in larger series published since
1995.10 Conduit necrosis occurred in 2.5% to 6% of the patients in these current-era
series. Anastomotic complications were reported in 3% to 15% of patients and are
more common at the esophagocolonic anastomosis than at the cologastric or coloco-
lonic anastomoses.
When the colon is mobilized appropriately, the blood supply to the colon is gener-
ally quite robust, reducing the incidence of ischemic complications at the esophageal
anastomosis, such as leaks or strictures. Watson et al.11 reported on 85 patients who
underwent colonic interposition for benign disease, with an esophagocolonic leak rate
of 3.5% and a need for postoperative anastomotic dilation in only 5% of patients. Both
of these rates were much less than those after cervical esophagogastrostomy, where
anastomotic leaks occurred in 20% and dilation was required in 30% of patients. Briel
et al.12 reported on 395 consecutive patients who underwent esophagectomy for either
malignant or benign diseases. The development of either anastomotic leak or stricture
was analyzed in patients who underwent gastric pull-up and compared with colonic
interposition. Leaks and strictures were more common (14.3% vs. 6.1%, p = 0.013, 31.3%
vs. 8.7%, p < 0.0001, respectively) and strictures were more severe after gastric pull-up.
In contrast, a large series from Japan by Mine et al. included 95 patients who underwent
colon interposition after esophagectomy with extended lymphadenectomy for esophageal
LWBK1254-ch28_p317-328.indd 325 19/02/14 7:52 AM

cancer between 1990 and 2008.13 Most (92/95) of the patients underwent reconstruction
via the retrosternal route, and 3 required microvascular supercharging. Anastomotic
leak occurred in 13%, the relatively high rate, likely secondary to their preference for
the retrosternal route. Conduit necrosis was rare. In Mine’s series, pulmonary complica-
tions occurred in 32.6% of patients and vocal cord paralysis in 12.6%.13 Similarly in
Thomas’ series of 60 patients who underwent colon interposition, pulmonary complica-
tions occurred in 30% of patients.14
Results
An objective analysis of foregut reconstruction should include both perioperative data,
including complications, mortality and length of stay, as well as long-term functional
outcomes. Comparisons between series and types of esophageal replacement are diffi-
cult, given the lack of uniformity in the reporting of data, the variability in methods of
assessing postoperative gastrointestinal function and side effects, the variety of colon
interposition techniques including supercharging, and the fact that many reports lump
together cohorts of patients with different esophageal replacement conduits.
Curet-Scott et al. reported on the University of Chicago experience with colon
interposition for benign disease.15 Perioperative mortality was 3.8% in the 53 patients
who underwent surgery, with a 26.4% major complication rate. Follow-up was com-
plete in 83% of patients at an average of 5 years after reconstruction. Results were
rated by the patients and physicians, with 75% of the patients claiming good or
excellent results and 72% of the patients classified by the physicians as having good
or excellent results. There was, however, a 37% reoperative rate for treatment of
delayed gastric emptying, anastomotic stricture, leak, or persistent symptoms. Despite
the complication and reoperation rates, the authors stated that colon interposition
remained their preferred technique for reconstruction after esophagectomy for benign
disease.
At the University of Southern California, 104 patients with benign esophageal dis-
ease underwent esophageal reconstruction over a 21-year period.11 For esophageal
replacement, colon was used in 85 patients, stomach in 10 patients, and jejunum in
9 patients. Overall hospital mortality was 2% and the median hospital stay was 17 days.
Forty-two patients answered a postoperative questionnaire at least 1 year after surgery
concerning their long-term functional outcome. Ninety-eight percent of patients
reported that the operation improved or cured the symptom driving the surgery.
Ninety-three percent were satisfied with the outcome of the operation. The numbers
of patients who underwent esophageal reconstruction using stomach or jejunum, how-
ever, were too small to allow meaningful comparisons between the different types of
reconstructions.
A report from the Mayo Clinic analyzed outcomes in 255 patients undergoing
esophagectomy for benign disease between 1956 and 1997.16 The esophageal substitute
was stomach in 66%, colon in 27%, and small bowel in 7%. Perioperative mortality
was 5% and morbidity was 56%. Median hospitalization was 14 days. Follow-up was
available in 88.6% of patients at a median of 52 months after surgery. Improvement was
noted in 77.4% of patients, with functional results classified as excellent in 31.8%,
good in 10.2%, fair in 35.4%, and poor in 22.6%. The method of reconstruction did
not appear to impact late functional results.
In Mine’s series of 95 patients who underwent colon interposition after esophagec-
tomy with extended lymphadenectomy, mortality was 5.3%, with no mortality during
the last 10 years of the study period, and 5-year survival was 43%. Dysphagia (39%) and
diarrhea (38%) were common, though stricture was uncommon (6%) after discharge.13
Colon interposition grafts can become dilated or tortuous when in place for many
years (Fig. 28.5), leading to problems with dysphagia, regurgitation, or aspiration. This
colonic redundancy is the most common long-term mechanical complication after long-
segment colon interposition.2 Surgical revision is often possible via a tailoring colo-
plasty or segmental resection with reanastomosis.1,2,17
LWBK1254-ch28_p317-328.indd 326 19/02/14 7:52 AM

Figure 28.5 Redundant substernal

colon interposition. Note the resected
medial left clavicle (along with left
hemimanubrium and heads of left
first and second ribs). The patient
suffered from dysphagia.
Conclusions

The esophageal surgeon should be well versed in a number of techniques of foregut

reconstruction. While the stomach remains the most common esophageal replacement
conduit utilized today, circumstances arise when the stomach is not preferred or is
unsuitable for this purpose and an alternative conduit is sought. Colon interpositions
possess several advantages over gastric pull-ups and are the next most common strategy
for esophageal replacement. While technically nuanced, the procedure of colon interpo-
sition can be performed successfully in the vast majority of cases after appropriate patient
selection and preoperative evaluation. In experienced hands, the interposed colon allows
return of satisfactory alimentation after esophageal extirpation with an acceptable risk of
perioperative morbidity, mortality, and long-term gastrointestinal side effects. Given the
infrequency with which colon interposition is utilized in the community at large, proce-
dures requiring the use of colon for esophageal replacement are best restricted to spe-
cialty centers caring for a high volume of patients with complex foregut pathology.
Recommended References and Readings 6. Kesler KA, Pillai ST, Birdas TJ, et al. Supercharged isoperistal-
tic colon interposition for long-segment esophageal reconstruc-
1. de Delva PE, Morse CR, Austen WG Jr, et al. Surgical manage- tion. Ann Thorac Surg. 2013;95(4):1162–1168; discussion
ment of failed colon interposition. Eur J Cardiothorac Surg. 1168–1169.
2008;34:432–437. 7. Fujita H, Yamana H, Sueyoshi S, et al. Impact on outcome of addi-
2. Strauss DC, Forshaw MJ, Tandon RC, et al. Surgical management tional microvascular anastomosis – supercharge - on colon inter-
of colonic redundancy following esophageal replacement. Dis position for esophageal replacement: Comparative and multivariate
Esophagus. 2008;21:E1–E5. analysis. World J Surg. 1997;21:998–1003.
3. DeMeester TR. Esophageal replacement with colon interposition. 8. Gaissert HA, Mathisen DJ, Grillo HC, et al. Short-segment intes-
Oper Tech Cardaic Thorac Surg. 1997;2:73–86. tinal interposition of the distal esophagus. J Thorac Cardiovasc
4. Peters JH, Kronson J, Katz M, et al. Arterial anatomic considera- Surg. 1993;106:860.
tions in colon interposition for esophageal replacement. Arch 9. Belsey R. Reconstruction of the esophagus with left colon.
Surg. 1995;130(8):858–862. J Thorac Cardiovasc Surg. 1965;49:33.
5. Martin LW, Swisher SG, Hofstetter W, et al. Intrathoracic leaks 10. Thomas PA, Gilardoni A, Trousse D, et al. Colon interposition
following esophagectomy are no longer associated with increased for oesophageal replacement. Multimed Man Cardiothorac Surg.
mortality. Ann Surg. 2005;242:392. 2009.
LWBK1254-ch28_p317-328.indd 327 19/02/14 7:52 AM

11. Watson TJ, DeMeester TR, Kauer WK, et al. Esophageal replace- 15. Curett-Scott MJ, Ferguson MK, Little AG, et al. Colon interpo-
ment for end-stage benign esophageal disease. J Thorac Cardiovasc sition for benign esophageal disease. Surgery. 1987;102:568–
Surg. 1998;115:1241–1247. 574.
12. Briel JW, Tamhankar AP, Hagen JA, et al. Prevalence and risk factors 16. Young MM, Deschamps C, Trastek VF, et al. Esophageal recon-
for ischemia, leak and stricture of esophageal anastomosis: Gastric struction for benign disease: Early morbidity, mortality, and
pull-up versus colon interposition. J Am Coll Surg. 2004;198:536. functional results. Ann Thorac Surg. 2000;70:1651–1655.
13. Mine S, Udagawa H, Tsutsumi K, et al. Colon interposition after 17. Jeyasingham K, Lerut T, Belsey RH. Revisional surgery after colon
esophagectomy with extended lymphadenectomy for esophageal interposition for benign oesophageal disease. Dis Esophagus.
cancer. Ann Thorac Surg. 2009;88:1647–1653. 1999;12:7–9.
14. Thomas P, Fuentes P, Giudicelli R, et al. Colon interposition for
esophageal replacement: Current indications and long-term
function. Ann Thorac Surg. 1997;64:757–764.
LWBK1254-ch28_p317-328.indd 328 19/02/14 7:52 AM

Part IV
Resection of Benign
Esophageal Tumors
29 Open Resection of
Esophageal Leiomyoma
and GIST
Alberto de Hoyos and Malcolm DeCamp
Introduction
In this chapter, we discuss the general approach to leiomyoma and gastrointestinal
stromal tumors (GISTs) of the esophagus and resection via thoracotomy. Many surgeons
today prefer a thoracoscopic approach for resection of most of these benign tumors, and
the thoracoscopic approach will be discussed in the next chapter.
Benign esophageal tumors are uncommon and account for less than 1% of all esopha-
geal neoplasms.1 The majority of these tumors are asymptomatic and often discovered
incidentally. Symptoms, when they develop, include dysphagia and chest pain and are
the result of intraluminal extension or large intramural tumors. Leiomyoma is the most
common benign esophageal tumor (50% to 70%) and esophageal leiomyoma accounts
for about 6% to 12% of gastrointestinal leiomyomas.2 Because esophageal cancer is
50 times more common than leiomyoma, and leiomyosarcoma is exceedingly rare, sur-
geons encounter few leiomyomas during their careers.3 The majority of esophageal
leiomyomas present between the ages of 20 and 60 years (mean age 44), are rare in
children, and are twice as common in men than in women.4
Leiomyomas arise from smooth muscle cells and thus are more common in the mid-
dle third (~40%) and lower third (~50%) of the esophagus than in the upper third (~10%)
(Fig. 29.1, See also Fig 30.1). Leiomyomas most commonly arise from the circular layer
of the muscularis propria and infrequently from the muscularis mucosa in which case
they can present as polypoid intraluminal tumors. Leiomyomas are usually solitary
(97%) and measure between 2 and 5 cm in diameter although tumors measuring from 2
mm to 20 cm have been described.4 Leiomyomas uncommonly present as extraesopha-
geal tumors causing compression of adjacent structures. In a review of 838 cases, 97%
of the leiomyomas were intramural, 1% were polypoid intraluminal, and 2% were
extraesophageal.1 Leiomyomas appear histologically as smooth muscle fibers arranged in
329
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330 Part IV Resection of Benign Esophageal Tumors
Figure 29.1 Computed tomography of the

chest demonstrating a mass in the
esophageal wall demonstrated by the
arrow. The leiomyoma was located just
above the azygos vein.
whorls of long thin spindle cells with eosinophilic cytoplasm mixed within a hypovas-
cular connective tissue matrix. It can sometimes be very difficult to differentiate between
leiomyoma, leiomyosarcoma, and GISTs.3 It is controversial whether leiomyomas can
undergo malignant degeneration although if it occurs, it must be exceedingly rare. In a
comprehensive review of more than 800 cases reported in the world literature, only two
(0.2%) were documented to show transformation from leiomyoma to leiomyosarcoma.1
Clinical Presentation and Diagnosis

More than 50% of leiomyomas are asymptomatic.3 Symptoms develop when the tumor
has reached a large size, typically 5 cm or more.4 Dysphagia and retrosternal discomfort
are the two most common symptoms. Respiratory complaints such as cough, dyspnea,
or wheezing may result from large tumors causing compression of the tracheobronchial
tree. Bleeding is uncommon since the overlying mucosa is almost always intact. Leio-
myomas in the distal esophagus may be associated with gastroesophageal reflux disease.
Diagnosis of leiomyoma can be made with confidence with a careful history, physical
examination, barium swallow, computed tomography, and endoscopy with ultrasonogra-
phy. Tissue diagnosis is not necessary except when the diagnosis of GIST or malignancy
is a possibility. On endoscopic ultrasonography, typical leiomyomas appear as homogene-
ous anechoic lesions within the muscularis propria. A heterogeneous echo pattern may
be seen in benign tumors but the presence of a lesion of greater than 4 cm is more
suggestive of malignancy. Nonetheless, malignancy is exceedingly rare.
Leiomyomas grow slowly and may be stable in size during observation for many years.
There is general consensus in the literature that esophageal leiomyomas should be
surgically removed in symptomatic patients; however, treatment of asymptomatic
patients continues to be debated. Many may advocate for the resection of these tumors
because of the possibility of malignant degeneration, the possibility of symptom devel-
opment in the future, the desire to obtain a definitive histologic diagnosis, and the
ability to exclude the possibility of malignancy. However, the literature and experience
have shown that asymptomatic patients rarely develop complications from their leio-
myomas if untreated. Therefore, since the risk of malignant transformation is low
and development of complications is rare in asymptomatic patients, it seems that
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Chapter 29 Open Resection of Esophageal Leiomyoma and GIST 331
asymptomatic patients with a tumor less than 2 to 3 cm can be managed with clinical
and radiographic/endoscopic follow-up.3,4 Endoscopic ultrasound seems to be the ideal
way to follow these tumors with a CT scan every 1 to 2 years. Indications for surgical
resection of a leiomyoma include the following.
n Symptoms – typically dysphagia and/or chest pain
n Increasing size of tumor during follow-up
n Need to obtain histologic diagnosis (i.e., clinical diagnosis is in doubt)
n Facilitation of other esophageal procedures (i.e., fundoplication, myotomy)
Giant leiomyomas requiring esophagectomy have been described but most com-
monly they can be treated effectively by esophageal-sparing techniques. Indications for
esophagectomy include the following.
n A very large or annular tumor that cannot be enucleated
n Esophageal mucosa or muscular wall that is badly ulcerated or damaged during
enucleation that cannot be repaired in a satisfactory manner
n Symptomatic multiple leiomyomas that cannot be enucleated or diffuse leiomyomatosis
n Leiomyosarcoma suspected and confirmed on biopsy
There are no specific contraindications for the resection of esophageal leiomyomas.

Resection is typically contraindicated for small (1 to 2 cm) tumors in asymptomatic
patients or when the general condition of the patient prohibits general anesthesia and
complications of resection may outweigh the benefits.
Resection of esophageal leiomyomas can be performed by utilizing a number of
approaches that include thoracotomy, video-assisted thoracoscopic surgery (VATS), and
endoscopic resections when the lesion is small, pedunculated, and submucosal in loca-
tion. Enucleation, or shelling out of the intramural leiomyoma, is the preferred treat-
ment.3–7 Rarely, the tumor will require esophageal resection with reconstruction due to
size and degree of esophageal involvement.
Surgery
Anesthesia
For open thoracotomy, a thoracic epidural catheter is placed by the anesthesiologist for
optimal management of postoperative pain. For thoracoscopic resection, an epidural is
generally not necessary. The patient is intubated with a left double-lumen tube or a
single-lumen tube and a bronchial blocker.
Positioning
Part IV: Resection of Benign
Tumors of the upper and middle thoracic esophagus are best approached through a right
Esophageal Tumors
lateral or posterolateral thoracotomy, while those in the lower third require a left thora-
cotomy (Fig. 29.2). Sequential compression devices are placed in the lower extremities
to deter deep vein thrombosis. A Foley catheter is placed. The patient is then turned to
the lateral position and a sandbag or a soft roll is placed under the upper ribs to avoid
pressure on the brachial plexus, while the head is supported in neutral spine alignment.
The arm on the side of the operation is supported and secured providing ample exposure
of the axillary region. The lower leg is slightly bent at the knee while the upper leg is
kept straight with pillows in between. Care is also taken to apply pads to all pressure
points. The patient is supported on a bean bag which is set after the operating table is
gently angulated at the level of the lower chest. A belt strap is placed over the hips to
secure the patient to the table (Fig. 29.2). The chest is prepped and draped.
LWBK1254-ch29_p329-342.indd 331 19/02/14 6:49 PM

Figure 29.2 This picture demon-

strates proper positioning of the
patient for a left thoracotomy.
Note the brake on the table,
suspension of the left arm, and
positioning of the legs. All pres-
sure points are padded and the
patient is secured to the table.
Technique
For leiomyoma, the principles of the operation include resection of the tumor (enu-
cleation) without injury to the underlying mucosa or vagus nerves and closure of the
muscularis propria, if possible, to prevent mucosal bulging and pseudodiverticulum
formation.
n On-table esophagogastroduodenoscopy (EGD) is performed to confirm tumor location
and size and assure the surgeon that the lateral approach chosen (left or right) will
work for the indicated patient.
n A standard lateral thoracotomy is performed (Fig. 29.3). On the right, the incision is
planned to enter the chest at the level of the fifth intercostal space while on the left,
at the level of the sixth or seventh intercostal space. Alternatively, a muscle-sparing
thoracotomy can be performed, preserving the integrity of the latissimus dorsi and
serratus anterior muscles (Fig. 29.4).
n Once the subcutaneous tissues have been divided, the latissimus dorsi muscle is
divided with cautery, while the serratus anterior muscle is mobilized anteriorly and
preserved (Fig. 29.5).
Figure 29.3 Skin incision for a Scapula Incision line

lateral thoracotomy. The posterior
margin of the incision ends at the
angle of the ribs, preserving the
trapezius and rhomboid major Latissimus dorsi
muscles, which are divided during muscle
a posterolateral thoracotomy.
Trapezius
muscle
LWBK1254-ch29_p329-342.indd 332 19/02/14 6:49 PM

Figure 29.4 Skin incision for a muscle-

sparing thoracotomy. The incision
extends from a point just posterior to
the tip of the scapula to just anterior to
the anterior border of the latissimus
dorsi muscle. A plane of dissection is
performed between the latissimus and
serratus muscles and a retractor
placed under both muscles. Under-
mined skin flaps facilitate mobilization
and retraction of the muscles. Keeping
the flaps small reduces the incidence
of seroma formation.
Serratus
anterior
Undermined
skin flap
Latissimus
dorsi
Figure 29.5 The latissimus dorsi

muscle is divided with electro-
cautery leaving the serratus
anterior muscle intact.
Latissimus dorsi
(partially divided)
Serratus
anterior
Esophageal Tumors
LWBK1254-ch29_p329-342.indd 333 19/02/14 6:49 PM

Figure 29.6 The posterior border Posterior end

of the serratus anterior muscle is of incision
dissected and elevated. The
muscle is retracted anteriorly and
preserved intact.
Divided latissimus
dorsi muscle
Posterior edge of
serratus anterior muscle
Serratus
anterior
Anterior end
n The areolar tissue along the posterior edge of the serratus is divided obliquely extend-
ing inferiorly toward the anterior inferior margin of the latissimus (Fig. 29.6).
n A plane of dissection is established above the ribs, and a hand is inserted under the
chest wall musculature to identify the first (flat upper surface) and second ribs (inser-
tion of middle scalene muscle).
n The ribs are then counted, and the selected intercostal space for entry is identified.
The intercostal tissues and pleura are divided along the top border of the correspond-
ing rib and entry into the thoracic cavity is accomplished.
n The posterior margin of the thoracotomy is at the level of the longitudinal spinous
ligament.
n The parietal pleura and intercostal muscles are incised from within the thoracic cav-
ity beyond the external margin of the incision in an effort to further relax the open-
ing. We do not routinely resect a portion of a rib.
n A Rienhoff retractor is inserted and slowly opened. Gradual opening of the retractor
to no more than 6 to 8 cm helps to prevent rib fractures and may reduce the occur-
rence of postthoracotomy pain syndrome. A Balfour retractor or a second Rienhoff
retractor positioned anteroposteriorly in the soft tissues of the chest wall at a right
angle to the Rienhoff retractor may help to improve exposure (Fig. 29.7).
n The lung is mobilized anteriorly and the posterior mediastinum is exposed. A leio-
myoma will often appear as a large bulge (>3 cm) under the parietal pleura covering
the esophagus (Fig. 29.8).
n Most leiomyomas are easily seen through the intact mediastinal pleura. If the leio-
myoma is not immediately seen through the intact pleura, it will frequently become
apparent after initial esophageal dissection. However, smaller, less than ideally situ-
ated leiomyoma may require simultaneous EGD and careful mobilization and palpa-
tion to confirm the location.
n The mediastinal pleura is incised to expose the leiomyoma and the esophagus above
and below.
LWBK1254-ch29_p329-342.indd 334 19/02/14 6:50 PM

Figure 29.7 Chest wall retractors

are placed at right angles to sepa-
Cephalad rate the ribs and fully distract the
soft tissues anteriorly and posteri-
orly. Care should be taken to limit
the rib spreading to no more than
6 to 8 cm.
Posterior Anterior
Lung
n Full esophageal mobilization is unnecessary unless the tumor is extensive and encir-
cles the esophagus. Resection can usually be achieved by extramucosal enucleation
or shelling out. When the outer longitudinal muscle layer over the tumor is divided
along the orientation of the fibers with electrocautery, the leiomyoma appears as an
avascular encapsulated mass. The dissection is performed with care to preserve the
vagus trunk and its branches and to preserve the integrity of the longitudinal muscle
fibers and to some degree the circular fibers.
n Leiomyomas are easily enucleated using blunt dissection away from the surrounding
muscle fibers and the mucosa unless there is inflammation or mucosal damage caused
by preoperative endoscopic biopsy. A plane of dissection is established in the sub-
mucosal layer using a combination of blunt and sharp dissection. Gentle traction in
the exposed part of the tumor is applied to facilitate development of the plane of
dissection. Care is taken not to enter the esophageal lumen (Fig. 29.9).
Figure 29.8 View of the posterior

mediastinum demonstrating a mass
above the azygos vein. Typical appear-
ance of esophageal leiomyoma.
Esophageal Tumors
LWBK1254-ch29_p329-342.indd 335 19/02/14 6:50 PM

Figure 29.9 The technique of

enucleation is illustrated. The
longitudinal esophageal fibers are
split and a combination of sharp
and blunt dissection is performed
to enucleate the leiomyoma from
the submucosa, sparing the
mucosa.
Esophagus
Submucosa
n After enucleation, the tumor is removed and the pleural cavity irrigated with saline.
Intraoperative endoscopy with air insufflation is performed to confirm mucosal integ-
rity. If the mucosa is perforated during the dissection, it should be repaired with fine
absorbable suture and the muscularis propria closed over the top with interrupted
silk suture (Fig. 29.10).
n It is important to carefully preserve and close both muscle layers to minimize the
likelihood of postoperative dysphagia and development of esophageal dysmotility
especially with larger, more complex leiomyoma.
n In the absence of perforation, there is some disagreement as to whether the myotomy
should be sutured closed after enucleation; however, most experts recommend reap-
proximation of the muscular layer to prevent bulging with subsequent diverticulum
formation.
n One or two chest tubes are placed in the thoracic cavity. After unflexing the table,
the ribs are reapproximated with large absorbable suture taking care not to create
overapproximation or to entrap the neurovascular bundle under the rib below (Fig.
29.11).
n The muscle layers are closed meticulously to include full thickness bites and the
corresponding fascia (Fig. 29.12). The lung is re-expanded and the subcutaneous tis-
sues and skin are closed in layers.
n A nasogastric tube is not necessary.
Figure 29.10 Once the leiomyoma is

removed, mucosal integrity is tested
by insufflation with the esophago-
scope. If no leak is detected, the
muscularis layer is reapproximated
with interrupted sutures.
LWBK1254-ch29_p329-342.indd 336 19/02/14 6:50 PM

Figure 29.11 The ribs are reap-

proximated with heavy gauge
Thoracotomy
reabsorbable sutures taking care
incision
not to create overapproximation
or to entrap the neurovascular
bundle under the rib below.
Ribs
Figure 29.12 The chest wall musculature

(latissimus and serratus) is reapproximated
in layers with heavy reabsorbable suture
taking full thickness bites.

Esophageal Tumors
LWBK1254-ch29_p329-342.indd 337 19/02/14 6:50 PM

After resection of a leiomyoma, patients are started on oral liquids on postoperative day
1 following a thin barium esophagram that does not demonstrate a leak. Diet is advanced
to a mechanical soft diet and eventually to regular foods. The epidural catheter is removed
on postoperative day 2 or 3, and the patient is started on an oral regimen of pain medica-
tion. Subcutaneous heparin is administered three times daily until discharge. Patients are
usually discharged on day 4 to 5 after resection.
Complications
Theoretically, enucleation of a large leiomyoma may result in an esophagus that func-
tionally resembles achalasia due to the extent of the myotomy. Tumors up to 10 cm long
can be enucleated without significant postoperative dysphagia as long as the mucosa is
intact and the myotomy is reapproximated. If the myotomy is not reapproximated, a
pseudodiverticulum may form leading to dysphagia. If the tumor is large and the
mucosa is badly damaged during resection of the tumor, esophagectomy may be required
if the mucosa cannot be satisfactorily repaired.
Postoperative esophageal leak is a serious complication that can arise due to
mucosal injury that is missed or inadequately repaired during the initial operation.
Routine use of intraoperative endoscopy with insufflation is recommended to safeguard
against this potentially catastrophic complication. If a leak is detected and repaired at
the time of the original operation, a soft drain, such as a Jackson-Pratt tube, is placed
in the vicinity of the repair and the barium swallow is delayed for 5 to 7 days.
Difficulty in establishing a plane of dissection and performing the enucleation may
be signs of leiomyosarcoma, which typically infiltrates the surrounding muscle. Frozen
section biopsy of the enucleated tumor may suggest leiomyosarcoma if it is very cel-
lular with a large number of mitotic figures, nuclear atypia, hemorrhage, and necrosis.
However, as described earlier, the distinction of benign from malignant tumors may be
very difficult even using permanent sections. If leiomyosarcoma is strongly suspected,
then esophagectomy is the treatment of choice.
Results
The surgical therapy of leiomyoma is safe and effective with low morbidity and mortal-
ity rates (0% to 1%). The majority of patients experience complete resolution of preop-
erative symptoms. Long-term results are also excellent with more than 90% of patients
remaining asymptomatic 5 years later. Tumor recurrence after enucleation and diver-
ticulum formation are extremely rare.5,6 Careful long-term follow-up is recommended
because patients may develop gastroesophageal reflux that may require medication or
antireflux repair.
GISTs
GISTs are the most common mesenchymal tumors of the gastrointestinal tract and are quite
distinct from esophageal leiomyoma.7 GIST can arise anywhere in the gastrointestinal tract,
but their most frequent location is the stomach (50%) or the small bowel (25%).
Other locations include the colon (10%), omentum, retroperitoneum, and pelvis (10%).8
Esophageal GISTs are uncommon (<1% of 1,458 GISTs reported in the Surveillance
Epidemiology and End Results database) but may be recognized as such more frequently
since the development of immunohistochemistry techniques to detect KIT mutations.9,10
Because esophageal GISTs are uncommon and the majority arise at the gastroesophageal
junction, a GIST located at the level of the thoracic esophagus is extremely rare.11
LWBK1254-ch29_p329-342.indd 338 19/02/14 6:50 PM

GISTs most commonly result from activating mutations in one of two receptor pro-
tein tyrosine kinases: KIT (CD117) or platelet-derived growth factor receptor alpha (PDG-
FRA).12 GISTs also share phenotypic characteristics with the interstitial pacemaker cells,
known as interstitial cells of Cajal, and are thought to arise from a common precursor
cell.13 These are innervated cells associated with Auerbach plexus that have autonomous
pacemaker function and coordinate peristalsis throughout the gastrointestinal tract.
GIST can have substantial histologic variation (epithelioid, spindle cell, or mixed),
and immunohistochemistry is often needed to verify the diagnosis. GIST can be positive
for KIT (CD117, 95%), CD34 (60% to 70%) and other mesenchymal markers, such as
smooth muscle actin (30% to 40%), desmin (<5%), and S100 protein (5%). KIT is the most
specific and sensitive marker but about 5% of GISTs are KIT-negative. DOG1 (discovered
on GIST 1) is also a specific and sensitive marker for GIST and some GISTs are DOG1-
positive and KIT-negative.14 Binding of ligand (stem cell factor) to mutated KIT results in
activation of receptors and phosphorylation of several signaling substrates known to pro-
mote cell growth and survival. Imatinib, a small molecule with a structure similar to ATP,
is a tyrosine kinase inhibitor (TKI) that binds competitively to the ATP binding sites of
KIT resulting in inhibition of growth in GIST containing a KIT gene mutation.12
Presentation and Diagnosis

Patients with esophageal GIST usually present with dysphagia and retrosternal discom-
fort or gastroesophageal reflux disease if the tumor is located near the lower esophageal
sphincter (Fig. 29.13). Small clinically insignificant lesions may be found incidentally
during endoscopy or on CT scan. GISTs range in size from tiny incidental tumors,
measuring less than 10 mm in diameter to large tumors measuring more than 20 cm.
Since all GISTs greater than 2 cm are considered malignant due to their potential for
recurrence and metastatic disease, they should be resected. The management of inci-
dentally encountered esophageal GIST smaller than 2 cm remains controversial. How-
ever, because not all intramural esophageal lesions are GISTs and the type of resection
may differ from that of leiomyoma, a preoperative diagnosis should be obtained. Because
the overlying esophageal mucosa is most commonly normal, conventional endoscopy
with biopsy has suboptimal accuracy. Diagnosis of GIST is based on endoscopic ultra-
sound with fine needle aspiration to obtain material for immunohistochemical analysis
for KIT mutations.15
Figure 29.13 Computed tomography

of the chest demonstrating a large
(8.5 cm) gastrointestinal stromal tumor
of the lower esophagus.

Esophageal Tumors
LWBK1254-ch29_p329-342.indd 339 19/02/14 6:50 PM

Prediction of prognosis in patients with GIST has been studied extensively. In intra-
abdominal GIST, tumor size >5 cm, mitotic index >5 per 50 high-power fields, and small
bowel origin correlate with risk of progressive disease.8 Data for esophageal GIST are
too few to offer meaningful information but the behavior of esophageal GIST may be
considered equal to their abdominal counterpart.
Treatment
Management guidelines for GIST have been defined by consensus of the National Com-
prehensive Cancer Network (NCCN), the Canadian Advisory Committee on GIST, and
the European Society of Medical Oncology.16 As opposed to leiomyomas, GISTs are
usually soft, fleshy, and fragile, and they should be handled with care to avoid tumor
rupture (“no touch technique”). If the pseudocapsule is torn, bleeding and tumor seed-
ing may ensue. The goal is complete gross resection with an intact pseudocapsule and
negative microscopic margins.8 Treatment of esophageal GIST remains controversial
because resection techniques in the esophagus are limited to enucleation or esophagec-
tomy and segmental resections, as performed for gastric and small bowel GIST, are
usually not technically feasible except for tumors located near the gastroesophageal
junction. In most cases, esophagectomy with clear margins and with an intact pseudo-
capsule has been recommended although there are some reports of esophageal-sparing
resections.17–22 The value of prophylactic lymphadenectomy has not been established
and is not currently recommended.5
Patients who present with esophageal GIST and metastatic disease should be con-
sidered for targeted therapy with a TKI such as imatinib.12 The value of adjuvant treat-
ment with a TKI is uncertain. However, in a recent phase III randomized study of
adjuvant imatinib therapy after surgical resection of c-kit-positive GIST, patients who
received adjuvant therapy had significantly better recurrence-free survival 1 year after
surgery than patients who received placebo (8% vs. 20%).23 The incidence of recurrence
of esophageal GIST after resection was high in small series;19,20 therefore, adjuvant
therapy should be considered in selected patients.
Results
The current literature on esophageal GIST remains limited with fewer than 100 cases
reported. Most series are from single institutions and include fewer than 10 patients
each.18 The 5-year survival after diagnosis of esophageal GIST was 14% from the Sur-
veillance Epidemiology and End Results database.10 Due to the possibility of recurrence
and potential for metastatic disease, esophageal-sparing resection is only recommended
for GISTs smaller than 5 cm. Larger lesions or involvement of the esophageal mucosa
require esophagectomy.
Conclusions
n Leiomyomas of the esophagus are rare and occur more frequently in the lower two-
thirds of the esophagus.
n Although the majority of these tumors may be asymptomatic, all symptomatic tumors
should be resected.
n Enucleation or shelling out of the tumor is the procedure of choice. This can be
accomplished with very low incidence of complications and with excellent long-
term functional outcomes.
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GISTs
n Esophageal GIST is a rare tumor that may mimic a leiomyoma on imaging studies.
n A definitive diagnosis of GIST is established by immunohistochemistry on samples
obtained by endoscopic ultrasound and fine needle aspiration.
n As opposed to leiomyomas, GISTs are unencapsulated, fragile tumors that may rup-
ture if not handled with care. Small GIST (<2 cm) may be resected locally but
esophagectomy is usually recommended to prevent recurrences for larger and/or
symptomatic lesions.
n After surgical resection of GIST, adjuvant therapy with a c-kit inhibitor, such as
imatinib, should be considered to decrease the likelihood of recurrence.
Recommended References and Readings 12. Rubin BP, Heinrich MC, Corless CL. Gastrointestinal stromal
tumour. Lancet. 2007;369:1731–1741.
1. Seremetis MG, Lyons WS, deGuzman VC, et al. Leiomyomata of 13. Kindblom LG, Remotti HE, Aldenborg F, et al. Gastrointestinal
the esophagus: An analysis of 838 cases. Cancer. 1976;38:2166– pacemaker cell tumor (GIPACT): Gastrointestinal stromal tumors
2177. show phenotypic characteristics of the interstitial cells of Cajal.
2. Arnorsson T, Aberg C, Aberg T. Benign tumors of the oesopha- Am J Pathol. 1998;152:1259–1269.
gus and oesophageal cysts. Scand J Thorac Cardiovasc Surg. 14. Lee CH, Liang CW, Espinosa I. The utility of discovered on gas-
1984;18:145–150. trointestinal stromal tumor 1 (DOG1) antibody in surgical
3. Pierre A. Benign esophageal tumors. In: Patterson GA, ed. Pear- pathology-the GIST of it. Adv Anat Pathol. 2010;17(3):222–232.
son’s Thoracic and Esophageal Surgery. 3rd ed. Philadelphia, 15. Ji F, Wang ZW, Wang LJ, et al. Clinicopathological characteristics
PA: Churchill Livingstone; 2008:431–438. of gastrointestinal mesenchymal tumors and diagnostic value of
4. Wright C, Gaissert H, Puma F, et al. The oesophagus: Benign and endoscopic ultrasonography. J Gastroenterol Hepatol. 2008;23:
malignant tumours. In: Morris PJ, ed. Oxford Textbook of Sur- e318–e324.
gery. Oxford: Oxford University Press; 1994:893–904. 16. Blay JY, von Mehren M, Blackstein ME. Perspective on updated
5. Mutrie CJ, Donahue DM, Wain JC, et al. Esophageal leiomyoma: treatment guidelines for patients with gastrointestinal stromal
A 40 year-experience. Ann Thorac Surg. 2005;79:1122–1125. tumors. Cancer. 2010;116:5126–5137.
6. Bonavina L, Segalin A, Rosati R, et al. Surgical therapy of 17. Hueman MT, Schulick RD. Management of gastrointestinal stro-
esophageal leiomyoma. J Am Coll Surg. 1995;181:257–262. mal tumors. Surg Clin North Am. 2008;88:599–614.
7. von Rahden BH, Stein HJ, Feussner H, et al. Enucleation of sub- 18. Blum MG, Bilimoria KY, Wayne JD, et al. Surgical considera-
mucosal tumors of the esophagus: Minimally invasive versus tions for the management and resection of esophageal gastroin-
open approach. Surg Endosc. 2004;18:924–930. testinal stromal tumors. Ann Thorac Surg. 2007;84:1717–1723.
8. Demetri GD, von Mehren M, Antonescu CR, et al. NCCN Task 19. Lee HJ, Park SI, Kim DK, et al. Surgical resection of esophageal
Force report: Update on the management of patients with gas- gastrointestinal stromal tumors. Ann Thorac Surg. 2009;87:1569–
trointestinal stromal tumors. J Natl Compr Canc Netw. 2010;8 1571.
(Suppl 2):1–40. 20. Das A, Wilson R, Biankin AV, et al. Surgical therapy for gastroin-
9. Miettinen M, Sarlomo-Rikala M, Sobin LH, et al. Esophageal testinal stromal tumours of the upper gastrointestinal tract.
stromal tumors: A clinicopathologic, immunohistochemical, J Gastrointest Surg. 2009;13:1220–1225.
and molecular genetic study of 17 cases and comparison with 21. Gouveia AM, Pimenta AP, Lopes JM, et al. Esophageal GIST:
esophageal leiomyomas and leiomyosarcomas. Am J Surg Pathol. Therapeutic implications of an uncommon presentation of a rare
2000;24:211–222. tumor. Dis Esophagus. 2005;18:70–73.
10. Tran T, Davila JA, El-Serag HB. The epidemiology of malignant 22. Milman S, Kim AW, Farlow E, et al. Enucleation of a giant
gastrointestinal stromal tumors: An analysis of 1,458 cases from esophageal gastrointestinal stromal tumor. Ann Thorac Surg.
1992 to 2000. Am J Gastroenterol. 2005;100:162–168. 2009;87:1603–1605.
11. Abraham SC, Krasinskas AM, Hofstetter WL, et al. “Seedling” 23. Dematteo RP, Ballman KV, Antonescu CR, et al. Adjuvant imat-
mesenchymal tumors (gastrointestinal stromal tumors and leio- inib mesylate after resection of localised, primary gastrointesti-
myomas) are common incidental tumors of the esophagogastric nal stromal tumour: A randomised, double-blind, placebo-
junction. Am J Surg Pathol. 2007;31:1629–1635. controlled trial. Lancet. 2009;373:1097–1104.

Esophageal Tumors
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LWBK1254-ch29_p329-342.indd 342 19/02/14 6:50 PM
30 Resection of GIST and
Leiomyoma: Thoracoscopic
Approach
Ian Makey, Rodney J. Landreneau, and Michael Kent
Introduction
Leiomyomas (LMs) account for 70% of esophageal submucosal tumors. Other submu-
cosal tumors of the esophagus include gastrointestinal stromal tumor (GIST), leiomy-
osarcoma, lipoma, fibroma, neurofibroma, schwannoma, granular cell tumor, glomus
tumor, and carcinoid tumor. The focus of this chapter will be the thoracoscopic manage-
ment of tumors that arise from the muscularis propria. These tumors include LMs,
GISTs, and leiomyosarcomas.
LMs are benign tumors that show unequivocal smooth muscle differentiation by
light microscopy. They were once thought to be the most common mesenchymal tumor
of the GI tract, but that distinction now goes to GISTs. LMs stain for the smooth muscle
markers actin and desmin but lack KIT mutations. A minority of esophageal LMs arise
from the muscularis mucosa. These LMs tend to be polypoid and can be resected endo-
scopically.1 LMs that arise from the muscularis propria are well-circumscribed lobu-
lated masses and occur most frequently in the lower third of the esophagus (Figs. 30.1
and 30.2).2
GISTs are spindle cell tumors that arise from the muscularis propria and are clini-
cally indistinguishable from LMs1 (Fig. 30.3). Historically, GISTs were misclassified as
either cellular LMs or leiomyosarcomas.3 Today they are defined by KIT (CD117) posi-
tivity or platelet-derived growth factor receptor alpha (PDGFRA) mutations.4 Some
experts are reluctant to use the term “benign” for any GIST. Therefore, GISTs are risk
stratified according to mitotic count and tumor size.5 The most common location of
GISTs is the stomach (50% to 60%) followed by the small intestine (30% to 40%). Only
5% are located in the esophagus.6
Leiomyosarcomas are high-grade sarcomas that commonly have infiltrated into the
surrounding tissue or metastasized by the time of diagnosis.1 Importantly, leiomyosar-
comas do not develop from malignant degeneration of LMs.7 With the classification of
GIST now based on immunohistochemistry, the reported incidence of leiomyosarcoma
has dropped while that of GIST has risen.8
343
LWBK1254-ch30_p343-352.indd 343 19/02/14 7:55 AM

Figure 30.1 Relative incidence of leio-

myoma in the esophagus.
Proximal
9%
Middle
38% Tumor
Lower
46%
GE junction
7%
Incidence and Presentation

of Leiomyoma
LMs have traditionally been thought of as very rare. Seremetis et al.9 stated that esophageal
carcinoma is 50 times more common than LM. However, the incidence of LM varies greatly
depending on the degree of inspection. Recent papers with detailed pathologic inspection
have reported a much higher incidence of esophageal LM than previously thought. For
example, in a study of 150 esophagectomy specimens, there was a 47% incidence of seed-
ling (<7 mm) LM tumors and a 10% incidence of seedling GISTs.10 This would suggest
that the incidence of LMs and GISTs is actually higher than carcinoma. This is relevant
when considering the management of asymptomatic lesions 1 to 2 cm in size.
Most small esophageal submucosal tumors are asymptomatic, and are usually
detected during routine upper endoscopy. When symptoms do occur, dysphagia and
retrosternal discomfort are the two most common complaints.11
Figure 30.2 A computed tomography

(CT) of a leiomyoma that presented
as a proximal esophageal mass.
LWBK1254-ch30_p343-352.indd 344 19/02/14 7:55 AM

Chapter 30 Resection of GIST and Leiomyoma: Thoracoscopic Approach 345
Figure 30.3 CT of a GIST that pre-

sented at the gastroesophageal
junction.
There is a general consensus that esophageal LMs should be surgically removed in symp-
tomatic patients. Most authors also advocate removal of lesions >5 cm in size, lesions
that are enlarging, or those in which a definite diagnosis cannot be obtained by biopsy.11
There is some controversy regarding the need for surgery in asymptomatic patients. Many
surgeons believe that asymptomatic patients with small, well-encapsulated
LMs <5 cm in size can be observed.12 Reports of malignant degeneration have been
vanishingly rare and are probably due to misdiagnosis.7 Other surgeons advocate resec-
tion of all lesions.
A barium esophagram may be the only diagnostic study needed for classic esophageal
LMs that are symptomatic and easily resectable. If additional information is needed, an
endoscopic ultrasound (EUS) is the best imaging procedure to further characterize sub-
mucosal tumors of the esophagus. The differential diagnosis of submucosal tumors can
be narrowed based on the sonographic layer of origin, the echo pattern, and the margins
of the lesion. LMs, GISTs, and leiomyosarcomas originate from the fourth sonographic
layer (muscularis propria). LMs appear hypoechoic, well-circumscribed, and homoge-
neous. At the other end of the spectrum, leiomyosarcomas appear heterogeneous with
irregular margins. Although LMs and leiomyosarcomas appear quite different, GISTs
Esophageal Tumors
can have features of both and therefore, cannot be reliably distinguished by EUS.13
Indication for Biopsy

The threshold to biopsy submucosal tumors should be fairly low. Landi and Palazzo13
recommended a histologic diagnosis whenever possible. For tumors arising from the
muscularis propria, <2 cm in size, and with smooth borders, the overwhelming majority
will be LMs14 and a biopsy may be omitted.
For lesions 2 to 5 cm in size, the decision to biopsy is predicated on the decision
to resect or not. If resection is planned, then a biopsy can be deferred. If surveillance
is the planned course of action, then biopsy is recommended to rule out a GIST.
LWBK1254-ch30_p343-352.indd 345 19/02/14 7:55 AM

One concern of obtaining an endoscopic biopsy is that scarring between the tumor
and the submucosa will lead to a higher rate of mucosal perforation during resection.15
However, more recently, surgeons have noted that fine-needle aspirations (FNAs) done
prior to surgical extirpation do not lead to any significant dissection difficulties.8,16
Most authors advocate FNA if EUS shows a tumor with irregular borders or that is
not confined to the muscularis propria. Because there is significant overlap in size,
growth rate, and EUS appearance between benign and malignant tumors, some authors
set a low threshold to obtain biopsies. For example, Blum recommends EUS–FNA for
submucosal tumors larger than 2 cm, those that are enlarging on serial examination, or
those with activity on PET scan.8 On the other hand, Lee et al.17 defer preoperative
biopsy of well-encapsulated tumors confined to the muscularis propria up to 5 cm.
For submucosal tumors larger than 5 cm, most authors advocate preoperative
biopsy. At this size, the likelihood of GIST or leiomyosarcoma is higher. Moreover,
5 cm is the size at which GISTs move into the intermediate risk category despite the
mitotic count. For GISTs 5 cm or larger, the preoperative biopsy may determine the
decision to enucleate versus perform an esophagectomy.
The accuracy of EUS-guided or EUS-assisted needle biopsy is based on studies
analyzing gastric GISTs. The average diagnostic yield for FNA was 67%. The average
diagnostic yield for fine needle biopsy or true-cut biopsy was 91%.14 Forceps biopsy
should be avoided.
In our experience of 20 patients with submucosal tumors, 15 of the 20 (75%) were
leiomyomas and 3 were GISTs (15%). There were 12 tumors ≤5 cm of which 2 were
GISTs.18 In a large series of GISTs, leiomyomas, and leiomyosarcomas, GISTs (17/68 tumors,
25%) ranged from 2.6 to 25 cm in maximum diameter (median: 8 cm). The leiomyomas
(48/68 tumors, 71%) ranged from 1 to 18 cm in maximum diameter with a median maxi-
mum diameter of 5 cm.19
Surgery
General Principles
The approach to the upper and middle esophagus is through a right thoracotomy or right
video-assisted thoracoscopic surgery (VATS). The traditional approach to the lower third
of the esophagus is through a left thoracotomy. With the application of minimally inva-
sive techniques, the lower third of the esophagus can be approached from the right chest,
left chest, or abdomen. The surgeon’s experience should dictate the approach to the
lower esophagus rather than the laterality of the tumor. Surgeons with minimally inva-
sive experience have approached tumors of the lower esophagus via a right VATS or left
VATS.18 Laparoscopy provides excellent visualization and exposure for tumors in the
distal thoracic esophagus, intra-abdominal esophagus or gastroesophageal junction. This
approach permits fundoplication in the event of extensive myotomy.
Right VATS Technique

The patient is intubated with a double-lumen tube. Endoscopy is performed to confirm
the location of the tumor. Knowing the precise location of the tumor is critical for
tumors in the upper esophagus because access via a VATS approach can be an issue
if the tumor is less than 20 cm from the incisors. Very high tumors may need to be
excised via a cervical incision approach.
For mid-to-lower esophageal tumors, we place a camera port in the eighth intercostal
space, at the mid-axillary line. A 5-mm port is placed at the eighth or ninth intercostal
space, posterior to the posterior axillary line, for the autosonic shears (Covidien), har-
monic scalpel (Ethicon), or other energy device. A 5-mm port is placed in the anterior
axillary line at the fourth intercostal space to retract the lung anteriorly. The last 5-mm
port is placed just posterior to the tip of the scapula and is used for retraction and
countertraction by the surgeon. The surgeon stands at the back of the patient; the assist-
ant with the camera and retractor stands at the front.
LWBK1254-ch30_p343-352.indd 346 19/02/14 7:55 AM

Figure 30.4 Circumferential dissection of the

esophagus taking care to avoid the vagus nerves.
Tumor
Often, the diaphragm may prevent adequate exposure of tumors in the distal
esophagus. In this case, a suture is placed through the central tendon of the diaphragm
and pulled out through the chest wall using a fascial closure device. In this way, the
diaphragm is retracted caudally without the need for an assistant. The inferior pulmo-
nary ligament is then divided using the harmonic scissors to completely mobilize the
lung from the esophagus. If the tumor is not immediately visible, the flexible esophago-
scope can be placed adjacent to the tumor to delineate its location. In some cases,
a 54-French bougie is placed to accentuate the location of the tumor and facilitate
dissection.
Next, the pleura that overlies the esophagus is divided. If necessary, the esophagus
can be circumferentially mobilized for exposure of the tumor (Fig. 30.4). A Penrose
drain is then placed around the esophagus, and if necessary, the esophagus can be
rotated to some degree so the tumor is visible.18 A longitudinal myotomy is then per-
formed over the tumor, taking care to preserve the main vagal trunks (Fig. 30.5). The
Figure 30.5 Using graspers to

perform the myotomy.

Esophageal Tumors
Tumor
LWBK1254-ch30_p343-352.indd 347 19/02/14 7:55 AM

Figure 30.6 Dissecting tumor away

from the submucosa.
plane between the tumor, muscularis propria, and underlying submucosa is developed.
To avoid grasping and fragmenting the tumor, it is useful to place a retracting suture in
the tumor itself (Fig. 30.6). Opposing tension will help develop the proper dissection
plane between the tumor and the esophageal submucosa. The tumor is enucleated by
a combination of dissection and gentle pushing away of the mucosa from the tumor
surface. Care should be taken to avoid mucosal injury. Next the specimen is placed in
a retrieval bag and removed. The integrity of the mucosa is then inspected with the
endoscope by submerging the esophagus underwater and insufflating the lumen with
air. If a small leak is identified, it is repaired primarily. The longitudinal muscle layer
is then re-approximated using sutures (Fig. 30.7). The ports are closed in a standard
Figure 30.7 Closure of myotomy.
LWBK1254-ch30_p343-352.indd 348 19/02/14 7:55 AM

fashion, and a 28-French chest tube is placed. If there is any concern that the dissection
was difficult and the mucosa may subsequently leak, we place a Jackson-Pratt (JP) drain
along the muscle closure line until the patient resumes oral intake. If no leak is observed
after several days of oral intake, we remove the drain.
The chest tube is removed the day after surgery after the barium swallow has been
reviewed. The JP drain is removed after a period of observation on an oral diet. We do
not routinely place a nasogastric tube.
Complications
The complications of VATS enucleation are the same as for enucleation performed
through a thoracotomy.
n Leak: Bilious drainage from the chest tube will be an early sign of an esophageal
leak. A leak from enucleation may be due to a missed injury or a delayed ischemic
insult due to trauma from the dissection. The techniques described above should
help identify mucosal injuries at the time of the initial operation. Although a leak is
rare, if it occurs and is a small, contained leak that is completely drained by the JP
drain, one may observe carefully and then subsequently slowly remove the drain
over the next few weeks. If there is a significant leak that is not fully contained or
drained, we recommend taking the patient promptly to the operating room for pri-
mary repair in most cases.
Gastroesophageal reflux: Enucleating tumors at or near the GE junction may lead to
n
new onset GERD or exacerbate pre-existing GERD symptoms. This is likely due to
damage to the lower esophageal sphincter during the enucleation. The decision
to perform an antireflux operation at the time of an enucleation should be made
discussed preoperatively but ultimately it may need to be made intraoperatively.
Results
VATS enucleation of LMs appears to be the technique of choice for most authors. Von
Rahden et al.16 recommended it be the standard procedure. They found that VATS
enucleation reduced pulmonary complications, hospital stay (4.1 days), and postopera-
tive wound-related pain. Bonavina et al.15 and Kent et al.18 also found that hospital stay
was shorter compared with open enucleation by 3.4 days and 2.75 days, respectively.
Management of Esophageal GISTs

Esophageal Tumors
The optimal management of esophageal GISTs is unknown because of their rarity. In

the SEER database, 45% of patients with esophageal GISTs presented with localized
disease while another 45% had regional or metastatic disease. The National Compre-
hensive Cancer Network (NCCN) guidelines recommend complete resection of all GISTs
>2 cm. No specific guidelines were offered for incidentally encountered GISTs <2 cm
in size. Otani et al.20 reported excellent results using nonoperative management and
surveillance of gastric GISTs <2 cm in size.
NCCN guidelines do not make specific recommendations regarding the role of enu-
cleation versus esophagectomy for esophageal GISTs. Regardless of the operative
approach, complete microscopic resection and avoidance of tumor rupture should be
achieved.4 Certainly esophagectomy carries the potential for significant morbidity and
LWBK1254-ch30_p343-352.indd 349 19/02/14 7:55 AM

should be avoided if enucleation is feasible. Lee et al.17 suggest consideration of

esophagectomy if the GIST has features such as size >5 cm, mucosal involvement, or
involvement at the GE junction. Patients with tumors >10 cm and with a high mitotic
count should undergo esophagectomy.
There is no evidence that patients treated with enucleation who have a micro-
scopic-positive margin (R1 resection) should undergo re-excision. An analysis of the
American College of Surgeons Oncology Group Z9000 and Z9001 trials showed that
there was no difference in recurrence-free survival in those patients who underwent a
complete (R0) versus those who underwent an R1 resection.21 NCCN guidelines recom-
mend imatinib therapy for patients who have persistent gross residual disease (R2 resec-
tion) or patients with completely resected GISTs who have an intermediate-to-high risk
of recurrence.22 As mentioned previously, the most useful predictors of malignant
behavior in GISTs are size and mitotic count. Joensuu et al.23 analyzed the recurrence-
free survival of resected GISTs. Esophageal GISTs (n = 8) had similar recurrence-free
survival as intestinal GISTs (60% at 5 years). An additional finding by Joensuu et al.
relevant to VATS enucleation was that tumor rupture was an independent adverse prog-
nostic factor. Conversion from VATS to open enucleation should be performed if it will
help delineate dissection planes or prevent tumor rupture. Lymphadenectomy is unnec-
essary because lymph node metastases are rare with GIST.
GISTs have an unpredictable behavior and long-term follow-up is essential for all
patients, independent of their tumors’ benign or malignant characteristics. According
to the NCCN guidelines, contrast CT is recommended every 3 to 6 months for 3 to 5
years and then yearly. Flexible upper endoscopy is performed at 6 months and 1 year
postoperatively and then annually for 2 years.4
There is less agreement in the literature regarding the optimal resection technique for
GISTs. Table 30.1 is a list of all the series published in English with more than one GIST
resection and with the method of resection and tumor size reported for each patient. From
these five series, there were 137 esophageal resections and a total of 26 GISTs. More than
half of the GISTs (17/26, 65%) were enucleated. The average size of enucleated GISTs
was 6 cm. The follow-up varied but there was only one recurrence for a recurrence rate
of 5.9% in the enucleation group. Nine of the GISTs (35%) were resected with the full
thickness of the esophageal wall or via an esophagectomy. The average size of GISTs
resected in this manner was 11 cm. There were seven recurrences for a recurrence rate
of 78% in the full-thickness/esophagectomy group. The difference in recurrence rate most
likely reflects the nature of the disease rather than therapeutic efficacy. This limited data
does suggest that enucleation is an effective resection technique for GISTs <5 cm.
The largest series of resected esophageal GISTs is by Miettinen. Of the 17 GISTs,
10 were enucleated and 7 were removed by esophagectomy or full-thickness resection.
The average follow-up was 53.5 months and there were nine recurrences. The median
survival for the patients with recurrences was 29 months and all died of their disease.
Although individual tumor size was not detailed, all patients with tumors larger than
10 cm died of disease, whereas none of the patients with tumors smaller than 5 cm
died of disease.19
T able 3 0 . 1
GIST Recurrence by Resection Method (Enucleation vs. Esophagectomy)
Follow-up Esophagectomy/Full- Follow-up

Series GIST (No.) Enucleation Size (cm) (mos) Recurrence thickness Resection Tumor Size (mos) Recurrence
Blum8 4 2 9.85 33 1 2 6.85 33.5 1
Von Rahden16 4 4 4.8 >3 0 0 n/a n/a n/a
Kent18 3 3 n/a 6 0 0 n/a n/a n/a
Lee17 7 5 n/a 53 0 2 n/a 53 2
Jiang24 8 3 5 77 0 5 12.6 62 4
Total 26 17 (65%) 6 44.6 1 (5.9%) 9 (35%) 11 54 7 (78%)
LWBK1254-ch30_p343-352.indd 350 19/02/14 7:55 AM

Conclusions
n LMs, GISTs, and leiomyosarcomas are submucosal tumors that arise from the muscula-
ris propria. The overwhelming majority of esophageal submucosal tumors will be LMs.
n For routine submucosal tumors <5 cm that are symptomatic and easily resectable, a
barium esophagram is our diagnostic procedure of choice.
n For more complex submucosal tumors or high-risk lesions or those more difficult to
resect, we recommend EUS to further characterize the tumor and a biopsy should be
considered for larger tumors or those with malignant characteristics on EUS.
n Pathologic differentiation of GISTs, LMs, and leiomyosarcomas must be performed using
immunohistochemistry and, therefore, cannot be verified in frozen section analysis.
n Asymptomatic LMs <5 cm in size can be managed nonoperatively, but patients should
undergo routine radiographic or endoscopic surveillance.
n Management of esophageal GISTs <2 cm in size is controversial because data is limited.
GISTs >2 cm in size should be resected.
n With the application of minimally invasive techniques, the lower third of the esopha-
gus can be approached from the right VATS, left VATS, or for very low tumors, lapar-
oscopically. The tumor location and surgeon’s experience should dictate the approach.
n Localized small GISTs should be resected with an intact pseudocapsule and negative
microscopic margins. If this is not possible via enucleation, then an esophagectomy
should be performed. In some cases of GE junction GISTs, a wedge resection of the
gastric cardia with a negative margin may be adequate.
Recommended References and Readings 13. Landi B, Palazzo L. The role of endosonography in submucosal
tumours. Best Pract Res Clin Gastroenterol. 2009;23(5):679–701.
1. Agaimy A, Wunsch PH. True smooth muscle neoplasms of the 14. Polkowski M. Endoscopic ultrasound and endoscopic ultrasound-
gastrointestinal tract: Morphological spectrum and classification guided fine-needle biopsy for the diagnosis of malignant submu-
in a series of 85 cases from a single institute. Langenbecks Arch cosal tumors. Endoscopy. 2005;37(7):635–645.
Surg. 2007;392(1):75–81. 15. Bonavina L, Segalin A, Rosati R, et al. Surgical therapy of esopha-
2. Hatch GF 3rd, Wertheimer-Hatch L, Hatch KF, et al. Tumors of geal leiomyoma. J Am Coll Surg. 1995;181(3):257–262.
the esophagus. World J Surg. 2000;24(4):401–411. 16. von Rahden BH, Stein HJ, Feussner H, et al. Enucleation of sub-
3. Mazur MT, Clark HB. Gastric stromal tumors. Reappraisal of his- mucosal tumors of the esophagus: Minimally invasive versus
togenesis. Am J Surg Pathol. 1983;7(6):507–519. open approach. Surg Endosc. 2004;18(6):924–930.
4. Demetri GD, Benjamin RS, Blanke CD, et al. NCCN Task Force 17. Lee HJ, Park SI, Kim DK, et al. Surgical resection of esophageal
report: Management of patients with gastrointestinal stromal gastrointestinal stromal tumors. Ann Thorac Surg. 2009;87(5):
tumor (GIST)–update of the NCCN clinical practice guidelines. 1569–1571.
J Natl Compr Canc Netw. 2007;5(suppl 2):S1-S29; quiz S30. 18. Kent M, d’Amato T, Nordman C, et al. Minimally invasive resec-
5. Fletcher CD, Berman JJ, Corless C, et al. Diagnosis of gastroin- tion of benign esophageal tumors. J Thorac Cardiovasc Surg.
testinal stromal tumors: A consensus approach. Hum Pathol. 2007;134(1):176–181.
2002;33(5):459–465. 19. Miettinen M, Sarlomo-Rikala M, Sobin LH, et al. Esophageal
6. Miettinen M, Lasota J. Gastrointestinal stromal tumors–defini- stromal tumors: A clinicopathologic, immunohistochemical,
tion, clinical, histological, immunohistochemical, and molecu- and molecular genetic study of 17 cases and comparison with
lar genetic features and differential diagnosis. Virchows Arch. esophageal leiomyomas and leiomyosarcomas. Am J Surg Pathol.
2001;438(1):1–12. 2000;24(2):211–222.
7. Lee YT. Leiomyosarcoma of the gastro-intestinal tract: General 20. Otani Y, Furukawa T, Yoshida M, et al. Operative indications for
pattern of metastasis and recurrence. Cancer Treat Rev. 1983; relatively small (2–5 cm) gastrointestinal stromal tumor of the
10(2):91–101. stomach based on analysis of 60 operated cases. Surgery. 2006;
8. Blum MG, Bilimoria KY, Wayne JD, et al. Surgical considera- 139(4):484–492.
tions for the management and resection of esophageal gastroin- 21. McCarter MD, Antonescu CR, Ballman KV, et al. Microscopically
Esophageal Tumors
testinal stromal tumors. Ann Thorac Surg 2007;84(5):1717–1723. positive margins for primary gastrointestinal stromal tumors:
9. Seremetis MG, De Guzman VC, Lyons WS, et al. Leiomyoma of Analysis of risk factors and tumor recurrence. J Am Coll Surg.
the esophagus. A report of 19 surgical cases. Ann Thorac Surg. 2012;215(1):53–59; discussion 59–60.
1973;16(3):308–316. 22. von Mehren M, Benjamin RS, Bui MM, et al. Soft tissue sarcoma,
10. Abraham SC, Krasinskas AM, Hofstetter WL, et al. “Seedling” version 2.2012: Featured updates to the NCCN guidelines. J Natl
mesenchymal tumors (gastrointestinal stromal tumors and leio- Compr Canc Netw. 2012;10(8):951–960.
myomas) are common incidental tumors of the esophagogastric 23. Joensuu H, Vehtari A, Riihimäki J, et al. Risk of recurrence of
junction. Am J Surg Pathol. 2007;31(11):1629–1635. gastrointestinal stromal tumour after surgery: An analysis of
11. Lee LS, Singhal S, Brinster CJ, et al. Current management of pooled population-based cohorts. Lancet Oncol. 2012;13(3):
esophageal leiomyoma. J Am Coll Surg. 2004;198(1):136–146. 265–274.
12. Glanz I, Grunebaum M. The radiological approach to leiomyoma 24. Jiang P, Jiao Z, Han B, et al. Clinical characteristics and surgical
of the oesophagus with a long-term follow-up. Clin Radiol. treatment of oesophageal gastrointestinal stromal tumours. Eur J
1977;28(2):197–200. Cardiothorac Surg. 2010;38(2):223–227.
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LWBK1254-ch30_p343-352.indd 352 19/02/14 7:55 AM
Part V
Endoscopic Ablative
Therapies and
Resection
31 Esophageal Radiofrequency
Ablation for the Treatment
of Barrett’s Esophagus with
and without Dysplasia
Felix G. Fernandez and Seth D. Force
Introduction
Barrett’s Esophagus (BE) is defined as the replacement of the normal esophageal squa-
mous epithelium with columnar epithelium, also known as intestinal metaplasia (IM).
Historically BE has been categorized according to endoscopic extent, short segment
(<3 cm) versus long segment (>3 cm), but often there can be discontinuous segments of
columnar mucosa or even abnormal mucosa that is not readily apparent with conven-
tional endoscopy. The incidence of BE reported in the literature ranges from 1.6% to
6.8%.1–3 This is of importance, because the presence of BE is considered to carry a 50
to 100 times increased risk for the development of esophageal carcinoma. The true
cancer risk is unknown but it has been estimated that 1 out of every 200 persons with
BE will develop esophageal cancer over their lifetime.4
Concerns for the development of progressive grades of dysplasia and invasive can-
cer in patients with BE has led to recommendations for lifelong serial endoscopic sur-
veillance and biopsies. More recently, ablative techniques, including photodynamic
therapy (PDT), endoscopic mucosal resection (EMR), cryotherapy, and radiofrequency
ablation (RFA), have been studied for the preventative removal of metaplastic and dys-
plastic esophageal mucosa. However, some of these therapies can be associated with
significant cost and morbidity. PDT is associated with postprocedure photosensitivity
that lasts 6 to 8 weeks (or even longer in some patients) and strictures in up to 36% of
patients following one or two treatments.5 EMR is associated with a low incidence of
perforation and postprocedure stricture formation. Generally, it is not possible to per-
form circumferential mucosal resection. EMR also has a significant learning curve and
is usually reserved for visible mucosal lesions (nodules) and for histologic staging of
these abnormalities. Cryotherapy is relatively new and available data on its efficacy and
indications are sparse.
353
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354 Part V Endoscopic Ablative Therapies and Resection
RFA devices generate an alternating electrical current to create thermal energy that
when applied directly to tissue leads to controlled tissue injury by way of water vapor-
ization, coagulation of proteins, and cell necrosis. There are a number of advantages of
RFA over other ablative modalities. One is that the desiccated tissue, which has a
greater resistance to current than normal tissues, can act as an insulator that controls
ablation depth. In addition, RFA devices also allow circumferential treatment or focal
treatment, and RFA is relatively easy to learn and perform compared with other ablative
techniques. This chapter reviews the current indications, technique, clinical results,
and recommendations for RFA.
Indications
n High-grade dysplasia (HGD): Recent reports have shown superior results of RFA
compared with surveillance alone, and RFA is associated with significantly less mor-
bidity than esophagectomy.
n Low-grade dysplasia (LGD): Good success rates are reported in the literature; how-
ever, the natural course of LGD in BE is uncertain, and therefore surveillance is also
an appropriate strategy.
n Non-dysplastic BE: Most controversial indication for RFA because the risk of progres-
sion to cancer in these patients is small. Good results with RFA for BE have been
reported in the literature.
Contraindications
n Pregnancy.
n Prior radiation therapy to the esophagus.
n Esophageal varices.
n Prior Heller myotomy.
n Nodular or ulcerated BE: Nodular or ulcerated areas in BE must undergo EMR to rule
out carcinoma.
n Esophageal adenocarcinoma: Standard management for esophageal cancer remains
esophagectomy. For intramucosal carcinomas, endoscopic resection followed by RFA
of residual BE is becoming a viable option.
n BE or dysplasia in the setting of a known stricture is a relative contraindication.
All patients should undergo a preoperative endoscopy with biopsy and identification
of the type and extent of BE and/or dysplasia. This allows for proper planning for the
procedure, such as the need for multiple initial treatments for longer lesions or consid-
eration of the presence of a hiatal hernia when selecting a sizing balloon. Patients
should be maintained on proton pump inhibitor (PPI) therapy and should not eat or
drink the evening prior to the procedure.
Surgery
RFA Device
In 2000, the BARRX corporation (Sunnyvale, CA) introduced the HALO 360 RFA device,
which received FDA approval for clinical use in 2001 (Fig. 31.1). The HALO 360 is a
pneumatic balloon that is connected to a computerized energy source. The balloon-based
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Chapter 31 Esophageal Radiofrequency Ablation for the Treatment of Barrett’s Esophagus with and without Dysplasia 355
Figure 31.1 HALO 360 RFA catheter.

Image supplied by BARRX Corpora-
Part V: Endoscopic Ablative Therapies

tion, Sunnyvale CA, with permission.
and Resection
ablation catheter contains a microelectrode array, encircling a balloon, that is capable of
delivering radiofrequency energy. The array is composed of 60 tightly spaced, bipolar
electrodes that circumferentially surround the balloon and cover a length of 3 cm. The
energy source calculates the optimal RFA balloon size, utilizing a computer-controlled
balloon sizer (Fig. 31.2 A,B). It then distributes energy through the electrode on the RFA
balloon. Ten to twelve J/cm2 are delivered in a 360-degree radius over the length of the
3-cm electrode allowing for a treatment depth of 1,000 microns. This depth is critical to
ensure complete treatment of the BE, which has been measured at 500 microns, while
avoiding deeper tissue destruction, which could lead to perforation or strictures.6 A
second RFA catheter, the HALO 90, was introduced by BARRX in 2006. This catheter is
affixed to the end of an endoscope and delivers the same amount of energy as the HALO
360 but confined to a 90-degree radius. This allows for treatment of non-circumferential
BE without treating adjacent, normal, esophageal mucosa (Fig. 31.3).
RFA Procedure
Ablation procedures may be performed under conscious sedation or general anesthesia
in an outpatient setting. The procedure begins with an esophagoscopy to carefully iden-
tify the location and length of the IM or dysplasia. N-acetylcysteine (1%) is then injected
through the endoscope to remove mucus from the mucosa to improve the contact of the
electrodes with the tissue. A stiff guidewire (e.g., Amplatz extra stiff 0.035-inch; Cook
Europe, Bjaeverskov, Denmark) is then placed through the endoscope into the stomach
and the scope is removed. A sizing catheter, with a 4-cm long balloon at its distal end,
is placed over the guidewire to measure the diameter of the esophagus. This is per-
formed as a blind procedure using the 1-cm scale on the catheter shaft for reference,
and measurements are begun with the catheter positioned 5 cm above the proximal
extent of the IM. The sizing balloon is inflated by the HALO 360 energy generator, and
the mean esophageal diameter is automatically calculated for the entire length of the
4-cm balloon. Measurement is then repeated for every centimeter of the targeted portion
of the esophagus. Once this has been done, an appropriately sized RFA balloon can be
chosen (22, 25, 28, 31, or 34 mm). The balloon may oversize the esophagus in patients
with large hiatal hernias, and in these patients, the operator should choose the average
or smaller balloon size to prevent esophageal injury.
A B
Figure 31.2 A: HALO energy generator. B: Sizing balloon. Images supplied by BARRX Corporation, Sunnyvale CA, with permission.
LWBK1254-ch31_p353-362.indd 355 19/02/14 7:57 AM

Figure 31.3 HALO 90 catheter affixed

to an endoscope. Image supplied by
BARRX Corporation, Sunnyvale CA,
with permission.
The RFA catheter is then placed over the guidewire, positioned at the level of the abnor-
mal mucosa and the endoscope is placed down the esophagus next to the RFA catheter
(Fig. 31.4). The RFA balloon is inflated and energy is delivered by stepping on a foot
pedal control, while simultaneously, suction is applied on the endoscope to ensure good
contact between the IM/dysplasia and the electrode. The electrode is advanced in 3 cm
increments until the entire length of the targeted tissue has been ablated (Fig. 31.5). The
RFA catheter is then removed and cleaned to clear the sloughed mucosa off of the elec-
trode. A soft plastic cap is attached to the endoscope and used to debride all coagulative
debris away from the treated area to prepare the area for a second treatment. A second
treatment is then performed. For ablation of IM, 10 J/cm2 is used, and 12 J/cm2 is used
for ablation of dysplastic tissue. The length of treatment for a single session should be
limited to 6 cm to decrease the chance of stricture formation.
At a minimum of 8 weeks after the first circumferential ablation, patients are
rescheduled for a second ablation. Localized IM found on subsequent surveillance
endoscopy can be treated with the HALO 90 catheter. Focal ablation, delivered with
the HALO 90 system, is performed by placing the endoscope-mounted electrode in
contact with the target epithelium by deflecting the tip of the endoscope upward, flatly
opposing the electrode to the esophageal wall (Fig. 31.6). Energy is delivered twice to
the ablation target. After the first application, the endoscope is removed, the device is
cleaned, and the procedure is repeated. This results in a total of four treatments to each
Figure 31.4 Circumferential abla-

tion with balloon-based RFA
system.
Endoscope
RFA catheter
Guidewire
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Figure 31.5 Esophagoscopy revealing

the ablation zone.

and Resection
area. Ablation can be repeated every 2 to 3 months until all IM has been eradicated
visually and eradication confirmed histologically.
Almost all patients experience some chest discomfort, sore throat, difficulty or pain
with swallowing, and/or nausea after therapy. This may be treated with viscous lido-
caine, liquid acetaminophen with or without codeine, and antiemetics. Antisecretory
therapy with PPIs is continued before and after the procedure to minimize discomfort
Figure 31.6 Focal ablation with endoscope-

mounted HALO 90 RFA system.
Endoscope
Electrode
Stomach
LWBK1254-ch31_p353-362.indd 357 19/02/14 7:57 AM

and allow the esophagus to heal and regenerate with squamous epithelium. Patients
are placed on a liquid diet for 24 hours after the procedure and may then gradually
advance their diet as tolerated. In absence of long-term follow-up data for RFA, it
is advised that patients undergo endoscopy 2 and 6 months after the last treatment
and then annually.
Complications
The most common postprocedural complication is chest discomfort, which in severe
cases may be accompanied by fever. The rate of stricture formation after RFA ranged
from 0% to 6% in most large studies. Perforation of the esophagus and the development
of significant bleeding after RFA are both rare events. Finally, the development of BE
underneath the neosquamous epithelium has been rarely reported.
Results
Multiple clinical trials have shown RFA to be safe and effective for treating IM and
dysplasia. The ablation of intestinal metaplasia (AIM) trial included 100 patients,
from eight different centers, who underwent circumferential RFA for BE.7 The study
was separated into two phases, AIM-I and AIM-II. The AIM-I trial determined that
10 J/cm2 was the optimal RFA dose for treating BE; the AIM-II trial enrolled 70 patients
who were treated at this optimal dose. One-year results showed a 70% complete
response rate and 25% partial response rate. Sixty-two patients required a second
ablation for residual BE. There were no strictures or buried glandular mucosa found
in any of the patients. The authors cited possible causes for significant residual BE
as: Imperfect balloon sizing (the study was conducted before the advent of the com-
puterized sizer), failure to clean the electrode between ablations, and the use of ace-
tic acid instead of 1% N-acetylcysteine to remove mucus covering the esophageal
mucosa.
Three recent studies have focused on the use of RFA in patients with dysplasia in
the setting of BE. Sharma et al. evaluated 24 patients with BE/HGD and 39 patients BE/
LGD who underwent a protocol of stepwise progressive ablation until complete remis-
sion of BE was achieved. Results at 18 months showed an 89% complete response rate
for dysplasia (95% for LGD, 79% for HGD) and a 79% complete response rate for BE.8
Ganz et al. evaluated 142 patients who underwent RFA, at 12 J/cm2, for HGD in the
setting of BE.9 Twenty-four patients underwent EMR prior to RFA and two patients
underwent esophagectomy after their initial 3-month endoscopy. Results at 1 year were
available for 92 patients; and showed 90% of patients with no evidence of HGD, 80%
of patients with no evidence of any dysplasia and 54% of patients with no evidence of
BE. Subgroup analysis showed no difference in response rates between patients who
underwent pre-RFA EMR as compared with patients who were treated with RFA alone.
The authors cited failure to clean the electrode between RFA treatments and not using
the HALO 90 to treat isolated, non-circumferential lesions, as possible reasons for the
lower-than-expected complete response rates for RFA treatment of BE.
Shaheen et al. recently reported their AIM Dysplasia trial data, which was a
19-center, randomized trial comparing RFA + PPI + surveillance versus sham endos-
copy + PPI + surveillance for patients with LGD or HGD. The study randomized 127
patients with dysplasia in a 2:1 ratio of RFA to sham. It must be noted that patients
with nodular BE or BE length greater than 8 cm were excluded from the trial. Com-
plete response rates in the RFA group were 92% for dysplasia and 83% for metapla-
sia. In comparison, the complete response rates in the sham RFA group were
significantly lower (23% for dysplasia [p < 0.001] and 3% for metaplasia [p < 0.001]).
The rate of progression to worsening dysplasia or invasive cancer was also lower in
the RFA treatment group compared with PPI and surveillance alone. However, in HGD
patients treated with RFA, 19% had persistent dysplasia, 26% had persistent BE/IM,
LWBK1254-ch31_p353-362.indd 358 19/02/14 7:57 AM

and 2.4% had progression to esophageal cancer during short-term follow-up of

12 months. Overall, including all patients (LGD and HGD) during the 12-month

follow-up, 3.6% of patients developed progression and 1.2% developed cancer. 10
Predictors of response to RFA included shorter length of BE, lower BMI, and shorter
history of dysplasia.
and Resection
In an interesting study, DeMeester et al. performed a retrospective comparison of
endoscopic treatment for early esophageal neoplasia (n = 40, HGD in 22 and T1a intra-
mucosal in 18) versus esophagectomy (n = 61; HGD in 13 and T1a intramucosal cancer
in 48). In this series of 40 patients treated with endoscopic intervention, a median of
3 ablations per patient were performed for a total of 102 EMRs and 79 mucosal ablations
primarily using RFA. The duration of follow-up was significantly longer in the
esophagectomy group (34 months vs. 17 months for endotherapy). There was no mortal-
ity in either group, and morbidity was lower in the endoscopic group. Local failure after
endoscopic treatment was higher, and a new or metachronous lesion developed in 20%
(n = 8) of patients who underwent endoscopic therapy, but none who underwent
esophagectomy. In the endoscopic group, 58% had eradication of all BE after multiple
treatments. Esophagectomy eradicated BE in all patients and none of the patients who
underwent esophagectomy developed BE in the remnant cervical esophagus. An anti-
reflux procedure after control of dysplasia was performed in eight patients in the endo-
scopic group.
Among the T1a cancer patients treated with endotherapy (n = 18), 3 (18%) devel-
oped metachronous cancer. Ultimately one patient in this group underwent esophagec-
tomy. Among the HGD patients (n = 22) treated with endotherapy, 2 (10%) later
underwent esophagectomy for HGD, and one died of an unrelated cause. Of the remain-
ing 19 patients, progression to cancer occurred in 26% (n = 5) of patients. All of these
patients were treated with endotherapy, one with submucosal invasion declined sur-
gery. With treatment of local failure, there were no differences overall or cancer-specific
survival in between the groups. The authors recommended repeated endoscopic therapy
every 2 months until all BE is eradicated.
DeMeester et al. also highlighted factors to consider in selection of treatment
including tumor-related factors (e.g., length of BE and whether all BE can be elimi-
nated), esophageal factors (e.g., end-stage esophageal dysfunction) and patient factors
(e.g., the willingness and ability for close follow-up, recognition that the endoscopic
therapy may fail, the ability to live with the uncertainty of complete disease eradica-
tion). The authors also emphasized that failure to carefully monitor and aggressively
eradicate all BE with repeated endoscopic therapies could potentially result in recur-
rent disease and advanced cancer. Previous systematic reviews of esophagectomy for
HGD have shown a mean incidence of invasive esophageal cancer in 41% (range, 18%
to 75%) of patients.11 It is important that the risks and benefits of all options, includ-
ing esophagectomy (with potential lower morbidity with MIE and vagal-sparing
approaches), be discussed with the patient, and so that he or she can make an informed
decision.
Surveillance After RFA

Currently, there are no published guidelines on short- or long-term follow-up for patients
who have undergone esophageal RFA for IM, LGD, or HGD. Most recommendations are
modifications of surveillance protocols for patients who have not undergone treatment
for their IM or dysplastic tissue. DeMeester et al. used the following surveillance for
patients with HGD in their study comparing RFA with esophagectomy for patients with
HGD and intramucosal carcinoma: Endoscopy and biopsy every 3 months for 1 year
with no evidence of abnormal mucosa, followed by every 6 months for a year and then
annually, provided that there was no recurrence of IM or dysplasia.12 Standardization
of surveillance practices will be an important topic, as RFA becomes a more common
treatment approach for patients with dysplastic esophageal mucosa.
LWBK1254-ch31_p353-362.indd 359 19/02/14 7:57 AM

Conclusions
Historically, non-dysplastic BE and LGD have been treated by surveillance endoscopy,
antisecretory medicines, and antireflux procedures, and HGD was treated with
esophagectomy. Recently, ablative techniques, such as RFA, are being used with encour-
aging short-term results for these indications. Prior to RFA, ablative procedures such as
PDT or other laser treatments existed for BE, but many of these carried significant mor-
bidity, were operator dependent, and had varying results. The advent of esophageal RFA
has provided an easily reproducible procedure for treating BE with and without dys-
plasia. Short-term results from multiple studies have shown reasonable complete
response rates, on the order of 70% for IM and higher for LGD and HGD with low
morbidity rates. However, most of these studies excluded patients at higher risk for
complications or progression. For example, patients with nodular BE and BE length
greater than 8 cm were excluded from the Shaheen RFA trial and other RFA trials. In
the DeMeester study12 comparing RFA and esophagectomy for HGD, it was noted that
with close follow-up, recurrent cancer occurs in up to 20% of patients who undergo
RFA even during a short follow-up (median, 17 months). This significant failure rate
occurred even at a very specialized center with exceptional follow-up. In this particular
study, RFA failure was recognized in a timely fashion and patients underwent esophagec-
tomy with good results, but other less experienced centers may not be capable of dupli-
cating these results. In spite of these concerns and without controlled trials or long-term
follow-up of RFA, this technology has begun to cause a paradigm shift with respect to
the recommended treatment for esophageal mucosal abnormalities. The American Gas-
troenterological Association recently released a position statement recommending
endoscopic treatment (RFA, EMR, or PDT) for patients with HGD and possibly for
patients with LGD and high-risk patients with BE.13 Current recommendations, how-
ever, still do not recommend the routine use of RFA for BE in the absence of dysplasia
in the general population, over routine surveillance endoscopy and biopsy.
Given the short-term follow-up of RFA for HGD and the known failure rates, we
recommend that a number of variables should be considered before treatment. For
example, is the HGD multi-focal or nodular? What is the experience level of the endo-
scopist doing the biopsies and the pathologist reading the slides? What is the length of
BE and the functional status of the esophagus? What is the age of the patient and are
they reliable and willing to undergo repeated lifetime surveillance and frequently addi-
tional ablations? In some of these higher-risk patients, especially in younger patients
and in patients otherwise fit for surgery, minimally invasive esophagectomy should be
considered and at a minimum discussed with the patient and family. Recently, mortal-
ity rates following minimally invasive esophagectomy or open esophagectomy in expe-
rienced centers are approaching 1% with good quality of life in the majority of patients.14
Also, it is important to note that not all clinicians are skilled enough or have the
expertise and tools to rule out coexisting cancers in the setting of a biopsy of HGD.
Previous studies have shown that invasive cancers were missed in a significant propor-
tion of patients diagnosed with HGD who subsequently underwent esophagectomy.
Thus, it is clear that if a patient is undergoing non-surgical ablation for HGD, ablation
should be performed by individuals with significant expertise in the recognition and
management of BE. Physicians and patients need to understand that RFA for HGD
requires a very careful initial diagnosis and clear education about the follow-up, the
need for repeated endoscopies and repeated RFA, and the unknown risk of developing
an occult progressive invasive cancer during long-term follow-up.
We currently await long-term data assessing the durability of RFA treatment and
answers to questions such as: Should all patients with IM be treated with RFA and how
long do we need to perform surveillance endoscopy on patients after RFA? Low morbid-
ity rates, a short learning curve, and good interim results have made RFA an excellent
option for patients with HGD and possibly LGD. Concerns will remain about using RFA
for HGD for fear of incompletely treating an unrecognized invasive cancer or developing
an invasive cancer during follow-up.
LWBK1254-ch31_p353-362.indd 360 19/02/14 7:57 AM

Recommended References and Readings 12. Zehetner J, DeMeester SR, Hagen JA, et al. Endoscopic resection
and ablation versus esophagectomy for high-grade dysplasia and

1. Hirota WK, Loughney TM, Lazas DJ, et al. Specialized intestinal intramucosal adenocarcinoma. J Thorac Cardiovasc Surg. 2011;
metaplasia, dysplasia, and cancer of the esophagus and esoph- 141(1)39-47.
agogastric junction: Prevalence and clinical data. Gastroenterol- 13. Spechler SJ, Sharma P, Souza RF, et al. American Gastroentero-
ogy. 1999;116:277. logical Association medical position statement on the manage-
2. Ronkainen J, Aro P, Storskrubb T, et al. Prevalence of Barrett’s ment of Barrett’s esophagus. Gastroenterology. 2011;140(3):
and Resection
Esophagus in the general population: An endoscopic study. Gas- 1084–1091.
troenterology. 2005;129:1825–1831. 14. Luketich JD, Pennathur A, Awais O, et al. Outcomes after mini-
3. Rex DK, Cummings OW, Shaw M, et al. Screening for Barrett’s mally invasive esophagectomy: Review of over 1000 patients.
Esophagus in colonoscopy patients with and without heartburn. Ann Surg. 2012;256(1):95–103.
Gastroenterology. 2003;125;1670–1677. 15. American Gastroenterological Association, Spechler SJ, Sharma
4. Shaheen NJ, Crosby MA, Bozymski EM, et al. Is there a publica- P, et al. American Gastroenterological Association medical posi-
tion bias in reporting cancer risk in Barrett’s Esophagus? Gastro- tion statement on the management of Barrett’s Esophagus. Gas-
enterology. 2000;119:333–338. troenterology. 2011;140:1084–1091.
5. Overholt BF, Lightdale CJ, Wang KK, et al. Photodynamic ther- 16. Eldaif SM, Lin E, Singh KA, et al. Radiofrequency ablation of
apy with porfimer sodium for ablation of high-grade dysplasia Barrett’s esophagus: Short-term results. Ann Thorac Surg. 2009;
in Barrett Esophagus: International, partially blinded, rand- 87:405–410; discussion 410–411.
omized phase III trial. Gastrointest Endosc. 2005;62:488–498. 17. Fleischer DE, Overholt BF, Sharma VK, et al. Endoscopic abla-
6. Ackroyd R, Brown NJ, Stephenson TJ, et al. Ablation treatment tion of Barrett’s esophagus: A multicenter study with 2.5-year
for Barrett’s Oesophagus: What depth of tissue destruction is follow-up. Gastrointest Endosc. 2008;68:867–876.
needed. J Clin Path. 1999;52:509–512. 18. Pouw RE, Wirths K, Eisendrath P, et al. Efficacy of radiofre-
7. Sharma VK, Wang KK, Bergein F, et al. Balloon-based, circumfer- quency ablation combined with endoscopic resection for Bar-
ential, endoscopic radiofrequency ablation of Barrett’s Esopha- rett’s esophagus with early neoplasia. Clin Gastroenterol Hepatol.
gus: 1-year follow-up of 100 patients. Clinical Endoscopy. 2010;8:23–29.
2007;65:185–195. 19. Sharma P, Wani S, Rastogi A. Endoscopic therapy for high-grade
8. Sharma VK, Jae Kim H, Das A, et al. Circumferential and focal dysplasia in Barrett’s esophagus: Ablate, resect, or both? Gas-
ablation of Barrett’s esophagus containing dysplasia. Am J Gas- trointest Endosc. 2007;66:469–474.
troenterol. 2009;104:310–317. 20. Sharma VK, Kim HJ, Das A, et al. A prospective pilot trial of
9. Ganz RA, Overholt BF, Sharma VK, et al. Circumferential abla- ablation of Barrett’s esophagus with low-grade dysplasia using
tion of Barrett’s esophagus that contains high-grade dysplasia: A stepwise circumferential and focal ablation (HALO system).
U.S. Multicenter Registry. Gastrointest Endosc. 2008;68:35–40. Endoscopy. 2008;40:380–387.
10. Shaheen NJ, Sharma P, Overholt BF, et al. Radiofrequency abla- 21. Vassiliou MC, von Renteln D, Wiener DC, et al. Treatment of
tion in Barrett’s esophagus with dysplasia. N Engl J Med. ultralongsegment Barrett’s using focal and balloon-based radiof-
2009;360:2277–2288. A randomized controlled trial demonstrat- requency ablation. Surg Endosc. 2010;24:786–791.
ing that treatment with RFA was associated with decreased rates 22. Velanovich V. Endoscopic endoluminal radiofrequency ablation
of persistent HGD and decreased cancer risk. of Barrett’s esophagus: Initial results and lessons learned. Surg
11. Pennathur A, Landreneau RJ, Luketich JD. Surgical aspects of Endosc. 2009;23:2175–2180.
the patient with high-grade dysplasia. Semin Thorac Cardiovasc
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LWBK1254-ch31_p353-362.indd 362 19/02/14 7:57 AM
32 Photodynamic Therapy,
Lasers, and Cryotherapy for
Esophageal Neoplasia
Virginia R. Litle and Mary S. Maish
Introduction
Endoscopic modalities for treatment of esophageal neoplasia have evolved from thermal
ablation with argon plasma coagulation (APC) and neodymium: yttrium-aluminum gar-
net (Nd:YAG) lasers to photodynamic therapy (PDT), and the newest technique cryo-
therapy.1–4 Other endoscopic modalities to treat Barrett’s metaplasia, high-grade
dysplasia (HGD), and some early-stage cancers in medically inoperable patients include
radiofrequency ablation (RFA) and endoscopic mucosal resection, and these are dis-
cussed in other chapters. While surgical resection is the standard treatment for resect-
able esophageal cancer, endoscopic approaches are particularly applicable in high-risk
patients.5 In this chapter, we discuss PDT, lasers and cryotherapy in the treatment of
early esophageal neoplasia.
Photodynamic Therapy
PDT requires a photosensitizer that can accumulate in tumor tissue. The most widely
used and studied photosensitizer is porfimer sodium (Photofrin; Pinnacle Biologics Inc.,
Bannockburn, IL). Porfimer sodium achieves an excited state after exposure to 630-nm
wavelength light, the absorption maxima of porfimer sodium, which then leads to reac-
tion with oxygen to generate singlet oxygen and other reactive oxygen species.6–9 The
630-nm wavelength of light leads to a penetration depth of 5 to 6 mm.9 The reactive
oxygen species cause damage, leading to disruption of multiple intracellular processes
that eventually result in cellular apoptosis, necrosis, ischemia, inflammation, and immune
responses.7 Other photosensitizers that have been utilized include 5-aminolevulinic
acid (ALA); however, this compound is not approved for use in the United States.
Administration of ALA results in the production of protoporphyrin IX (PpIX), a pho-
toactive compound, that is activated when exposed to red light at 630 nm. PpIX is
selectively produced by the esophageal mucosa, in comparison to the muscularis, which
may lead to a lower rate of strictures.7,10
363
LWBK1254-ch32_p363-372.indd 363 19/02/14 10:31 PM

Laser Therapy
Nd:YAG and potassium-titanyl-phosphate (KTP):YAG lasers have been studied in the
treatment of Barrett’s esophagus (BE). Nd:YAG laser has been used as an adjuvant to
PDT in the ablation of BE.7,12 Argon gas (plasma) is used in APC, and this conveys
electrical energy to tissue, resulting in thermal destruction. As the tissue is burnt, it
dries, decreasing further conduction, which limits the depth of injury. It is an easy-to-
use technique and has been studied extensively for the ablation of BE.7,11–13 The coagu-
lation depth is generally in the range of 1 to 3 mm.
Cryotherapy
During cryotherapy, freeze cycles are mediated by nitrogen (liquid or gas), carbon
dioxide gas, or argon gas systems. Rapid cooling leads to disruption of enzyme and cell
membrane function, and ongoing crystallization with prolonged cooling perpetuates
this damage. In addition, hypertonicity is caused by ice formation in the extracellular
matrix and leads to intracellular dehydration via osmotic efflux of water from the cell.
With thawing, rapid intracellular return of water induces cell lysis.14 Multiple freeze/
thaw cycles are generally applied to achieve tumor destruction.
The indications for PDT, laser and cryotherapy range from ablation of superficial early
cancers in high-risk patients to palliative treatment of malignant dysphagia and bleed-
ing from advanced esophageal cancer. With the advent of RFA (Barrx Medical, Sun-
nyvale, CA) for dysplastic BE, the indications for laser ablation and PDT are now
limited mostly to palliation of bleeding or obstructing esophageal cancers. RFA burns
the mucosal layer of the esophagus while PDT using porfimer sodium (Photofrin; Pin-
nacle Biologics Inc., Bannockburn, IL) penetrates to the submucosal layer, thus resulting
in strictures in up to 42% of patients.15 Cryotherapy is becoming increasingly more
available and is being used to ablate dysplastic BE and early neoplasms, palliate malig-
nant dysphagia, and control bleeding. Concurrent chemotherapy and radiation therapy
are not considered contraindications to these endoscopic laser and freezing treatments.
The presence of a tracheoesophageal or bronchoesophageal fistula is a contraindication
for all three modalities (PDT, laser ablation, and cryotherapy).
Photodynamic Therapy and Thermal Laser Therapy Indications

n Palliate malignant dysphagia
n Control superficial bleeding from esophageal cancer
n Used as a primary or adjunct for treatment of BE, HGD, and intramucosal cancers in
medically inoperable patients15–17
Cryotherapy Indications
n Ablation of dysplastic BE
n Primary tumors of the esophagus
n Definitive treatment of intramucosal tumors
n Local control of esophageal cancer in patients deemed high risk for esophagec-
tomy due to comorbidities
n Control bleeding from esophageal cancer
Photodynamic Therapy Contraindications

n Porphyria
n Tracheoesophageal or bronchoesophageal fistula
n Relative: Hepatic or renal impairment
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Chapter 32 Photodynamic Therapy, Lasers, and Cryotherapy for Esophageal Neoplasia 365
Cryotherapy Contraindications

n Tumor that is completely obstructing or near-completely obstructing the esophagus.
n Tracheoesophageal or bronchoesophageal fistula
and Resection
Prior to the selection of endoscopic therapy, the patient is staged and evaluated, and in
patients with early-stage or locally advanced cancer the risk for surgical therapy is assessed.
An endoscopy is done to evaluate the extent of disease. If the therapy is offered with
curative intent, then a CT scan of the chest and abdomen, endoscopic ultrasound to eval-
uate the depth of the tumor and nodal status, and a PET-CT scan are done before admin-
istering endoscopic therapy to confirm that the tumor is early stage. In patients with more
advanced disease, endoscopic therapies can be offered as part of palliative treatment.
n Before PDT, the surgeon must educate the patient about the systemic photosensitizing
risks of the porfimer sodium. Photofrin (Pinnacle Biologics Inc., Bannockburn, IL) is
the most widely used photosensitizing agent, and is approved for use in the United
States. Aside from the primary risk of a severe sunburn, other potential side effects
include an allergic reaction, chest pain, and wheezing. These must be discussed with
the patient before injecting them with Photofrin.
Thermal Laser Therapy (APC; Nd:YAG)

n No specific planning
Cryotherapy
n Cryotherapy involves the use of nitrogen, a rapidly expanding gas, that if not prop-
erly evacuated may lead to perforation of a hollow viscus. A decompression tube is
placed in the stomach to eliminate the gas and reduce the risk of injury to the enteric
viscera. Placement of this tube may result in postoperative oropharyngeal discomfort.
Expelling gas after the procedure is expected.
n As the cryogen is released into the esophagus, a transmural freeze occurs and may
affect surrounding organs, including the heart. Cardiac arrhythmias from these asso-
ciated temperature changes may occur. A preoperative cardiac assessment including
a recent electrocardiogram is recommended.
n Risks and side effects should be discussed with the patient prior to surgery.
Surgery
All of these endoscopic modalities can be performed as an outpatient procedure either
in the main operating room or in a controlled outpatient endoscopy suite. In the oper-
ating room, the patient remains supine and is placed under general anesthesia or under
monitored anaesthesia care. In the endoscopy suite, the patient is positioned into the
left lateral decubitus position; oropharyngeal anaesthesia is achieved with Lidocaine
spray, and intravenous conscious sedation is administered. After the endoscope is
inserted (Fig. 32.1), the extent of the tumor is examined, biopsies are obtained if indi-
cated, and the procedure is initiated.
Photodynamic Therapy Technique

n The dose of Photofrin is 2 mg/kg, intravenously administered slowly over 3 to
5 minutes.7,10 We wait for 48 hours before administering endoscopic treatment (from
LWBK1254-ch32_p363-372.indd 365 19/02/14 10:31 PM

Figure 32.1 Patient is in left lateral

decubitus position, sedated and the
endoscope is inserted transorally.
photosensitizer injection to administration of light therapy) because tumor cells need

time to selectively retain more photosensitizer than normal tissue. This selective
retention is due to differences in cancerous tissue vascular supply and lymphatic
drainage.7,10
n The injection can be done in the outpatient setting but more often is indicated when
the patient has been admitted for bleeding from the tumor or to treat aspiration from
malignant obstruction.
n 5-ALA may be used as a photosensitizing agent in Europe. It is not approved as such
in the United States.
n During endoscopic therapy/light administration, protective eyewear is required for
all operating personnel (Fig. 32.2).
n A diffusing tip fiber is introduced through the biopsy channel of the endoscope. Avail-
able fiber lengths are 1, 2.5, and 5 cm and are chosen depending on the target area.7,18
n A 630-nm wavelength laser light is administered at a dose of 300 J/cm of fiber optic
diffuser length (Fig. 32.3).
n Since the mucosal folds are not flattened, light delivery may not be uniform, and this
may lead to an increased dose in some areas, resulting in stricture, and inadequate
dosing in others, resulting in incomplete ablation. The use of balloon centering
Figure 32.2 PDT laser eyewear is required for ocular

safety.
LWBK1254-ch32_p363-372.indd 366 19/02/14 10:31 PM


and Resection
A
Figure 32.3 Endoscopic view as well as illustration of obstructing esophageal cancer (A) before, (B) during, and (C) after photody
namic therapy (PDT). (From: Abbas G, Pennathur A, Keeley SB, et al. Laser ablation therapies for Barrett’s esophagus. Semin Tho-
rac Cardiovasc Surg. 2005;17(4):313–319, used with permission from Elsevier and the Society of Thoracic Surgeons.).
devices may help address this issue by decreasing the mucosal folds and facilitating
more uniform delivery (Fig. 32.4).
n A balloon centering device may allow more uniform light exposure resulting in bet-
ter treatment and fewer strictures. Caution is necessary to avoid overdistention of the
esophagus using the balloon as this may decrease blood flow and make the treatment
less effective.
n A balloon fiber (Wizard X-Cell PDT balloon, Wilson-Cook Medical, Winston-Salem,
NC, USA) has been approved for esophageal PDT. The balloon induces distention of
esophageal lumen leading to the flattening of the mucosal folds and is available in
LWBK1254-ch32_p363-372.indd 367 19/02/14 10:31 PM

Figure 32.4 Esophageal centering

balloons. Reprinted from: Overholt BF,
Panjehpour M, Haydek JM. Photo
dynamic therapy for Barrett’s esopha
gus: Follow-up in 100 patients.
Gastrointest Endosc. 1999;49:1–7.
Copyright (1999), with permission from
Elsevier.
three lengths (3, 5, and 7 cm). A pediatric endoscope alongside the balloon can be
used to verify the position of the balloon.
n A total power output is set to deliver about 12 minutes of exposure.
n Follow-up endoscopy 24 to 48 hours after ablation is often done to assess the degree
of tumor necrosis and to clean up the necrotic debris.
Thermal Laser Therapy Technique

n Protective eyewear is required for all operating personnel.
n Laser energy was delivered with a noncontact technique via quartz fibers.
n Nd: YAG settings are adjusted. In a randomized trial investigating Nd: YAG, the laser
power setting of between 15 and 90 W and a pulse duration starting from 0.5 seconds
was used.19
Cryotherapy Technique
n Place an orogastric decompression tube.
n Prime the cryospray catheter (Fig. 32.5) and place the decompression tube on con-
tinuous suction.
Figure 32.5 Priming the cryospray from endoscope.
LWBK1254-ch32_p363-372.indd 368 19/02/14 10:31 PM


and Resection
A B
Figure 32.6 Endoscopic view of dysplastic Barrett’s esophagus before (A) and immediately after (B) cryotherapy.
n Expose the upper abdomen and apply gentle pressure consistently throughout the
procedure.
n A protective cap (as used with endoscopic mucosal resection) may be placed on the
tip of the endoscope to shield the camera from the cryogen. (This is optional.)
n Direct the catheter tip toward the tumor, beginning distal and moving caudad.
n Apply the cryogen spray for 10 seconds for dysplastic BE and small (<2 cm) tumors
and 20 seconds for larger (>2 cm) tumors (Fig. 32.6).
n Allow complete thawing of tissue in between freezes (2 to 3 minutes).
n Apply three separate freezes.
n Remove the decompression tube.
n Perform endoscopy to evacuate air and evaluate for injury.
n Withdraw the endoscope.
n Postprocedural monitoring (∼2 hours).
n Liquid diet for 24 hours.
n Tylenol or Ibuprofen for discomfort.
n Avoid direct sunlight and bright indoor light for 4 to 6 weeks. Ambient indoor light
exposure is encouraged. Patients must wear hats and gloves at all times while outside
to reduce the risk of sunburn.
n Proton pump inhibitors are used for acid suppression.
n Ocular sensitivity is rare but can occur and typically manifests as eye discomfort.
n PDT laser treatment may be repeated within 30 days without reinjection of additional
Photofrin.
n Repeat injection of Photofrin can be administered after 90 days for additional treatments.
Thermal Laser Therapy (APC and Nd:YAG)

n Postoperative observation for bleeding (4% to 6%) or perforation (<4%). Major bleed-
ing has been reported in up to 3.9% of patients after APC therapy and minor bleed-
ing in 6% of Nd:YAG-treated patients. Patients are observed in the recovery room for
about 2 hours for evidence of any bleeding and then may be discharged home if vital
signs are stable.
n Liquid diet for 24 hours.
n Acetaminophen or ibuprofen for discomfort.
LWBK1254-ch32_p363-372.indd 369 21/02/14 6:50 PM

Cryotherapy
n Postprocedural monitoring (2 hours)
n Liquid diet for 24 hours
n Tylenol or Ibuprofen for discomfort
n Repeat procedure in 2 to 8 weeks
n Continue with treatment until one of the following is noted
n No evidence of disease on two consecutive biopsies spaced 3 months apart
n Persistent disease after six to eight treatments
n Progression of disease on therapy
n Poor patient tolerance
Complications
Photodynamic Therapy Complications
Early Complications (10% of patients)6,20

n Photosensitivity reaction, sunburn (6% to 19%)
n Pleural effusion (3%)
n Perforation risk is low (<2%)
n Aspiration pneumonia (1%)
n Chest pain
n Fever
Later Complications
n Strictures occur in 30% to 40% of patients when PDT is used to treat HGD and
superficial cancers. Strictures can present from 2 weeks to 6 months after treatment.
The management of strictures involves esophageal dilation with a 50% success rate
with one to five dilations. Oral steroids do not significantly reduce stricture
rate.
n Stricture rate after palliative PDT is 2%.
Thermal Laser Therapy Complications

n Pain (occurs in 2% to 48% of patients)
n Perforation
n Fistula or stricture formation (12%)
Cryotherapy Complications and Side Effects

n Perforation
n Chest pain
n Heartburn
n Dysphagia
Results
Photodynamic and Thermal Laser Therapy

In 2003, Litle and colleagues from the University of Pittsburgh reported in a series of
PDT in 215 patients with bleeding, obstructing, or bleeding and obstructing esophageal
cancer, and this series remains one of the largest published to date. They evaluated
LWBK1254-ch32_p363-372.indd 370 19/02/14 10:31 PM

dysphagia scores, duration of palliation, reinterventions, complications, and survival.

Successful palliation of malignant dysphagia occurred in 85% of patients with a mean

dysphagia-free interval of 66 days.6,20 Tumor bleeding was controlled in 93% of patients
with one course of PDT. Further, a subgroup of patients (30%) was able to discontinue
their supplemental nutrition as they were able to nourish themselves by mouth. Esopha-
and Resection
geal stents were placed in 35 patients, with a mean interval to reintervention of
58.5 days.
In a study comparing Nd:YAG and PDT for treatment of malignant dysphagia, the
patients who received PDT experienced a 50% longer period of palliation (84 days with
PDT vs. 57 days with Nd: YAG).21 In a prospective randomized multicenter trial, the
efficacy and safety of PDT with porfimer sodium was compared with Nd:YAG laser in
the treatment of patients with obstructing esophageal cancer.19 A total of 236 patients
from 24 institutions were randomized, of which 218 patients were treated (110 with
PDT and 108 with Nd:YAG laser). Objective tumor response was equivalent at 1 week,
but was significantly better at 1 month in the PDT group. Improvement in dysphagia
was equivalent in the two groups. Of note, sunburn occurred in 19% of patients in the
PDT group and termination of the laser endoscopy session due to adverse reaction
occurred more frequently in the Nd:YAG group (19% vs. 3%; p < 0.05). Similarly per-
forations from the treatment or associated dilation occurred significantly more often in
the Nd:YAG group (7%) compared with the PDT group (1%, p < 0.05). These authors
concluded that PDT and Nd:YAG laser ablation resulted in equal relief of dysphagia;
however, the objective tumor response was equal or better in the PDT group. In addi-
tion, PDT was associated with fewer acute perforations when compared with the
Nd:YAG laser therapy.
Overholt et al.16 conducted a multicenter randomized Phase III trial of PDT and
omeprazole versus omeprazole alone for BE with HGD.16 A total of 208 patients were
enrolled, 138 patients in PDT arm (of which 132 patients underwent treatment) and
70 patients in the omeprazole only arm, after central pathology confirmation of HGD
in BE. The primary endpoint, ablation of HGD, occurred in 77% of patients in the
PDT group versus 39% in the omeprazole only group. The secondary end points
studied were elimination of all BE, which occurred in 52% in the PDT group versus
7% in the omeprazole group, and ablation of all grades of dysplasia which occurred
in 59% in the PDT arm versus 14% in the omeprazole only group, respectively.
However 13% in the PDT group and 28% in the omeprazole group were diagnosed
with adenocarcinoma. In our experience with PDT in medically inoperable patients,
PDT was effective in approximately one-third of patients with superficial cancer.15
PDT can be used as adjunct to other endoscopic therapies such as endoscopic mucosal
resection. Ell et al.17 reported the use of PDT in approximately 50% of 100 selected
patients who were treated with endoscopic mucosal resection for intramucosal
cancer.
Overholt et al.22 reported treating residual areas of BE after Photofrin PDT with
Nd:YAG laser. A wide range of initial success rates of APC ablation of BE eradication
has been reported with a long-term relapse of intestinal metaplasia up to 68%. 16–18
Persistent acid exposure after APC is an important predictor of relapse.12
One of the concerns after PDT is the persistence of genetic abnormalities after
ablation.7,23 In addition, studies have shown submerged BE underneath squamous
mucosa has the potential for neoplastic progression after argon photocoagulation and
PDT.24,25
Cryotherapy
Relative to PDT and thermal laser ablation, there is far less reported experience with
cryoablation of esophageal tumors. For early stage disease (T1a), the best data shows a
72% endoscopic complete response (CR) at a mean follow-up of 1 year. For moderate
stage disease (T2), the best data shows 30% endoscopic CR at 1-year mean follow-up.
For advanced stage disease (T3), the best data shows a 50% endoscopic CR at a mean
of 1-year follow-up.26–28
LWBK1254-ch32_p363-372.indd 371 19/02/14 10:31 PM

Conclusions
PDT successfully palliates malignant dysphagia from obstructing esophageal cancers
and is also effective in bleeding tumors. A randomized trial data of PDT versus Nd:YAG
laser therapy demonstrated similar palliation of endoluminal lesions, with a decreased
risk of perforation with PDT.19 While endoscopic therapy has its limitations in early
esophageal neoplasia, PDT has also been used as primary or adjunct to endoscopic
mucosal resection in the treatment of BE, HGD and superficial tumors and is applicable
in medically inoperable patients. Cryotherapy is a relatively new but promising technol-
ogy for premalignant and malignant lesions of the esophagus. It can be used in combi-
nation with chemotherapy to treat nodal disease but it is not a replacement for potentially
curative esophagectomy if the patient is a good operative candidate. Follow-up after
treatment of early cancer may require repeat endoscopies and additional cryotherapy
administrations. Clinical trials using cryospray followed by esophagectomy would help
determine the response of esophageal cancer to cryoablation.
Recommended References and Readings 15. Keeley SB, Pennathur A, Gooding W, et al. Photodynamic ther-
apy with curative intent for Barrett’s esophagus with high grade
1. Dumot JA, Greenwald BD. Argon plasma coagulation, bipolar dysplasia and superficial esophageal cancer. Ann Surg Oncol.
cautery, and cryotherapy: ABC’s of ablative techniques. Endos- 2007;14(8):2406–2410.
copy. 2008;40(12):1026–1032. 16. Overholt BF, Lightdale CJ, Wang KK, et al. Photodynamic ther-
2. McCaughan JS Jr, Barabash RD, Penn GM, et al. Nd:YAG laser apy with porfimer sodium for ablation of high-grade dysplasia
and photodynamic therapy for esophageal and endobronchial in Barrett’s esophagus: International, partially blinded, rand-
tumors under general and local anesthesia. Effects on arterial omized phase III trial. Gastrointest Endosc. 2005;62(4):488–498.
blood gas levels. Chest. 1990;98(6):1374–1378. 17. Ell C, May A, Pech O, et al. Curative endoscopic resection of
3. Cash BD, Johnston LR, Johnston MH. Cryospray ablation (CSA) early esophageal adenocarcinomas (Barrett’s cancer). Gastroin-
in the palliative treatment of squamous cell carcinoma of the test Endosc. 2007;65(1):3–10.
esophagus. World J Surg Oncol. 2007;5:34. 18. Panjehpour M, Overholt BF, Haydek JM. Light sources and
4. McCaughan JS. Photodynamic therapy for obstructive esopha- delivery devices for photodynamic therapy in the gastrointesti-
geal malignancies. Diagn Ther Endosc. 1999;5(3):167–174. nal tract. Gastrointest Endosc Clin N Am. 2000;10(3):513–532.
5. Pennathur A, Farkas A, Krasinskas AM, et al. Esophagectomy 19. Lightdale CJ, Heier SK, Marcon NE, et al. Photodynamic therapy
for T1 esophageal cancer: Outcomes in 100 patients and impli- with porfimer sodium versus thermal ablation therapy with
cations for endoscopic therapy. Ann Thorac Surg. 2009;87(4): Nd:YAG laser for palliation of esophageal cancer: A multicenter
1048–1054; discussion 54–55. randomized trial. Gastrointest Endosc. 1995;42(6):507–512.
6. Chen M, Pennathur A, Luketich JD. Role of photodynamic ther- 20. Litle VR, Luketich JD, Christie NA, et al. Photodynamic therapy
apy in unresectable esophageal and lung cancer. Lasers Surg as palliation for esophageal cancer: Experience in 215 patients.
Med. 2006;38(5):396–402. Ann Thorac Surg. 2003;76(5):1687–192; discussion 92–93.
7. Abbas G, Pennathur A, Keeley SB, et al. Laser ablation therapies 21. Heier SK, Rothman KA, Heier LM, et al. Photodynamic therapy
for Barrett’s esophagus. Semin Thorac Cardiovasc Surg. 2005; for obstructing esophageal cancer: Light dosimetry and rand-
17(4):313–319. omized comparison with Nd:YAG laser therapy. Gastroenterol-
8. Dougherty TJ, Kaufman JE, Goldfarb A, et al. Photoradiation ogy. 1995;109(1):63–72.
therapy for the treatment of malignant tumors. Cancer Res. 22. Overholt BF, Panjehpour M, Haydek JM. Photodynamic therapy
1978;38(8):2628–2635. for Barrett’s esophagus: Follow-up in 100 patients. Gastrointest
9. Dougherty TJ, MacDonald IJ. Basic principles of photodynamic Endosc. 1999;49(1):1–7.
therapy. J Porphyrins Phthalocyanines. 2001;5(2):105–129. 23. Krishnadath KK, Wang KK, Taniguchi K, et al. Persistent genetic
10. Ackroyd R, Kelty C, Brown N, et al. The history of photodetec- abnormalities in Barrett’s esophagus after photodynamic ther-
tion and photodynamic therapy. Photochem Photobiol. 2001; apy. Gastroenterology. 2000;119(3):624–630.
74(5):656–669. 24. Van Laethem JL, Peny MO, Salmon I, et al. Intramucosal adeno-
11. Basu KK, Pick B, Bale R, et al. Efficacy and one year follow up carcinoma arising under squamous re-epithelialisation of
of argon plasma coagulation therapy for ablation of Barrett’s Barrett’s oesophagus. Gut. 2000;46(4):574–577.
oesophagus: Factors determining persistence and recurrence of 25. Ban S, Mino M, Nishioka NS, et al. Histopathologic aspects of pho-
Barrett’s epithelium. Gut. 2002;51(6):776–780. todynamic therapy for dysplasia and early adenocarcinoma arising
12. Kahaleh M, Van Laethem JL, Nagy N, et al. Long-term follow-up in Barrett’s esophagus. Am J Surg Pathol. 2004;28(11):1466–1473.
and factors predictive of recurrence in Barrett’s esophagus 26. Greenwald BD, Dumot JA. Cryotherapy for Barrett’s esophagus and
treated by argon plasma coagulation and acid suppression. esophageal cancer. Curr Opin Gastroenterol. 2011;27(4):363–367.
Endoscopy. 2002;34(12):950–955. 27. Greenwald BD, Dumot JA, Abrams JA, et al. Endoscopic spray
13. Van Laethem JL, Cremer M, Peny MO, et al. Eradication of Bar- cryotherapy for esophageal cancer: Safety and efficacy. Gastroin-
rett’s mucosa with argon plasma coagulation and acid suppres- test Endosc. 2010;71(4):686–693.
sion: Immediate and mid term results. Gut. 1998;43(6):747–751. 28. Shaheen NJ, Greenwald BD, Peery AF, et al. Safety and efficacy
14. Hoffmann NE, Bischof JC. The cryobiology of cryosurgical of endoscopic spray cryotherapy for Barrett’s esophagus with
injury. Urology. 2002;60(2 suppl 1):40–49. high-grade dysplasia. Gastrointest Endosc. 2010;71(4):680–685.
LWBK1254-ch32_p363-372.indd 372 19/02/14 10:31 PM

33 Endoscopic Mucosal
Resection
Toshitaka Hoppo and Blair A. Jobe
Endoscopic resection is a minimally invasive, organ-preserving technique to endo-
scopically remove premalignancy or early-stage cancer arising from the gastrointesti-
nal epithelium as a mucosal–submucosal complex. Patients with no risk of lymph
node involvement or lower risk for developing lymph node metastasis compared with
the risk of mortality from surgery are ideal candidates for endoscopic treatments such
as endoscopic resection and ablation therapy. Unlike endoscopic ablation therapy,
such as radiofrequency ablation and cryoablation, endoscopic resection can provide
specimens for complete histologic assessment including depth of cancer invasion,
degree of cellular differentiation, and lymphovascular invasion. Accurate staging
based on the histologic assessment is crucial to assess the risk of lymph node involve-
ment and determine whether endoscopic treatment is appropriate for the individual
patient. For the purposes of staging, the mucosal and submucosal layers have been
subdivided into thirds with each third going deeper into the gastrointestinal wall. As
such, T1 tumors have six different layers of invasion: T1m1–m3 (m1 = limited to the
epithelial layer, m2 = invades into the lamina propria, m3 = invades into but not
through the muscularis mucosa) and T1sm1–sm3 (different thirds of the submucosa)
(Fig. 33.1).
Indications for endoscopic resection for each type of esophageal cancer are sum-
marized in Tables 33.1 and 33.2. For esophageal high-grade dysplasia (HGD) and intra-
mucosal adenocarcinoma, esophagectomy has been recommended as a standard of care
based on the fact that HGD is likely to progress to cancer and unexpected cancer is
found in approximately 40% of surgically resected specimens obtained from patients
with the preoperative diagnosis of only HGD. However, the rate of lymph node involve-
ment is low (<10% for intramucosal cancer) and endoscopic resection can be a good
option in some patients to avoid unnecessary, invasive surgery, particularly, in patients
with medical comorbidities. It is crucial to differentiate patients at higher risk for
progression or for having concomitant invasive cancer with possible lymph node
involvement based on the criteria of low- and high-risk factors (Table 33.1). Patients
with high-risk for progression will likely be better treated with esophagectomy. Low-
risk factors include unifocal (limited or focal) or flat HGD, type I, IIa <2 cm, IIb, IIc
373
LWBK1254-ch33_p373-382.indd 373 19/02/14 7:01 PM

m1 m2 m3 sm1 sm2 sm3

m1
Epithelium m2
m3
Lamina propria
Muscularis mucosa
sm1
Submucosa
Muscularis sm2
propria
sm3
Figure 33.1 Subdivision of early cancers of the gastrointestinal tract based on the depth of invasion. Left panel: Scheme of the gas-
trointestinal wall. m1, intramucosal cancers; m2, cancer invasion to the lamina propria; m3, cancer invasion into the muscularis
mucosa. The submucosa is divided into thirds; sm1, to the upper third; sm2, to the middle third; and sm3, to the lower third. Right
panel: The corresponding histologic appearance. (Reproduced from Witteman BP, Foxwell TJ, Monsheimer S, et al. Transoral
endoscopic inner layer esophagectomy: management of high-grade dysplasia and superficial cancer with organ preservation.
J Gastrointest Surg. 2009;13:2104–2112, with permission.)
<1 cm, well or moderately differentiated adenocarcinoma, mucosal cancer (m) and no
lymphovascular invasion. Esophageal squamous cell cancer appears to be biologically
more aggressive compared with adenocarcinoma and the risk of lymph node involve-
ment appears higher in patients with squamous cell cancer. Intraepithelial cancers (m1)
and cancers invading the lamina propria (m2) are associated with almost no risk of
lymph node metastasis. However, the risk of lymph node involvement in cancers
invading the muscularis mucosa (m3) and the submucosa ranges from 0% to 10% and
50% to 55%, respectively. Therefore, endoscopic resection can be indicated for super-
ficial well or moderately differentiated squamous cell carcinoma (SCC) limited to the
lamina propria (m1–m2). Patients with cancers invading the muscularis mucosa (m3)
may be treated endoscopically if there are no further risk factors for lymph node
involvement. However, patients with submucosal invasion should be considered for
surgery (Table 33.2).
Endoscopic resection includes two techniques: Endoscopic mucosal resection
(EMR) and endoscopic submucosal dissection (ESD). Overall, EMR is commonly used
as both a diagnostic as well as a therapeutic tool for the tumor <2 cm in diameter, and
ESD is considered for en bloc resection when the diameter of tumors is >2 cm. In any
situation, en bloc resection is ideal. Piecemeal resection is acceptable, but is associated
with the high rate of metachronous lesions due to incomplete resection and compro-
mised histologic assessment.
T able 3 3 . 1 Factors to Consider for Endoscopic Resection of High-grade Dysplasia

(HGD) and Intramucosal Adenocarcinoma
Indications Relative Contraindications
Low-risk for Progression High-risk for Progression
Unifocal (limited or focal), flat HGD Multifocal HGD, HGD with nodules
Type I, IIa <2 cm, IIb, IIc <1 cm Type I, II >3 cm, Type III
Well or moderately differentiated adenocarcinoma Poorly differentiated adenocarcinoma
Lesions limited to the mucosa (m) Invasion into the submucosa (sm)
No lymphovascular invasion Presence of lymphovascular invasion
Type I, polypoid type; IIa, flat, elevated; IIb, level with the mucosa; IIc, slightly depressed; III, ulcerated type.
LWBK1254-ch33_p373-382.indd 374 19/02/14 7:02 PM

Chapter 33 Endoscopic Mucosal Resection 375
T able 3 3 . 2 Indications for Endoscopic Resection of Esophageal Squamous Cell

Carcinoma (SCC)

Indications Relative Contraindications
Low-risk for Progression High-risk for Progression
and Resection
No consensus on the maximal size
Well or moderately differentiated SCC Poorly differentiated SCC
Limited to the lamina propria (m1–m2) Invasion into the deeper layer than the muscularis mucosa (m3, sm)
No lymphovascular invasion Presence of lymphovascular invasion
Accurate endoscopic examination and clinical staging are essential to select patients
who are appropriate candidates for endoscopic resection. It is crucial to exclude patients
with high risk of lymph node involvement or metastatic disease. Therefore, preoperative
work-up should include endoscopic ultrasound (EUS), and positron emission tomography/
computed tomography (PET/CT) to assess lymph node involvement and metastatic dis-
ease, in addition to the careful evaluation of extension of the tumor using advanced
imaging techniques such as high-resolution endoscopy, chromoendoscopy, or narrow-
band imaging. A diagnostic endoscopic resection can be included for staging. The depth
of tumor invasion is highly associated with the likelihood of lymph node metastasis.
The role of EUS is to exclude lymph node metastasis and to determine the depth
of tumor invasion. It has been shown that EUS can accurately differentiate T1 and T2
tumors but not T1a (m cancer) and T1b (sm cancer) with the current technology. Even
the high-frequency miniprobe (20 or 30 MHz) still has a limited accuracy to discrimi-
nate between T1a and T1b tumors. Because EUS may not be sufficiently reliable to
exclude submucosal invasion in early cancers, the EMR must be diagnostic for this
staging purpose. EMR provides specimens for histologic analysis including both mucosa
and submucosa, and can reliably determine the T stage of suspicious lesions (i.e., dif-
ferentiating T1a from T1b). A positive lateral margin can be addressed with further
endoscopic intervention, but a positive deep margin should be addressed with surgery.
Because PET/CT has been shown to be less accurate than EUS in determining nodal
staging but EUS is ineffective in detection of distant metastasis, these modalities should
be used in combination during the preoperative work-up. The major role of PET/CT is
to confirm the absence of metastatic disease.
Endoscopic resection often requires several sessions. In addition, an intensive fol-
low-up endoscopy is required. Strict acid suppression with high-dose proton pump
inhibitors (PPIs) and/or H2 blockade is critical to allow the resected area to heal to
normal “neosquamous” epithelium, especially in patients with esophageal HGD or
intramucosal adenocarcinoma. These points should be discussed with patients prior to
the initiation of treatment.
Surgery
Endoscopic resection can be performed under deep sedation using the combination
of narcotics and short-acting benzodiazepines in either the GI laboratory or the oper-
ating room. ESD often requires a longer time to complete and the general anesthesia
in the operating room should be considered. As is typical for endoscopy, the patient
is placed in the left lateral decubitus position with the proper monitoring such as
cardiogram, blood pressure, and percutaneous oxygen saturation. At the beginning of
the procedure, it is important to re-evaluate the extension of the lesions. Placement
of an overtube may be useful to keep an easy access to the lesions and facilitate the
following procedure.
LWBK1254-ch33_p373-382.indd 375 19/02/14 7:02 PM

C
D
Figure 33.2 Four types of endoscopic mucosal resection (EMR) techniques. A: Snare polypectomy. B: Strip biopsy technique.
C: The cap resection technique. D: The ligate-and-cut technique.
Endoscopic Mucosal Resection

Although several EMR techniques have been introduced (Fig. 33.2), two methods com-
monly used for EMR are the endoscopic cap resection technique (Fig. 33.2C) and the
ligate-and-cut technique (Fig. 33.2D). These two methods were found to be similarly
efficacious in a randomized trial. Both methods start with injection of normal saline or
diluted epinephrine into the submucosal space to lift the lesions away from the mus-
cularis propria. The injection needle should be inserted into the submucosal space at
a sharp angle to avoid transmural penetration of the needle. Injected saline acts as a
“safety cushion” between the mucosa and the muscle layer to prevent mechanical or
electrocautery damage to the deep layers of the gastrointestinal tract wall. However, the
injected saline disappears within a few minutes and the repeat injection of saline
should be considered to reduce the risk of unexpected complications, such as perfora-
tion, during the procedure. Marking the tumor margin using an electrocautery may be
helpful to guide accurate resection after the submucosal injection of saline. For the cap
resection technique, a clear plastic cap is attached to the tip of the forward-viewing
endoscope, and the endoscope is introduced through the overtube if an overtube has
been placed. The caps are available with flat, circular (straight)- or oblique-shaped tips
both with outer diameters ranging from 12.9 to 18 mm (Fig. 33.3). The oblique caps are
usually used for esophageal lesions, whereas the straight caps are most commonly used
in the stomach and colon. Mucosa and submucosa are sucked into the cap to create a
pseudopolyp and a specially designed crescent-shaped electrocautery snare positioned
inside the cap is then closed to resect the pseudopolyp. For the ligate-and-cut tech-
nique, suction is applied to retract the lesion into the banding device, and a band is
deployed to create a pseudopolyp. The pseudopolyp is then resected by being captured
at its base using an electrocautery snare. This technique requires the repeated with-
drawal and insertion of the endoscope for band ligation and subsequent resection. A
novel multiband mucosectomy device (Duette, Cook Medical Inc., Bloomington, IN),
LWBK1254-ch33_p373-382.indd 376 19/02/14 7:02 PM

Figure 33.3 Several sizes and

types of caps for endoscopic cap

resection technique. A: Straight
type is most commonly used in the
stomach and colon. B: Oblique-
shaped cap is usually used for
esophageal lesions. (Reproduced
and Resection
from Gotoda T. Endoscopic resection
of early gastric cancer. Gastric
Cancer 2007;10:1–11, with
permission.)
A B
which uses a specially designed 6-band ligator, has been commonly used in our practice
(Fig. 33.4). Because a snare wire can be passed through the ligator handle, the band
deployment for ligation and subsequent resection can be performed immediately with-
out withdrawal of the endoscope. Two sizes of ligating caps are available to fit endo-
scopes with outer diameters of 9.5 to 13 mm and 11 to 14 mm. Regardless of the EMR
technique employed, residual Barrett’s esophagus (BE) or HGD after EMR should be
treated with endoscopic ablation.
Endoscopic Submucosal Dissection

ESD has been established in Japan for en bloc resection of tumors greater than 2 cm in
diameter, thus allowing more accurate histologic evaluation of the lateral and deep
margins of the lesion, and potentially preventing the development of metachronous
Figure 33.4 A multiband mucosec-

A B tomy device (Duette, Cook Medi-
cal Inc.). A: This device uses a
specially designed 6-band ligator.
B: A band is deployed to create a
pseudopolyp. C and D: A snare
wire is placed below the band and
the pseudopolyp is resected.
(Permission for use granted by
Cook Medical Incorporated,
Bloomington, Indiana.)
C D
LWBK1254-ch33_p373-382.indd 377 19/02/14 7:02 PM

Lesion
M
SM
MP
A D
B E
C F
Figure 33.5 Schematic representation of endoscopic submucosal dissection. A: Mucosal markings for the incision line.
B: Submucosal injections of a solution. C: Complete elevation of the lesion by injecting a solution into the submucosal space.
D: Mucosal incision around the mucosal markings. E: Submucosal dissection with a needle knife through the cap attached
on the tip of endoscope. F: En bloc resection of the tumor. M, mucosa; SM, submucosa; MP, muscularis propria.
lesions. The procedure is usually performed in several steps (Fig. 33.5 and 33.6). Since
ESD targets larger lesions (>2 cm), marking around the lesion using an electrocautery
is particularly important to guide the successful en bloc resection. After the markings
are placed (Fig. 33.6A), the lesion should be lifted away from the muscularis propria
by injecting a solution into the submucosal space. The injection solutions for ESD
include normal saline, glycerol solution, and sodium hyaluronate solution. Sodium
hyaluronate solution stays in the submucosal space longer than other solutions so that
the submucosal plane can be effectively visible during the submucosal dissection.
Diluted sodium hyaluronate (∼0.5% solution) is usually mixed with epinephrine (0.01
mg/mL) and indigo carmine (0.04 mg/mL). At this point, the mucosal cutting, ∼5 mm
outside the markings, is performed using a specialized endoscopic electrocautery nee-
dle knife (Fig. 33.6B). Several types of needle knife having the different-shaped tips
have been introduced and are available in Japan (Fig. 33.7). However, only one type of
needle knife (Olympus America Inc., Center Valley, PA) is currently available in the
United States. Once the access to the submucosal space is achieved, tension and coun-
tertension are maintained by an endoscope-mounted cap, which is placed in the plane
between the mucosal–submucosal complex and the muscularis propria. The submu-
cosal dissection is then carried out using the needle knife by dissecting the attachments
and bridging vessels between these two layers (Fig. 33.6C). At the completion of the
procedure, the tumor can be resected en bloc regardless of its size and the remaining
thin layer of sm3 is observed over the muscle layer (Fig. 33.6D). It is important to
LWBK1254-ch33_p373-382.indd 378 19/02/14 7:02 PM

Figure 33.6 Endoscopic submu-

A B cosal dissection of early esopha-

geal SCC. A: Chromoendoscopy
showed the presence of an irreg-
ular unstained area in the middle
esophagus. Markings were made
using an electrocautery. B: After
and Resection
the submucosal injection of
sodium hyaluronate, the submu-
cosal dissection plane becomes
apparent, and dissection can
begin. C: The entry for submu-
cosal dissection was created and
submucosal dissection was per-
formed using the needle knife. D:
The tumor was resected en bloc.
A thin layer of sm3 was observed
C D over the muscle layer. E: The
resected specimen was spread
out and pinned on a flat cork.
Figure 33.7 Different types of needle

knives for endoscopic submucosal
dissection. A: Insulation-tipped
diathermic electrosurgical knife
(IT knife). B: Hook knife. C: Flex knife.
D: Triangle-tip knife (TT knife).
A B C D
LWBK1254-ch33_p373-382.indd 379 19/02/14 7:02 PM

preserve this thin layer to avoid the damage to the muscle layer. ESD is a “one-person”
procedure and the surgeon cannot use an assistant’s hands. Therefore, it is critical to
maintain somehow the adequate countertraction on the resecting mucosa throughout
the procedure. For this purpose, a partial mucosal incision should be made rather than
a circumferential mucosal incision, and mucosal incision and submucosal dissection
should be repeated step by step. To take advantage of gravity, mucosal incision and
subsequent submucosal dissection should be started from the upper portion of lesion,
so that the dissected mucosa is pulled down by gravity and the submucosal layer can
be exposed spontaneously. The position of patient can be changed to move the lesion
to an appropriate position to take advantage of gravity.
Handling of Resected Specimens

Accurate staging can only be achieved when the specimen is properly oriented by the
endoscopist or the assistant immediately after excision, prior to the specimen being
immersed in formalin solution. For this purpose, the specimen should be spread out
and pinned on a flat cork (Fig. 33.6E). Fixed specimens should be sectioned serially at
2-mm intervals parallel to a line that includes the closest resection margin of the spec-
imen, so that both lateral and deep margins can be assessed. The depth of tumor inva-
sion is then evaluated in conjunction with the degree of differentiation and the lymphatic
or vascular involvement.
Patients should be observed in the recovery room until they awaken. Repetitive, careful,
physical examination is important to exclude subcutaneous emphysema and chest or
abdominal pain suspicious for perforation. For patients who underwent EMR, no fur-
ther examinations, such as chest x-rays or blood tests, are required if there is no evi-
dence of bleeding or perforation, and they can be discharged on the same day of the
procedure. For patients who underwent ESD, a chest x-ray or an upper GI contrast study
is often required depending on the intraoperative findings and patient’s condition.
Patients are instructed to stay on the liquid diet for 24 hours and then advance to the
regular diet as tolerated. Temporal antisecretory medication, such as PPIs or H2 block-
ers, should be prescribed. Especially for patients with BE or esophageal adenocarci-
noma, strict acid suppression with the maximal dose of PPIs and nocturnal H2 blockade
is critical for the normal tissue healing process.
Currently, there is no consensus on the optimal protocol for the follow-up after
endoscopic resection. Most patients should be closely followed with multiple follow-up
endoscopies and serial treatments, if needed. Our current approach is to perform the
first follow-up endoscopy 6 weeks after endoscopic resection to ensure that normal tis-
sue healing occurs, and to repeat endoscopic surveillance with biopsies every 3 months.
Complications
The most frequent complication of endoscopic resection is bleeding, ranging from 1%
to 45% with average rates of 10% in larger series. Most bleeding occurs intraoperatively
or within the first 24 hours. Delayed bleeding has been reported in approximately 14%
of patients. Bleeding can be addressed by grasping and coagulation of the bleeding ves-
sels using hot biopsy forceps. Endoclips can be deployed for severe bleeding. The most
serious complication is perforation. The perforation rate during ESD has been reported
to be much higher compared with that during EMR (4%–10% vs. 0.3%–0.5%, respec-
tively). Small perforations recognized during the procedure can be addressed by deploying
LWBK1254-ch33_p373-382.indd 380 19/02/14 7:02 PM

endoclips. However, large perforations require an emergent surgery to avoid peritonitis

or mediastinitis. In addition, another major complication of ESD is stenosis due to

stricture formation. Stenosis is more likely to occur after ESD for esophageal lesions
(up to 26%). Esophageal stricture can cause severe dysphagia and sometimes requires
multiple sessions of dilation. Because of the high rates of perforation and stenosis, ESD
and Resection
has not been widely accepted especially for esophageal lesions.
Results
Esophageal High-grade Dysplasia and Intramucosal

Adenocarcinoma
Long-term follow-up data of endoscopic resection in patients with esophageal HGD
and intramucosal adenocarcinoma are limited. In the only available large prospective
study with long-term follow-up, Pech et al. investigated the efficacy, safety, and risk
factors for recurrence in 349 patients with HGD and intramucosal adenocarcinoma
who received endoscopic therapy with curative intent (279 underwent EMR). During
a mean follow-up of 5 years, complete response (CR; defined as an R0 resection and
one normal endoscopic follow-up evaluation) was achieved in 96.6% of patients and
surgery was required in only 3.7% of patients. Importantly, in patients who received
ablation therapy for the remaining nonneoplastic field of BE, 16.5% developed a met-
achronous neoplasia during the follow-up, compared with 28.3% in the group that
did not receive ablation. The rate of bleeding (major and minor) was 12%, and the
rate of stenosis was 4.3%. Risk factors for recurrence of early esophageal cancer after
endoscopic resection included piecemeal resection, long-segment BE, no ablative
therapy of Barrett’s lesion after CR, time until CR achieved >10 months, and multifo-
cal neoplasia (Table 33.3).
Esophageal Squamous Cell Carcinoma

Excellent results with a low complication rate and a good disease-specific 5-year sur-
vival rate for the endoscopic resection of esophageal SCC have been reported. In the
most recent retrospective cohort study by Ciocirlan et al., 51 patients with either dys-
plasia or mucosal (m) cancer underwent repeated EMR until complete local remission
was achieved. Complete response was achieved in 91% of patients and the disease-
specific 5-year survival rate was 95%. There were no perforations, but minor bleeding
was observed in 17% of patients and three patients (6%) developed mild stenosis
requiring dilation. During the follow-up period, local disease recurrence was observed
in 26% of patients.
T able 3 3 . 3 Risk Factors Potentially Associated with Recurrence after Endoscopic

Resection of Early Esophageal Cancer
Risk Factors for Recurrence after Endoscopic Resection of Early Esophageal Cancer
1. Piecemeal resection
2. Long-segment BE
3. No ablation therapy of BE after CR
4. Time until CR achieved >10 mo
5. Multifocal neoplasia
BE, Barrett’s esophagus; CR, complete response (defined as an R0 resection and one normal endoscopic follow-up evaluation).
Modified from Pech O, Behrens A, May A, et al. Long-term results and risk factor analysis for recurrence after curative endo-
scopic therapy in 349 patients with high-grade intraepithelial neoplasia and mucosal adenocarcinoma in Barrett’s oesophagus.
Gut. 2008;57(9):1200–1206.
LWBK1254-ch33_p373-382.indd 381 19/02/14 7:02 PM

Conclusions
Endoscopic resection, such as EMR and ESD, is a minimally invasive, organ-preserving
approach to treat premalignancy or early-stage cancer in the gastrointestinal tract. Accu-
rate staging is crucial to avoid inappropriate endoscopic treatments in patients with a
high risk of lymph node involvement and metastatic disease. Overall, the outcomes of
endoscopic resection are acceptable. However, endoscopic resection is highly associated
with the development of metachronous lesions especially when tumors cannot be
resected en bloc, and an intensive endoscopic follow-up is therefore required. ESD has
been introduced as a promising technique to resect the larger tumors (>2 cm) en bloc.
However, ESD is a time-consuming procedure and requires highly advanced skills. In
addition, ESD is still associated with the high rate of complications such as perforation,
bleeding, and stenosis. A large, prospective, randomized-controlled trial with a long-
term follow-up will be required to determine the true benefit of ESD. In addition,
advanced instrumentation, especially the needle knife, is an important component for
successful ESD. Further refinement of devices to enhance the safety of ESD is needed.
Recommended References and Readings stage cancer of the esophagus. Gastrointest Endosc. 2003;58(2):
167–175.
1. ASGE technology committee, Kantsevoy SV, Adler DG, et al. 6. Pech O, Behrens A, May A, et al. Long-term results and risk fac-
Endoscopic mucosal resection and endoscopic submucosal distor analysis for recurrence after curative endoscopic therapy in
section. Gastrointest Endosc. 2008;68(1):11–18. 349 patients with high-grade intraepithelial neoplasia and
2. Ciocirlan M, Lapalus MG, Hervieu V, et al. Endoscopic mucosal mucosal adenocarcinoma in Barrett’s oesophagus. Gut. 2008;
resection for squamous premalignant and early malignant lesions 57(9):1200–1206.
of the esophagus. Endoscopy. 2007;39(1):24–29. 7. Pech O, May A, Gossner L, et al. Curative endoscopic therapy in
3. Ell C, May A, Pech O, et al. Curative endoscopic resection of patients with early esophageal squamous-cell carcinoma or high-
early esophageal adenocarcinomas (Barrett’s cancer). Gastrointest grade intraepithelial neoplasia. Endoscopy. 2007;39(1):30–35.
Endosc. 2007;65(1):3–10. 8. Soetikno R, Kaltenbach T, Yeh R, et al. Endoscopic mucosal
4. Inoue H, Sato Y, Sugaya S, et al. Endoscopic mucosal resection resection for early cancers of the upper gastrointestinal tract.
for early-stage gastrointestinal cancers. Best Pract Res Clin Gas- J Clin Oncol. 2005;23(20):4490–4498.
troenterol. 2005;19(6):871–887. 9. Yamamoto H. Technology insight: Endoscopic submucosal dis-
5. May A, Gossner L, Behrens A, et al. A prospective randomized section of gastrointestinal neoplasms. Nat Clin Pract Gastroen-
trial of two different endoscopic resection techniques for early terol Hepatol. 2007;4(9):511–520.
LWBK1254-ch33_p373-382.indd 382 19/02/14 7:02 PM

Part VI
Miscellaneous
Esophageal
Procedures
34 Esophageal Stents
Matthew J. Schuchert
Introduction
The primary goals of palliation in patients with unresectable esophageal cancer include
the relief of dysphagia and the maintenance of oral intake; management of complica-
tions; relief of pain; and prevention of reflux, regurgitation and aspiration, while mini-
mizing the length of hospital stay and maximizing quality of life.1 Although a variety
of treatment options exist (including photodynamic therapy [PDT], chemotherapy, radi-
ation therapy, brachytherapy, and laser ablation), esophageal stenting provides immedi-
ate and durable results in the majority of patients (Table 34.1). A combination of
modalities can be employed to maximize the palliative effects if needed.
Stenting of the esophagus is the most commonly used first-line modality to palliate
dysphagia and prevent malnutrition secondary to esophageal and proximal gastric can-
cers (Fig. 34.1).1 Over the last two decades, there has been a dramatic evolution in stent-
ing technology that has broadened its application in the management of a variety of
malignant and benign esophageal conditions. The repertoire of available devices includes
rigid plastic conduits as well as self-expandable metal and plastic stents. Uncovered
stents have the advantage of better purchase on the esophageal wall, thus limiting stent
migration. However, they allow (and even stimulate) tumor and granulation tissue
ingrowth. Expandable stents may be covered with a plastic coating to retard tissue
ingrowth, but have an increased risk of stent migration. Stent selection is tailored to
the individual patient, and is dependent on such variables as tumor length, bulk, and
location. Deployment is achieved under simultaneous fluoroscopic and endoscopic guid-
ance. Stents are highly effective in palliating dysphagia in the setting of esophageal
malignancy, but can be associated with a substantial complication rate, predominantly
due to the patient’s poor functional and nutritional status as well as the extent of the
underlying esophageal disease.2 In this chapter, we review the indications, technique,
and outcomes of esophageal stenting for both malignant and benign esophageal diseases.
Indications
Current indications for stent placement approved by U.S. Food and Drug Administra-
tion include the palliation of esophageal obstruction and tracheoesophageal fistulas
secondary to malignancy. Other less common applications for esophageal stent place-
ment include dysphagia secondary to external compression by benign neoplasms,
benign strictures, and esophageal leak or perforation.
383
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384 Part VI Miscellaneous Esophageal Procedures
Ta b l e 3 4 . 1 Available Modalities for the Palliation of Dysphagia from

Esophageal Cancer
Stent placement
Laser therapy (Nd:YAG; photodynamic therapy)
Radiation therapy (External beam; intraluminal brachytherapy)
Chemotherapy
Dilation
Electrocoagulation (BICAP Probe)
Chemical injection therapy
Best supportive care (nutritional support, feeding tube)
Adapted from: Homs MV, Kuipers EJ, Siersema PD. Palliative therapy. J Surg Oncol. 2005;92:246–256.
The most common indication for esophageal stent insertion is relief of dysphagia in
the setting of unresectable esophageal cancer. The majority of newly diagnosed patients
with esophageal cancer have advanced disease at the time of diagnosis, with dismal
5-year survival rates of less than 20%.3 Palliation of dysphagia, therefore, becomes a
paramount component of care in this setting. Stents provide safe and expeditious relief
of dysphagia, thereby enhancing the patient’s nutritional status and quality of life. Dys-
phagia can also result from obstructing lesions of the esophagus related to adjacent lung
cancer or mediastinal lymphadenopathy due to extrinsic compression. Benign, refractory
strictures related to peptic ulcer disease or prior caustic injury can be treated with stent
insertion in selected cases. Stent placement may be either temporary or permanent,
depending upon the clinical circumstances. In the setting of malignancy, temporary
stents represent useful adjuncts prior to surgical resection by relieving dysphagia and
enhancing nutrition. However, we have noted, as have others, that expandable metal
Figure 34.1 Esophageal stent insertion

for malignant disease.
Cancer
Stent
LWBK1254-ch34_p383-400.indd 384 19/02/14 8:00 AM

Chapter 34 Esophageal Stents 385
stents deployed prior to chemotherapy and radiation therapy have been associated with
significant esophageal fibrosis, and even perforation, that can cause significant technical
difficulties during subsequent surgical resection. Thus, we recommend avoiding esopha-
geal stents in the setting of planned chemotherapy and radiation therapy in the neoad-
juvant setting. Temporary stent placement has been successful when used selectively in
the management of perforations, leaks, and benign strictures.
Special Considerations
Bridge to surgery: Esophageal stents can be utilized as a temporary measure to enhance
oral intake in preparation for definitive surgical resection. Potential limitations of
the use of partially covered and uncovered nonremovable stents in this setting include
the finding of increased periesophageal desmoplastic reaction that can obscure tissue
planes and make the planned surgery difficult. This is especially notable in the setting
of neoadjuvant therapy (chemotherapy, chemoradiation). Some authors have suggested
that the concomitant use of esophageal stents during chemotherapy and radiation ther-
Part VI: Miscellaneous Esophageal

apy may be associated with an increased risk of complications including migration,
bleeding, and fistulization.4,5 Fully covered stents can be placed preoperatively and
removed prior to surgery during the course of neoadjuvant therapy to minimize the risk
of these delayed complications.6 In our experience, the combination of chemotherapy
Procedures
and radiation has been the most problematic in the setting of an expandable metal stent
in the esophagus.
Proximal esophageal cancer: Esophageal stents can be employed in the proximal
esophagus to relieve esophageal obstruction and control fistulae. The use of stents in
this setting can be limited due to patient intolerance secondary to pain and globus
sensation, as well as airway compression.7 Stent positioning distal to the cricopharyn-
geus is critical in minimizing the risk of these symptoms. Performing flexible bronchos-
copy before placing a stent for proximal obstructing esophageal cancers can be helpful
in minimizing complications of airway compression. In some cases, we place a guidewire
and a Savary dilator of the approximate size of the planned esophageal stent, then flex-
ible bronchoscopy can be performed to assess airway compression. If airway compres-
sion is present, it may be prudent to consider an alternative mode of palliating the
proximal esophageal obstruction, such as PDT, or even a smaller stent. In some cases,
we have placed an airway stent at the same setting to maintain airway patency.
Antireflux valves: For tumors involving the gastroesophageal (GE) junction, stent
placement can lead to the development of severe reflux symptoms due to compromise
of the lower esophageal sphincter valve mechanism. Several stent modifications have
been developed in an attempt to create an antireflux valve mechanism. Dua et al.8
reported a significant improvement in reflux in patients treated with a modified Z stent
containing a windsock valve. Results from randomized studies, however, are mixed.
Laasch et al.9 demonstrated a significant reduction (12% vs. 96%, p < 0.001) in reflux
among 50 patients receiving either the Dua-modified Z stent compared with those
treated with the Flamingo Wallstent. In another study evaluating the effectiveness of an
S-shaped antireflux valve (Dostent, MI Tech Co. Ltd., Incheon, South Korea), the frac-
tion of time with an intraesophageal pH < 4 was 3% in the group with the antireflux
stent and 15% in the group with self-expanding metallic stents (SEMS).10 Other rand-
omized trials, however, have failed to demonstrate improvement in reflux symptoms or
objective measures of gastroesophageal reflux during pH testing with the use of antire-
flux valves.11,12 As a result of these disparate findings, antireflux valves are not routinely
used during esophageal stenting in the setting of malignancy.
Drug-eluting stents: Drug-eluting stents have been developed in an attempt to min-
imize tissue ingrowth in partially covered stents.13 This type of stent is not currently
available for use in humans.
Biodegradable stents: Stents composed of biodegradable material (knitted poly-L-
lactic acid monofilaments) have been used to prevent stricture formation following large
area endoscopic mucosal resection.14 Another biodegradable stent model (Ella-CS) has
been studied in Europe for the treatment of benign disease.15 Biodegradable stents have
LWBK1254-ch34_p383-400.indd 385 19/02/14 8:00 AM

the advantage of potentially reducing the need for repeat endoscopy to accomplish stent
removal.
Stent Design
Prior to 1990, virtually all esophageal stents were composed of polyvinyl plastic or rubber.
These early stents were cumbersome and very difficult to place, requiring insertion at
the time of open surgery or during rigid endoscopy. With the introduction of SEMS, the
use of rigid stent prostheses fell out of favor. SEMS are easier to deploy, achieve a wider
luminal diameter and are associated with a reduced periprocedural complication rate
(including mortality).16 Although the cost of SEMS is greater than rigid prostheses, the
need for repeat interventions is less, leading to an overall reduced cost over the limited
expected lifetime of a patient with advanced esophageal cancer.17
Most SEMS that are currently available today are constructed with Nitinol (a com-
posite of nickel and titanium), which is a highly elastic alloy with intrinsic properties
of elasticity and shape memory that allow conformation to varying degrees of stenosis
and angulation. The application of these pliable constructs allows the use of a lower
profile delivery system while achieving efficient transmission of adequate radial force
upon stent expansion. Initially, all SEMS were uncovered (Fig. 34.2A). Examples of
uncovered stents include the Ultraflex uncovered esophageal stent and the Microvasive
Wallstent I (Boston Scientific, Natick, MA). Uncovered stents expand radially and incor-
porate into the wall of the esophagus with time.18 This incorporation effect dramatically
reduces the potential for stent migration seen with rigid plastic prostheses and with
covered metal stents. However, the open spaces within the interstices of the uncovered
metallic stent permit the ingrowth of granulation tissue or tumor leading to recurrent
symptoms of dysphagia in 13% to 26% of cases.19
A B
Figure 34.2 Uncovered (A) and Covered (B) expanding metallic stent. (From: Perry Y, Luketich JD. The use of esophageal
stents. Cameron JL, ed. Current Surgical Therapy. 8th ed. Philadelphia, PA: Mosby; 2004:49–55.)
LWBK1254-ch34_p383-400.indd 386 19/02/14 8:00 AM

Figure 34.3 Partially covered self-

expanding metallic stents. (A) Wallflex,
(B) Z stent with Dua anti-reflux valve,
(C) Ultraflex, (D) Wallstent, (E) Evolution.
(From: Schembre D. Advances in
esophageal stenting: The evolution of
fully covered stents for malignant and
benign disease. Adv Ther. 2010;27(7):
413–425.)
C D E
A B

To minimize the occurrence of tumor ingrowth and the development of esophageal
erosions or tracheoesophageal fistulas, stents were developed that were partially cov-
ered with silicone, polyurethane, or other polymers (Fig. 34.2B). Current designs main-
Procedures
tain a 1- to 1.5-cm margin of exposed wire struts on the proximal and distal flanges of
the stent to optimize stent purchase and permit integration into the esophageal wall
(Fig. 34.3). The use of a covered stent has been shown to significantly decrease the
severity of tumor ingrowth and consequent dysphagia, but is associated with a slightly
higher migration rate. In a large retrospective analysis of 152 patients who underwent
either uncovered (n = 54) or covered (n = 98) SEMS placement, uncovered stents were
associated with reduced migration (0% vs. 10 %, p = 0.04) but were also associated
with a significantly increased rate of tissue ingrowth (100% vs. 53%, p < 0.0001) and
a markedly higher restenosis rate resulting in recurrent dysphagia (37% vs. 8%, p <
0.0001).20 In a prospective, randomized comparison of 62 patients with inoperable GE
junction tumors treated with either covered or uncovered stents, a significantly higher
reintervention rate was noted in patients with uncovered stents compared with covered
stents (27% vs. 0%). There was comparable relief of dysphagia between groups. Tumor
ingrowth or granulation tissue was more commonly encountered in the uncovered stent
group (30% vs. 3%, p = 0.005). There was no difference in survival noted between
groups.19 Although this new generation of covered stents dramatically reduced tumor
ingrowth, mucosal hyperplasia/hypertrophic granulation tissue still develops at the
uncovered proximal and distal margins of the stent leading to recurrent obstruction.
Incorporated stents may thus be difficult or impossible to remove. Examples of currently
available covered stents include the Ultraflex Covered Esophageal Stent (Microvasive
Endoscopy/Boston Scientific Corp., Natick, MA), the Alimaxx-E (Alveolus, Inc, Char-
lotte, NC), the Flamingo Wallstent (Schneider AG, Bulach, Switzerland), the Gianturco-Z
stent (Wilson-Cook Europe AIS, Bjæverskov, Denmark), the Song stent (Sooho Meditech,
Seoul, Korea), and the Esophacoil stent (Medtronic/InStent Inc., Eden Prairie, MN)
(Fig. 34.3; Table 34.2). The most commonly used partially covered stent in the United
States is the Ultraflex stent. The Ultraflex stent is made of nitinol and is covered along
its midsection by a polyurethane coat. There is approximately 1.5 cm of uncovered
nitinol mesh at the proximal and distal ends of the stent. The stent is positioned over
a guidewire and is deployed with the release of a slip-knotted binding string. Proximal
and distal drawstrings allow adjustment of stent position following deployment. The
Wallflex stent is also composed of nitinol and may be partially covered or completely
covered. Its deployment mechanism allows recapture of the stent up to approximately
75% deployment. Similar to the Ultraflex stent, a proximal purse-string suture can be
utilized to adjust stent position. The length of the proximal and distal flares is longer
than the Ultraflex stent in the hope of reducing stent migration. The Z stents, also
known as Gianturco-Rösch Z stents (Cook Endoscopy, Winston-Salem, NC), are con-
structed from stainless steel woven in an interlocking “Z” configuration. A modification
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Ta b l e 3 4 . 2 FDA-approved Self-expanding Stents Currently Available in the

United States
Diameter Shaft/
Stent Manufacturer Material Length (cm) Flare (mm) Covering
Ultraflex Boston Scientific Nitinol 10/12/15 18/23 NC; PC
23/28
Wallflex Boston Scientific Nitinol 10/12/15 12/28 PC; TC
23/28
Esophageal Z Cook Stainless steel 8/10/12/14 18/25 PC
Evolution Cook Nitinol 8/10/12.5/15 20/25 PC
Alimaxx-E Alveolus Nitinol 7/10/12 18/22 TC
Niti-S Taewoong Medical Nitinol 8/10/12/14 16/20 TC
18/23
20/25
Polyflex Boston Scientific Polyester 9/12/15 16/20 TC
18/23
21/28
FDA, Food and Drug Administration; NC, noncovered; PC, partially covered; TC, totally covered.
Adapted from: Sharma P, Kozarek R, Practice Parameters Committee of American College of Gastroenterology. Am J
Gastroenterol. 2010;105:258–273.
of the standard configuration involves the addition of a windsock extension at the dis-
tal end of the stent which acts as a one-way valve, thus reducing the risk of reflux (Dua
antireflux system). Cook has also produced the Evolution partially covered stent that is
deployed with a gun-like deployment mechanism. Similar to the Wallflex stent, this
mechanism allows for recapture prior to complete deployment.
To date, prospective, randomized trials have not demonstrated any significant
advantage of one design of covered SEMS over another in terms of technical success,
morbidity, relief of dysphagia, or survival in the setting of malignant obstruction.21,22 In
a direct, prospective, randomized comparison of the Ultraflex, Wallstent, and Gianturco
Z stent, there was no significant difference noted in the palliation of dysphagia. The
Flamingo Wall stent had the lowest morbidity profile (18%), but this finding did not
achieve statistical significance when compared with the Ultraflex stent (24%) and the
Gianturco Z stent (36%).21 Similar findings were obtained in another study comparing
these same three stent types, with equivalent relief of dysphagia. In this study, the
Gianturco Z stent was associated with a significantly higher complication rate compared
with the Ultraflex and Flamingo Wallstent.23 The Gianturco Z stent is no longer avail-
able in the United States.
Completely covered plastic stents were introduced into the market in 2001, and
expanded the number of applications for stent usage, including benign conditions not
readily treatable by SEMS due to their erosive tendencies. These stents lack the ingrowth
properties of metallic stents and are removable. Plastic stents are limited, however, by
increased migration rates due to the mechanical characteristics of the plastic coating
and decreased purchase upon the esophageal wall. Plastic stents do exert greater radial
force than SEMS, which can lead to migration by “squirting” either proximally or dis-
tally with respect to the narrowed segment. The increased radial force can also lead to
discomfort or pain. Some of the plastic stent delivery systems are stiff and bulky, making
deployment difficult in severely narrowed segments. The Polyflex stent (Boston Scien-
tific, Natick, MA) is composed of a polyester mesh coated with an outer layer of sili-
cone. It is deployed via a push-and-release technique after being loaded into the delivery
system. The proximal portion of the stent is flared to help minimize the risk of migra-
tion. The Alimaxx-E stent is composed of a nitinol core structure completely covered
with silicone. The outer surface of the stent has small struts that help to keep the stent
anchored to the esophageal lumen and to prevent migration. This stent can be released
over a wire using a trigger-graded release mechanism, and can also be loaded directly
onto a pediatric endoscope and deployed under direct visualization without the need
LWBK1254-ch34_p383-400.indd 388 19/02/14 8:00 AM

Figure 34.4 Completely covered

self-expanding stents. (A) Wallflex,
(B) Niti-S, (C) Alimaxx-E, (D) Polyflex.
(From: Schembre D. Advances in
esophageal stenting: The evolution
of fully covered stents for malignant
and benign disease. Adv Ther. 2010;
27(7):413–425.)
A B C D

for fluoroscopy. Another completely covered stent is the Niti-S stent (Taewoong Medi-
cal, Seoul, Korea). This stent has a design that is similar to the Wallflex stent with broad
flaring ends. It is currently in limited distribution within the United States (Fig. 34.4).
Procedures
Early experience with the use of self-expanding plastic stents reveals similar relief
of dysphagia compared with SEMS in >98% of patients. The most notable problem with
expandable, plastic stents is the issue of stent migration.24 Conigliaro et al.25 docu-
mented a 20% stent migration rate (n = 12/60) with seven early migrations and five
occurring late. Prospective randomized studies comparing SEMS with self-expanding
plastic stents have demonstrated equivalent relief of dysphagia in the setting of esopha-
geal cancer; however, self-expanding plastic stents have been associated with increased
difficulty of insertion and complication rates (migration, hemorrhage, food impaction)
in comparison with SEMS. In a randomized comparison of 101 patients (Ultraflex = 54;
Polyflex = 47) who underwent stent placement for unresectable esophageal carcinoma,
success of stent insertion, initial relief of dysphagia, and overall survival were similar
between groups. Self-expanding plastic stents were, however, associated with a signifi-
cantly higher complication rate (hyperplastic overgrowth, migration, food impaction)
compared with SEMS (odds ratio = 2.3; 95% confidence interval: 1.2 to 4.4).26 In another
prospective, randomized comparison of patients undergoing stent placement for malig-
nant dysphagia (Ultraflex = 42, Niti-S = 42, Polyflex = 41), relief of dysphagia, and
overall survival was similar between groups. There was an increased rate of tissue
ingrowth in the partially covered SEMS (Ultraflex) group, though this did not attain
statistical significance. Self-expanding plastic stents were associated with an increased
rate of stent migration (29%, p = 0.01) as well as increased technical difficulties in stent
placement (p = 0.008) when compared with SEMS.27
The most recent generation of stents highlights fully covered SEMS that are designed
to overcome the limitations of partially covered SEMS and self-expanding plastic stents
(Fig. 34.4). These stents may promote less granulation tissue and associated stenosis, and
may be removable after several weeks. However, an increased migration rate still may be
expected as a result.28 Published data on the performance of fully covered stents are awaited.
Preoperative assessment of clinical symptoms should be objectively recorded. Dys-
phagia scores are utilized to gauge the degree of symptomatic esophageal obstruction.
The following scoring system is commonly employed: 0, tolerating a regular diet, no
dysphagia; 1, difficulty with solids; 2, difficulty with soft foods; 3, difficulty with liq-
uids; 4, difficulty managing saliva. Careful preoperative radiographic assessment is
imperative in planning the optimal approach. Barium esophagography provides a
roadmap of the esophagus, and allows assessment of the extent of obstruction, the length
LWBK1254-ch34_p383-400.indd 389 19/02/14 8:00 AM

of esophageal involvement, and the presence of other anatomic abnormalities such as

leak, perforation, or fistula. Computed tomography and PET scanning are critical in the
setting of malignancy in helping to stage the extent of disease. Esophagogastroduode-
noscopy (EGD) allows confirmation of the underlying pathology, a real-time assessment
of the extent of disease, and whether the obstruction is intrinsic or extrinsic in nature.
Flexible bronchoscopy is a useful adjunct in assessing patients with esophageal cancers
of the proximal-mid esophagus and in those with suspected tracheoesophageal fistulas.
Technique
Esophageal stents may be inserted endoscopically under conscious sedation or via a
general anesthetic. The authors prefer to employ a general anesthetic in most cases in
an effort to minimize the risk of aspiration and optimize stent positioning. During EGD,
the following features of the case are assessed: (1) degree of esophageal narrowing, (2)
location and length of esophageal involvement, and (3) the integrity of surrounding
esophageal tissues. On occasion, significant narrowing may prevent the safe passage of
the endoscope, and gentle dilation is performed to enable advancement of the scope
beyond the distal extent of the lesion. Care should be taken to minimize the extent of
dilation if anticipating the need for stent insertion. Overdilation of a malignant stricture
might decrease stent purchase after deployment, leading to a higher risk of stent migra-
tion. Once the obstructing lesion has been assessed, the proximal and distal extent of
the lesion is mapped with radio-opaque markers that are placed on the skin of the chest
wall (Fig. 34.5). The scope is then advanced into the duodenum, and a guidewire is
inserted. The scope is withdrawn, and the distance between the two external markers
is measured. This distance is used to estimate the length of the stent chosen to cover
the lesion. Overall stent length will need to extend 1 to 2 cm above and below the
marked interval to ensure complete coverage and to optimize stent position and mini-
mize the risk of the end of the stent “crimping” and not fully deploying if it is too near
the obstructive tumor. The stent delivery system (Fig. 34.6) is then advanced over the
wire under fluoroscopic guidance. The stent is identified by radio-opaque proximal and
Figure 34.5 Deployment of esophageal

stent. Note the proximal and distal
skin markers that delineate the extent
of obstructing tumor (arrows). Fluor-
oscopy demonstrates good stent
position and expansion. (From: Perry
Y, Luketich JD. The use of esophageal
stents. Cameron JL, ed. Current
Surgical Therapy. 8th ed. Philadelphia,
PA: Mosby, 2004: 49–55.)
LWBK1254-ch34_p383-400.indd 390 19/02/14 8:00 AM


Procedures
Figure 34.6 Esophageal stent delivery system. The Ultraflex stent is mounted upon a plastic delivery vehicle and is advanced over a
wire to the desired position. The stent is then deployed by pulling the release string, while monitoring stent expansion under fluoro-
scopic guidance. (From: Cameron JL, ed. Current Surgical Therapy. 8th ed. Philadelphia, PA: Mosby, 2004:49–55.)
distal markers that are aligned with the previously placed skin markers. Once adequate
position is confirmed, the stent is deployed under fluoroscopic guidance. Delivery sys-
tems may employ a proximal release or distal release technique. Slight adjustments to
stent position can be made during deployment to optimize stent position. Following
deployment, the delivery system and guidewire are removed, and repeat endoscopy is
performed to assess the adequacy of stent position and expansion (Fig. 34.7). Stents
should be slightly oversized to permit increased pressure of the stent against the
esophageal wall, so as to minimize the risk of stent migration. Care should be taken not
to select a diameter that is too large, which can lead to pain and incomplete stent
expansion with residual infolding of the stent that will partially obstruct the stent
lumen. Appropriate deployment will result in a stent that is well expanded with good
purchase along the esophageal wall. A slight indentation at the level of obstruction is
evident on fluoroscopy (Fig. 34.8). Ideally, there should be no gap between the esopha-
geal stent wall and proximal stent lumen. Areas of incomplete expansion can be aug-
mented with the assistance of a balloon dilator. Most stents are equipped with proximal
and distal purse strings that permit stent repositioning as required following deploy-
ment. Utilizing careful technique, success rates of 80% to 90% for stent deployment
can be expected.
Post-stent management includes a barium esophagram to assess luminal patency, and
then a trial of oral liquids and dietary advancement. Nutritional counseling is impera-
tive to educate the patient and the family about the goals of the stent and limitations.
For example, patients need to understand that many solid foods will stick and cause
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A B
Figure 34.7 Endoscopic (A) and radiographic (B) appearance of esophageal stent after deployment. (From: http://www.gastrohep.
com/images/image.asp?id=455. Accessed July 19, 2013.)
obstructive problems. Stents that traverse the GE junction can be expected to increase
reflux, and proton pump inhibitors (PPIs) and other measures to minimize reflux, such
as elevating the head of the bed and minimizing oral consumption before lying down,
should be discussed. The patient should be seen again in clinic early after stent place-
ment to assess how the patient is doing with regard to nutritional intake and determine
if side effects of the stent are present.
Figure 34.8 Barium esophagram

before (A) and after (B) esophageal
stent placement for a malignant
stricture. (From: Cameron JL, ed.
Current Surgical Therapy. 8th ed.
Philadelphia, PA: Mosby, 2004:
49–55)
A B
LWBK1254-ch34_p383-400.indd 392 19/02/14 8:00 AM

Ta b l e 3 4 . 3 Complications of Esophageal Stent Placement
Tumor ingrowth/overgrowth 42 (33%)

Severe reflux 14 (11%)
Stent migration 11 (8.7%)
Food impaction 10 (7.9%)
Unsuccessful deployment 4 (3.1%)
Esophageal erosion/fistula 3 (2.3%)
Intractable pain requiring removal 2 (1.6%)
Perforation 1 (0.8%)
Adapted from: Christie NA, Buenaventura PO, Fernando HC, et al. Results of expandable metal stents for malignant esophageal
obstruction in 100 patients: Short-term and long-term follow-up. Ann Thorac Surg. 2001;71(6):1797–1801; discussion 801–802.
Complications

Numerous complications related to stent placement have been documented and range
Procedures
from 30% to 50% in most series (Table 34.3).29 The most common complication
encountered with SEMS placement is the development of exuberant granulation tis-
sue or tumor ingrowth in the proximal and distal uncovered portions of the stent,
which occurs in approximately half of the patients within 2 to 3 months of stent
placement (Fig. 34.9).30 Tumor ingrowth can result in recurring dysphagia, necessitat-
ing mechanical debridement or further endoluminal therapy (e.g., Nd:YAG laser, PDT,
brachytherapy).31 Stent migration can occur in 10% to 40% of cases, and is more
common when self-expanding plastic stents are employed (Fig. 34.10) (see Stent
Design above). Proximal stents are associated with a higher rate of airway compro-
mise due to tracheal compression and migration, and distal stents (especially those
that span the GE junction) can lead to wide open reflux (10% to 20%), regurgitation,
and even aspiration (1% to 2%). Stents can be associated with severe discomfort and/
or nausea following placement that may be unremitting in nature and may require
stent repositioning, revision, or removal (1% to 2%). Procedure-related perforation
has been reported in 1% to 2% of cases. Other less common stent-related complica-
tions include hemorrhage, tracheoesophageal fistula formation, food impaction, stent
fracture during manipulation, entrapment of the stent delivery system, and epidural
abscess formation (in the setting of perforation/leak). It has been reported that over
Figure 34.9 Extensive overgrowth of

exuberant granulation tissue at the
distal end of an Ultraflex stent 4
months after insertion. (From: Schem-
bre D. Advances in esophageal
stenting: The evolution of fully cov-
ered stents for malignant and benign
disease. Adv Ther. 2010;27(7):413–425.)
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A B
Figure 34.10 Esophageal stent migration to stomach (A) and small bowel (B). (From: Ko HK, Song HY, Shin JH, et al. Fate of migrated
esophageal and gastroduodenal stents: Experience in 70 patients. J Vasc Interv Radiol. 2007;18:725–732.) (A) and http://www.gastrohep.
com/classcases/classcases.asp?id=25. Accessed July 19, 2013 (B).
half of the patients require endoscopic reintervention for complications at a mean

interval of 82 days.32 Despite numerous modifications in stent design over time, there
has been no significant reduction in postprocedure complications, which is likely
due to the generally poor medical and nutritional status of patients experiencing
malignant esophageal obstruction.33
Pitfalls in the deployment of esophageal stents include undersizing or oversizing
the stents both in terms of stent length and stent width. Undersized stents will have
reduced purchase against the esophageal wall and will be prone to leaks of ingested
material around the stent and stent migration. Excessive dilation of strictures prior to
stent insertion will similarly reduce stent traction and increase the risk of stent migra-
tion. Ideally, dilation should be limited to a size necessary to permit safe stent insertion.
Furthermore, inadequate length might lead to residual obstruction at either the proxi-
mal or distal margin of the stent by tumor (technical error). Oversized stents can lead
to pain and incomplete stent expansion with residual infolding of the stent that will
partially obstruct the stent lumen. Stents that are too long can telescope into the stom-
ach, which can create intermittent stent obstruction with gastric mucosa being drawn
into the stent lumen due to the negative intrathoracic pressure. Proximal stents that are
deployed in proximity to the cricopharyngeus can create discomfort and globus sensa-
tion, as well as acute airway compression. When both the esophagus and trachea are
stented, overlapping stents can be associated with a high incidence of tracheoesopha-
geal fistula formation from mechanical stent-on-stent erosion. The combination of stent
placement and radiation may also be associated with a higher rate of stent erosion and
fistula formation. Following stent insertion, patients should be carefully followed to
ensure adequate symptomatic palliation, and to monitor for any of the abovementioned
complications. Adequacy of stent position can be assessed with a standard chest x-ray
in most cases, or via chest CT. Objective assessment of swallowing function can be
performed with a barium swallow.
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Results
Rigid Versus Expandable Stents

With the advent of flexible endoscopic techniques, a new generation SEMS was intro-
duced that greatly simplified stent insertion. With the publication of the seminal pro-
spective, randomized trial by Knyrim et al.,34 SEMS were found to be associated with
significant reduction of perioperative complications, reduced perioperative 30-day mor-
tality (29% vs. 14%) and were found to be cost effective when compared with rigid
prostheses. In another prospective study, SEMS were compared with plastic prostheses
in 31 consecutive patients undergoing palliation for inoperable malignant obstruction.
In this study, complication rates were similar between groups, but SEMS were associ-
ated with better palliation of dysphagia, earlier patient discharge and prolonged sur-
vival when compared with patients who received plastic rigid prostheses.35 In a larger,
retrospective study of 158 patients undergoing SEMS placement versus rigid prostheses,

SEMS placement was associated with comparable reduction in dysphagia and signifi-
cantly reduced complication rates.36 These studies have established that SEMS are
superior to rigid prostheses in the management of patients with malignant esophageal
Procedures
obstruction. Self-expanding esophageal stents are now the most commonly used method
of palliation in esophageal cancer.
Esophageal Stents in the Management of Malignant Disease

The majority of patients (>60%) with esophageal cancer will present with unresectable
or inoperable esophageal cancer due to local invasion, distant metastases, or medical
comorbidities. Quality of life, therefore, will tend to take precedence over long-term
prognosis. Multiple modalities exist that can be employed in the treatment of dysphagia
due to cancer (Table 34.1). Esophageal stents provide a safe and expeditious method of
relieving dysphagia, while minimizing length of stay and the risk of complications. It
is probably the simplest and quickest method for improving quality of life in this set-
ting. Most series document successful stent insertion in 80% to 95% of patients. In a
series of 100 consecutive stent placements, immediate improvement of dysphagia was
obtained in 85% of patients, with no procedure-related deaths.32 Although SEMS are
associated with immediate relief of symptoms and lower cost than other palliative
measures such as PDT and Nd:YAG laser ablation, quality of life may be worse in cer-
tain circumstances due to complications.37 In a retrospective analysis of 82 patients com-
paring the outcomes of Gianturco-Rösch Z stents (n = 20), Wallstents (covered, n = 31;
uncovered, n = 13) and Ultraflex stents (covered, n = 8; uncovered, n = 10), the mean
survival was 4.5 months after stent placement, and the incidence of complications was
75%, 68.1%, and 44.4%, respectively. Complications were more frequently encountered
when stents were placed in the proximal third of the esophagus. Thirteen patients
(15.9%) died from complications directly related to stent placement.38
Nd:YAG laser therapy has been shown to be effective at reducing tumor bulk, con-
trolling bleeding, and relieving obstruction due to endoluminal tumor involvement. Less
reflux is encountered when compared with stents that traverse the GE junction. Esopha-
geal stent placement is quicker and appears to be equally effective in relieving dysphagia,
and has been shown to be more effective in cases of extrinsic compression.39 There have
been a few studies examining the impact of Nd:YAG laser therapy (with or without
radiation) versus expandable stent placement in the setting of malignant dysphagia. In
one study, 125 patients with malignant dysphagia were treated with either Nd:YAG laser
± radiation therapy versus stent placement. Relief of dysphagia was similar between
groups. However, stent placement was associated with a significant increase in periop-
erative morbidity, including an 8- to 10-fold increase in major complications.40 In another
study comparing the use of Nd:YAG laser therapy and brachytherapy versus stent inser-
tion, the Nd:YAG/brachytherapy arm demonstrated a higher rate of bleeding, fistula for-
mation, and need for retreatment and higher cost compared with stent insertion.41
LWBK1254-ch34_p383-400.indd 395 19/02/14 8:00 AM

Symptomatic Advanced EC
Bleeding Obstruction
Nd: YAG PDT Extrinsic compression Endoluminal tumor
Stent PDT Nd: YAG Brachytherapy
Figure 34.11 Multimodality approach in the management of advanced esophageal cancer. (From: Litle VR,
Luketich JD, Christie NA, et al. Photodynamic therapy as palliation for esophageal cancer: Experience in 215
patients. Ann Thorac Surg. 2003;76:1687–1693.)
PDT has also been employed in the palliation of malignant dysphagia. It is especially
useful in reducing endoluminal tumor bulk and minimizing tumor-related bleeding.
Palliation of dysphagia is achieved in 5 to 7 days, and persists from 9.5 to 14.4 weeks.42,43
Although YAG laser ablation and PDT represent useful adjuncts in the palliation of
malignant dysphagia, the ease and simplicity of stent insertion, and the rapidity of
symptomatic improvement have made esophageal stenting the first-line approach in the
majority of patients.
Chemotherapy and radiation therapy can improve survival in patients with advanced
esophageal cancer, and can be very effective in controlling malignant dysphagia but the
time from starting therapy to relief of dysphagia can be several weeks.44 In the setting
of malignancy, esophageal stent placement has been compared with chemotherapy and
radiation therapy. In a study of 66 patients who were treated with esophageal stent
insertion, freedom from dysphagia was achieved in 81%, compared with 49% in the
chemotherapy group and 56% in the radiation therapy group.45 Prior radiation and/or
chemotherapy have not been consistently demonstrated as risk factors for complications
or poor outcomes following placement of esophageal stents for malignancy.46
Single-dose intraluminal brachytherapy has also been demonstrated to be effective
in reducing dysphagia. In a prospective, randomized comparison, patients were treated
with either single-dose brachytherapy (n = 101) or stent placement (n = 108). Dysphagia
was relieved more rapidly with stent placement; however, brachytherapy achieved better
long-term control of symptoms. A greater number of complications were seen in the
stent group (33% vs. 21%, p = 0.02).47 In a study comparing outcomes following single-
dose (12 Gy) brachytherapy and esophageal stent placement by the Dutch SIREC study
group, the application of a single dose of brachytherapy resulted in a 75% improvement
in dysphagia at 4 weeks. Although esophageal stenting was associated with a more
rapid improvement in dysphagia, brachytherapy was associated with a more sustained
effect with improved quality of life at 6 months compared with stenting.48 In a cost-
effectiveness analysis, brachytherapy was found to be more cost-effective than Nd:YAG
laser therapy or stent placement, producing the largest net health benefit.49 The reduced
availability of brachytherapy in many hospitals, however, has limited the application
of this modality in the management of patients with malignant dysphagia. A multimo-
dality approach in the management of malignant obstruction probably yields the best
results (Fig. 34.11). Following initial stenting, the use of PDT and brachytherapy can
be used to control the tissue ingrowth. The chosen treatment strategy should be tailored
to individual patient and tumor characteristics.
Esophageal stents have also demonstrated efficacy in the management of tra-
cheoesophageal fistulas associated with malignancy.50 In a study that included 22
patients with tracheoesophageal fistula secondary to malignancy, airway symptoms
improved in 90%.51 In the largest study, Shin et al. treated 61 patients with esophagores-
piratory fistulas utilizing covered esophageal stents, with successful control of the fis-
tula in 80%. Concomitant airway stenting was required in 16.4% of cases. During
long-term follow-up, approximately one-third of patients were noted to develop recur-
rent fistulas, approximately one-half of whom were successfully managed with place-
ment of a second SEMS.52
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Esophageal Stents in the Management of Benign Disease

Esophageal stents have also demonstrated utility in the case of benign disease. Due to
a high rate of delayed complications (erosion, granulation tissue, bleeding, fistula),
metallic stents are not indicated in the setting of benign disease. With the emergence
of self-expanding plastic stents, multiple reports have reexplored the utility of stenting
in the setting of benign disease. Success rates range from 17% to 95%. Fully covered
plastic stents (e.g., Polyflex) exhibit a reduced tendency for ingrowth of granulation
tissue or fistula formation, and are readily removed when clinically indicated.29 Condi-
tions amenable to esophageal stenting include peptic strictures, caustic or postradiation
strictures, esophageal perforations, and anastomotic leaks. In the case of benign, recal-
citrant strictures (e.g., peptic, radiation-induced), the use of plastic stents has been
shown to provide immediate relief of dysphagia, and the radial force of the stent encour-
ages gradual and progressive dilation of the strictured segment and underlying tissue
remodeling. Following removal of these stents, up to 80% of patients may experience
substantial improvement in their symptoms without the need for further dilation over
a 2-year follow-up period.53,54 Other studies have reported lower success rates in the

management of benign strictures and fistulae, including a prospective evaluation of 40
patients with benign strictures treated with insertion of a plastic stent for 4 weeks.55,56
Stent deployment was unsuccessful in two patients. Only 32% experienced lasting
Procedures
improvement in symptoms. Complications included stent migration (22%), severe chest
pain (11%), bleeding (8%), inability to remove stent (6%), and fistula (3%).56 Other
studies have demonstrated a very high migration rate (up to 73%) with the use of self-
expanding plastic stents (e.g., Polyflex stent) and a reintervention rate of 81.6%.24 Fully
covered SEMS can also be used for benign disease, but have been shown to have
similar problems with stent migration (36%), and lack of sustained improvement
(29%).57
Although results of fully covered removable stents have been variable in the man-
agement of strictures, greater efficacy has been demonstrated in the management of
leaks and perforations [Fig. 34.12). Multiple studies have reported efficacy in managing
limited perforations of the esophagus, both spontaneous and iatrogenic, with esopha-
geal stent placement.58,59 Freeman et al. employed stents for the management of intratho-
racic, iatrogenic esophageal perforations. Leaks were successfully occluded in 16/17
(94%) of the patients, with 14/17 (82%) being able to reinitiate an oral diet within
A B
Figure 34.12 A: Self-expanding plastic stent insertion to cover an iatrogenic esophageal perforation (arrow). B: Endoscopic view
depicting complete coverage of perforation. (From: Bunch TJ, Nelson J, Foley T, et al. Temporary esophageal stenting allows healing of
esophageal perforations following atrial fibrillation ablation procedures. J Cardiovasc Electrophysiol. 2006;17:435–439.)
LWBK1254-ch34_p383-400.indd 397 19/02/14 8:00 AM

72 hours of stent placement. Only 3/17 (18%) patients required stent repositioning due
to stent migration. There was one failure (6%) that went on to require surgical interven-
tion secondary to continued leak following stent placement. All stents were removed
at a mean of 52 ± 20 days from the time of initial stent placement.59 In another study
of 32 patients with spontaneous perforations and postsurgical leaks that were managed
with the placement of self-expanding plastic stents, successful closure was achieved in
70% of patients.60
Placement of retrievable stents in the setting of spontaneous esophageal perforation
(Boerhaave syndrome) has been detailed in several case reports. In these reports, stent-
ing allowed healing of the perforation, and safe removal of the stent within 2 to
6 months.61,62 In the setting of iatrogenic perforations, stenting has been shown to
achieve early closure of the perforation in 9/11 (81.8%) cases.63 In another prospective
study reporting the use of esophageal stents in 13 cases of benign esophageal perfora-
tion, stenting achieved successful closure of the perforation in 12/13 (92.3%) cases. All
stents were retrieved endoscopically after 3 weeks.64 Self-expanding plastic stents have
also been employed successfully in the management of esophageal perforations. In a
prospective series evaluating the use of self-expanding plastic stents in 17 patients with
esophageal perforations, leak occlusion was accomplished in 16/17 (94.1%) of patients
as demonstrated by barium esophagram. Stent migration was seen with the use of self-
expanding plastic stents in three (17.6%) of the patients.59 Other reports have described
the use of partially covered SEMS in controlling esophageal anastomotic leaks, with
successful closure of all reported leaks, allowing for earlier resumption of oral intake.65,66
The placement of large diameter self-expanding plastic stents has also been found to
be effective in this setting (78% to 89% leak occlusion).67
Radecke et al. reported their experience with the placement of 60 plastic stents in
39 patients for a variety of benign and malignant stenoses and fistulae. Following stent
placement, 69% of patients could resume eating, and another 15% could handle their
own secretions but were still unable to eat.68 Due to the focal and less constrictive
nature of most benign lesions, plastic stent migration is the most common complication
encountered.69,70 Early migration rates have been reported in 25% to 30% of patients,
with late migration seen in an additional one-third of those treated with self-expanding
plastic stents.27,53 Prospective, randomized trials are needed to better delineate the
advantages and drawbacks of fully covered stents in benign disease.
Conclusions
The use of expandable stents represents a safe and expeditious approach in the pallia-
tion of malignant dysphagia. Changes in stent design have simplified stent insertion
and have broadened its application to a variety of benign conditions. SEMS have
emerged as a superior construct when compared to rigid prostheses in terms of ease of
insertion and procedure-related morbidity. Partially covered SEMS are associated with
reduced tissue ingrowth and recurrent dysphagia when compared with uncovered
stents. Among partially covered SEMS, there are no proven advantages of one design
versus another. Although self-expanding plastic stents have demonstrated equivalent
relief of dysphagia when compared to SEMS, self-expanding plastic stents have been
associated with increased difficulty of insertion and complication rates (migration, hem-
orrhage, food impaction) in the management of patients with malignant dysphagia. The
use of temporary SEMS or self-expanding plastic stents for the management of esopha-
geal perforation and anastomotic leaks is clearly emerging as an option in selected
patients. Most successful series include surgical drainage of any significant areas of
extravasation after stent placement. The use of stents in this setting is promising, but
the ideal patients and technique will need to be validated in larger studies with more
detailed follow-up. Long-term, prospective randomized data regarding the use of retriev-
able, fully covered SEMS will be necessary to delineate their usefulness in benign
disease. Careful patient selection and postoperative follow-up are required to optimize
LWBK1254-ch34_p383-400.indd 398 19/02/14 8:00 AM

patient outcomes. As technology improves, and as clinicians gain experience in

employing an individualized multimodality approach in the treatment of malignant
obstruction of the esophagus (stenting, dilation, laser, PDT, XRT, chemotherapy), the
palliative benefits of these approaches will be optimized.
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105(2):258–273; quiz 74. geal junction. Am J Gastroenterol. 2001;96(6):1791–1796.
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35 Bougie and Balloon Dilation
of Esophageal Strictures—
Malignant and Benign
Konstantinos I. Makris and Christy M. Dunst
Introduction
Esophageal dilation or bougienage was first reported in the sixteenth century and was
initially used for disimpaction of the esophagus by pushing the obstructing food bolus
into the stomach. Wax-made dilators were used for that purpose. The term bougie
originates from the name of the Algerian city Boujiyah, a medieval center of wax and
candle trade. Leather, iron, lead, and whalebone are some of the materials subsequently
used for the construction of esophageal dilators until the advent of the modern-era
synthetic bougies.1
Esophageal dilation evolved over the years from a blind technique with a high risk
of perforation to a sophisticated and safe technique facilitated by flexible endoscopy,
guidewires, fluoroscopy, and other adjunct tools. The armamentarium of the modern
endoscopist offers a variety of treatment options and a multitude of approaches, which
can address the majority of obstructing lesions in the esophagus.
Several types of esophageal dilators are available (Table 35.1) and are usually clas-
sified as push dilators (i.e., Maloney, Savary-Gilliard), and balloon dilators (i.e., through-
the-scope [TTS] balloon dilators). Push dilators can be advanced with or without the
use of a guidewire, under fluoroscopic monitoring. The balloon dilators can be used in
a similar fashion over a guidewire or passed through the flexible endoscope and dilation
is performed under direct endoscopic view.
The mechanical aim of dilation is the effective stretching and disruption of the
stenotic features in the submucosal and muscular layers of the esophageal wall, while
optimally a full thickness disruption does not occur. Balloon dilation transmits only
radial forces to the esophageal wall, which theoretically represents the desired mecha-
nism of dilation of short stenotic lesions. In contrast, push dilators generate both a
radial and an additional longitudinal force as a result of shearing effects. Despite this
difference, no clear advantage of one type of dilator over the other has been demon-
strated when used for the most common indications of esophageal dilation.
401
LWBK1254-ch35_p401-412.indd 401 19/02/14 7:04 PM

Ta b l e 3 5 . 1
Types of Esophageal Dilators
Push Dilators
A. Nonguided rubber bougies
– Maloney (tapered, mercury-filled, 12–60F in 2-French increments)
– Hurst (blunt-tipped, tungsten-filled, 12–60F in 2-French increments)
B. Wire-guided dilators
– Savary-Gilliard (polyvinyl, tapered, central channel for guidewire, 5–20-mm diameter)
– Eder-Puestow (flexible system with metal olive tips, 12 olive sizes, 6.6–19.3-mm diameter)
C. Other
– Gum elastic dilators (semi-flexible, passed through rigid esophagoscope, rarely used)
– KeyMed dilator (variation of Eder-Puestow system, not used anymore)
– Celestin and Buess dilators (variations of Savary system, not commonly used)
– Optical dilator (clear, over-the-scope bougie with sequential dilating segments)
Through-the-scope (TTS) Balloon Dilators
TTS balloon dilators (used under endoscopic or fluoroscopic vision, with or without guidewire, 6–40-mm
diameter), single or multiple-diameter
Esophageal dilation is indicated for the treatment of dysphagia caused by esophageal-
obstructing pathologies and functional disorders (Table 35.2). Achalasia, malignant
strictures, and postoperative anastomotic strictures constitute the most common indica-
tions.2 Peptic strictures are also an indication, although the incidence of peptic stric-
tures has markedly declined since the introduction of proton pump inhibitors (PPIs).
The clinical goal of esophageal dilation is the relief of dysphagia by eliminating the
obstructing process in the esophagus. This allows maintenance of adequate oral nutrition
and prevents aspiration. Dysphagia is usually significantly improved when a luminal diam-
eter of 12 to 15 mm is achieved or at least a 36F dilator is passed. Maintenance of a 15-mm-
diameter lumen (45 French) generally allows near normal dietary intake. Dilation of an
obstructing esophageal lesion also allows the passage of the endoscope to the stomach for
gastroscopy, the endoscopic ultrasound (EUS) probe for evaluation of the esophageal
pathology, and for the potential placement of a stent. Large diameter esophageal dilators
(50 to 60 French) are also frequently used intraoperatively during the creation of a fundo
plication to lower the risk of iatrogenic dysphagia.3 Similarly, these dilators can be used
to treat postfundoplication dysphagia. Early dilation has been cited by many experienced
esophageal surgeons to be beneficial in the early management of esophageal anastomotic
Ta b l e 3 5 . 2
Most Common Indications for Esophageal Dilation
Motility Disorders
• Achalasia
• Cricopharyngeal dysphagia
Benign Diseases
• Peptic stricture
• Corrosive esophagitis
• Schatzki’s ring and esophageal webs
• Iatrogenic (radiation, esophageal ablation, postfundoplication, anastomotic, postinstrumentation)
• Eosinophilic esophagitis
• Other (fungal–viral–mycobacterial infections, autoimmune disorders, drug-induced esophagitis)
Malignant Diseases
• Primary esophageal cancer
• Secondary thoracic neoplasia with extrinsic compression/infiltration (tracheal, lung, laryngeal neoplasia or
lymphoma)
LWBK1254-ch35_p401-412.indd 402 21/02/14 6:53 PM

Chapter 35 Bougie and Balloon Dilation of Esophageal Strictures—Malignant and Benign 403
leaks to help preserve a distal patent lumen and facilitate fistula closure. In other settings,
esophageal dilation may be required prior to placement of an expandable stent.
Active esophageal perforation is an absolute contraindication to esophageal dila-
tion. History of previous esophageal perforation is a relative contraindication to future
dilations and extreme caution should be used. Conditions that increase the difficulty
of the procedure and increase the risk of perforation or other complications also con-
stitute relative contraindications. This includes esophageal malignancy, large thoracic
aortic aneurysms, and pharyngeal or cervical deformities including vertebral bone
spurs, compromised cardiorespiratory status, and severe coagulopathy. Radiotherapy
and concurrent esophageal biopsies are not considered contraindications to esophageal
dilation.4,5
Candidates for esophageal dilation should be thoroughly evaluated prior to the proce-

dure to determine the cause of the esophageal obstruction as well as the procedural
risks associated with the patients’ comorbidities. History should be taken and physical
examination performed before making the decision to intervene. A barium swallow is
obtained to assess the extent and nature of the obstruction, although endoscopic assess-
Procedures
ment is essential as well. It should be noted that patients with proximal dysphagia may
be harboring other pathologies (i.e., pharyngeal pouch, Zenker’s diverticulum, postcri-
coid web) that increase the risk of perforation. Other available imaging studies should
also be reviewed.
Endoscopy provides valuable information on the anatomic site, the length, and the
nature of the obstructing lesion. Biopsies or brush cytology should be performed to
detect malignancy, which would affect the overall management and may increase the
risk of perforation. Other endoscopic findings, such as hiatal hernia, tortuous esopha-
gus, angulation of the stricture, and esophageal diverticula can also influence the deci-
sion on the type of dilators that need to be used. Simple strictures can be biopsied and
dilated in the same session, while suspicion of malignancy may defer dilation due to
the increased risk of perforation.
The procedure should be explained in detail to the patient. The anticipated bene-
fits, the alternative treatment options, and the potential risks should be discussed, and
consent should be obtained.
Esophageal dilation can cause bleeding in patients receiving anticoagulants, which
may be difficult to control endoscopically. Therefore, warfarin should be discontinued
prior to the dilation, and a prothrombin time test should be performed. In patients at
high risk for thromboembolic events, bridging with heparin may be considered. Heparin
should be withheld 4 to 6 hours prior to the procedure and resumed 4 to 6 hours after.
Warfarin can typically be restarted on the night of the procedure. There is no solid data
indicating the need to discontinue aspirin or nonsteroidal anti-inflammatory medica-
tions prior to esophageal dilation. However, antiplatelet agents like clopidogrel should
be discontinued 7 to 10 days prior to the procedure.
The patients fast for 4 to 6 hours prior to the procedure to ensure that the stomach
and the esophagus are empty for the procedure. This is essential not only for a techni-
cally successful endoscopy and dilation, but also for prevention of aspiration. Achalasia
patients, who develop severe esophageal stasis, may require longer fasting.
Transient bacteremia with esophageal dilation has been observed.6 Therefore, pre-
procedure antibiotics should be administered to patients at risk for endocarditis and
patients with immunosuppression. The guidelines on antibiotic coverage for endoscopy
should be followed.
Although upper endoscopy and esophageal dilation may be performed on awake
patients, deeper levels of sedation or even general anesthesia may be required for
the patient’s comfort during the procedure. The type of sedation is decided on the
basis of the patient’s overall health condition, the expected duration and type of inter-
vention, the patient’s previous tolerance to common sedative medications, and the
LWBK1254-ch35_p401-412.indd 403 19/02/14 7:04 PM

preferences of the endoscopist. Most commonly, sedation is obtained with intravenous

midazolam, fentanyl, or propofol. Continuous pulse oximetry and hemodynamic mon-
itoring are provided. Spraying the oropharynx with lidocaine or asking the patient to
swallow viscous lidocaine prior to the procedure can make the endoscopy and dilation
more comfortable, but is generally not needed. Under specific circumstances, general
endotracheal anesthesia is required or may be preferred by some patients.
The plan on which approach and what type of dilator will be used should be for-
mulated before the procedure and finalized during the endoscopy based on the findings.
Nonguided bougies (Maloney) can be used with simple strictures, webs, or rings in a
fairly straight esophagus. However, it must be noted that esophageal perforation is
always a consideration and may be mitigated by fluoroscopy, guidewires, and endo-
scopic direct visualization. Patients with particularly refractory and straightforward
strictures, such as cervical radiation or anastomotic strictures, can be taught to use these
types of bougies at home. Tighter or more complex strictures are approached with
guided dilators, either TTS balloons or push dilators (Savary-Gilliard). The use of con-
trast and fluoroscopy enhances the safety of the intervention in difficult situations. The
experience and facility of the endoscopist with a specific type of dilator also play a key
role in the decision making.4
Surgery
Principles
Despite the specific differences in the technique used, there are some principles that
apply to all the types of esophageal dilation. (a) The size of the first dilator used, either
balloon or bougie, should correspond to the diameter of the stricture; (b) Traditionally,
it is advised that no more than three bougie dilators of sequentially increasing size
should be used in every one session (“rule of three”). Multiple sessions may be required
for the desired total dilation; (c) The clinical end point of esophageal dilation is the
relief of dysphagia. It has been suggested that luminal diameter of 12 to 15 mm suffices
for unobstructed swallowing. Esophageal webs or Schatzki’s rings require larger-caliber
dilators (16 to 20 mm), whereas treatment of achalasia is attempted with even larger
dilators (30 to 40 mm). The risk of perforation, though, increases linearly with the size
of the dilator. Caution should be used when malignant strictures are dilated because of
the higher risk of perforation. Dilation should be gentle and wide enough to allow
biopsy, passage of the EUS probe, and palliative stent placement; (d) Dilation of the
stenotic lesion starts when moderate resistance is encountered during passage of the
bougie through the stricture or during balloon inflation. Excessive resistance should
be avoided, since rupturing forces are developing.
Positioning
Most commonly, the patient is placed in the left lateral decubitus position, which is
the typical for upper endoscopy. This allows the use of all types of esophageal dilators
and does not interfere with patient monitoring, while it facilitates the management if
intraoperative regurgitation occurs and minimizes the risk of aspiration. The supine
position can be used when general endotracheal anesthesia is administered or fluoros-
copy is planned, in order to improve the view without the overlying humerus. Trans
nasal, office-based esophageal dilations have also been reported in the sitting position.7
Dilation with Maloney bougies can be done in the sitting position as well, particularly
when self-dilations are performed.
Push Dilators
The guided passage of push dilators, such as the Savary-Gilliard, lowers the risk of
perforation. These dilators have a central lumen which allows their advancement over
LWBK1254-ch35_p401-412.indd 404 19/02/14 7:04 PM

Figure 35.1 Savary-Gilliard dilator with

guidewire in place.

a stiff guidewire with a soft spring tip (Savary guidewire) (Figs. 35.1 and 35.2). Softer
guidewires can be used with caution when more complex strictures need to be negoti-
ated. However, these may be too flexible to direct the dilator and can lead to perforation.
Procedures
The guidewire is advanced through the working channel of the endoscope and its
tip is preferably positioned in the antrum or positioned through the pylorus into the
duodenum. If the stricture cannot be traversed by the endoscope, a pediatric endoscope
might transverse the stricture, or a guidewire can be passed using endoscopic vision
and fluoroscopic guidance through the stricture and into the stomach. Subsequent fluo
roscopic controlled bougienage can then be performed. Alternatively, a dilating balloon
catheter can be similarly passed through the narrowing, and dilation performed. Typi-
cally, the endoscope can be subsequently passed through the dilated stricture into the
stomach for full evaluation of the esophagus and stomach. Alternatively, the guidewire
can be placed under fluoroscopy ensuring that the tip passes at least 20 to 30 cm distal
to the stenotic lesion. Endoscopic use of contrast may improve the evaluation of the
stricture intraoperatively.
After proper positioning of the guidewire, the endoscope is withdrawn slowly with
synchronous equal advancement of the guidewire through the working channel so that
the tip of the wire remains stable. This is the standard Seldinger technique also used
for advancement of central vascular access catheters. This task is more easily performed
A B C
Esophageal Savary dilator

cancer expanding lumen
Spring tipped
guidewire
Figure 35.2 Esophageal dilation technique using the Savary-Gilliard dilator.
LWBK1254-ch35_p401-412.indd 405 19/02/14 7:04 PM

by the coordinated actions of two people and can be monitored either endoscopically
or under fluoroscopy. As soon as the tip of the endoscope is outside the patient’s mouth,
the guidewire is grasped and stabilized against the bite-block. The guidewire is marked
for depth and the position should be noted before passing the dilator to make sure that
the guidewire tip has remained in the stomach.
The Savary-Gilliard dilator is then back-loaded and slowly advanced in the patient’s
mouth and upper esophagus. Insertion and advancement is facilitated by lubrication of
the dilator (i.e., lubrication gel) and occasionally the dilator’s central channel (i.e.,
lubrication spray), through which the guidewire is passed. The guidewire is kept steady
while the dilator is pushed, by holding the proximal end of the guidewire against a
fixed point outside the patient’s body. This prevents distal migration of the guidewire
or kinking in front of the dilator tip. The dilators are radio-opaque or have a radio-
opaque band at the transition zone (between the tapered tip and the widest portion of
the dilator) allowing fluoroscopic monitoring during advancement.
Advancement should be slow and gentle with a finger grasp of the dilator close to
the patient’s mouth. If resistance is encountered, advancement is stopped; and fluoro-
scopic assessment of the alignment of the dilator to the esophageal axis is assessed. If
alignment is correct, continued advancement can be attempted. If resistance is signifi-
cant, the dilation at that bougie size should be stopped and repeat endoscopic examina-
tion of the esophagus performed. If further dilation is planned, the dilator is withdrawn,
while the guidewire is kept steady as described above. Dilation is repeated with larger-
caliber dilators as needed. Some consider blood on the dilator to be a sign that no
further dilation should be done in that setting or, at a minimum, a sign that caution
should be exercised. The guidewire is removed simultaneously with the last dilator.
The Maloney dilators are advanced in a similar manner but without a guidewire
(Fig. 35.3). After the endoscope is removed, the tapered tip of the dilator is lubricated
and placed in the patient’s hypopharynx. Slow passes are attempted until the tip
traverses the upper esophageal sphincter and enters the upper esophagus. Swallowing
can facilitate this passage. The dilator is then advanced slowly with the same precau-
tions regarding pressure described for the Savary-Gilliard system. Dilation is completed
when 10 to 15 cm of dilator length is left outside the mouth (particularly for distal
strictures) and the dilator is kept in place for 20 to 60 seconds.
Balloon Dilators
The TTS balloon dilators exist as single or multi-diameter balloon catheters. The desired
diameter of expansion is obtained when infusion of fluid (water or contrast) in the balloon
reaches predefined levels of pressure (Fig. 35.4A). In multi-diameter balloon dilators,
A B
Figure 35.3 A: Maloney dilators of various calibers. B: Tapered tip of Maloney dilator.
LWBK1254-ch35_p401-412.indd 406 19/02/14 7:05 PM


A
B
Figure 35.4 A: Through-the-scope (TTS) balloon dilator. B: Endoscopic view of balloon dilation of anastomotic stricture.
Procedures
three separate inflation pressures correspond to three different diameters of the same bal-
loon, allowing staged dilation of a stricture without removal of the dilator. Accuracy and
control of the inflation is ensured by the use of a manometer attached to the system.
The TTS balloon dilator is advanced through the working channel of the standard
flexible endoscope (Fig. 35.5). The soft tip of the balloon is passed through the stricture
under endoscopic vision (Fig. 35.4B). If the stricture is wide enough, the endoscope is
A B
Figure 35.5 A: Insertion of the balloon dilator into a channel endoscope. B: Full endoscopic set-up with balloon catheter and piston pump.
LWBK1254-ch35_p401-412.indd 407 19/02/14 7:05 PM

advanced into the stomach where the deflated balloon is exposed. Then, they are slowly
withdrawn into the esophagus, so that the mid-portion of the balloon is positioned at
the level of the tightest part of the stricture. In the case of a complex, tight stricture that
does not allow passage of the endoscope, a guidewire (with or without fluoroscopy) can
be used for guidance of the balloon dilator. Depiction of the poststenotic part of the
esophagus with contrast infused through an endoscopic catheter can confirm patency
of the stricture prior to any attempt at advancing the balloon or the guidewire and can
facilitate proper positioning of the dilator.
The proximal end of the balloon is kept at the tip of the endoscope for continuous
visualization. After positioning of the balloon through the stricture, the system is sta-
bilized, with the endoscopist holding the dilator catheter against the working port of
the endoscope with one hand and the endoscope against the bite-block with the other
hand. This two-point control ensures stability of the balloon during dilation and allows
microadjustments if small migration is endoscopically observed. The balloon is inflated
by the endoscopy assistant. The duration of the inflation has not been standardized but
most endoscopists report 20 to 60 seconds as with the Savary-Gilliard dilators.
The dilated stricture is reassessed after the balloon is deflated and further dilation
to a larger diameter can be performed in the same session. Fluoroscopy and contrast
for balloon filling could be used for complex or tight strictures, when clinically indi-
cated to avoid luminal injury distal to the narrowing during passage of the balloon
catheter and during inflation, but these adjuncts are not routinely required.
Rendezvous Procedure
In some clinical scenarios, there appears to be complete or near-complete luminal clo-
sure. Examples might include a poorly managed anastomotic stricture or postradiation
stricture or strictures caused by caustic injury. In a rendezvous procedure, the surgeon
scopes from above and from below through a gastrostomy site, attempting to meet the
scopes and gently transverse a short area of luminal obliteration (Fig. 35.6). These are
Figure 35.6 Simultaneous endoscopy

through the mouth and through a gas-
trostomy to assess and dilate short
stricture with near-complete esophageal
occlusion.
LWBK1254-ch35_p401-412.indd 408 19/02/14 7:05 PM

risky but may be the only option. In these unusual cases of complete luminal oblitera-
tion, the goal is re-establishment of a distal, functional esophageal lumen. In some
cases, this may not be possible or advisable without major reoperation and possibly a
new conduit. However, one can consider antegrade and simultaneous retrograde endos-
copy via a gastrostomy. We refer to this as a rendezvous procedure. In this setting, an
endoscope is passed from above and via the G-tube site. Using the endoscopic view and
fluoroscopy, one can assess the length of luminal obliteration and determine if it can
be re-established with acceptable risk using wires, biopsy forceps, laser, etc. If the
length of luminal obliteration is negligible or considered manageable, one can attempt
to re-establish patency. Again, only in very controlled circumstances with risk of per-
foration fully explained to the patient and, in general, by experienced endoscopists
capable of simultaneous surgical intervention, if needed. In this setting extreme caution
should be used including on-the-table contrast studies, admission and observation, and
prophylactic antibiotics. We frequently leave a proline suture across this area and return
for dilation and endoscopy at frequent intervals, up to 2 to 3 per week initially (J.D.
Luketich, personal communication).8,9

Procedures
The patient is closely monitored after the completion of the dilation, while the sed-
atives wear off. Attention is given to the heart rate, blood pressure, oximetry, and
temperature for detection of early signs of sepsis. Subcutaneous emphysema could
be indicative of esophageal perforation. Although this may represent clinically insig-
nificant microperforations, the presence of subcutaneous air mandates a careful eval-
uation and clinical observation with prophylactic antibiotics. While routine barium
or gastrografin swallows are not performed following every dilation, they should be
used liberally if there is any concern over results of the dilation or to assess for
perforation.
The patient should be able to drink liquids, and detailed instructions should be
given prior to discharge regarding diet modifications, if any. Expectations of possible
discomfort and chance of recurrent symptoms should be addressed with the patient
depending on individualized findings. We typically advise a soft diet for 24 hours. Any
concerning clinical findings should prompt further evaluation including contrast esoph-
agography. However, contrast esophagography may have a false-negative rate of 10% to
38%10 and CT scan with on-table esophageal contrast may be helpful. Admission to the
hospital for closer observation may be warranted, and treatment is decided based on
the findings and clinical circumstances regarding concern for perforation.
Repeat dilation may be needed until the goal diameter of the esophageal lumen is
reached, if complete dilation of the stricture cannot be safely completed in one session.
The interval between these sessions is not clearly defined but usually ranges between
3 and 6 weeks. In some patients with very tight strictures or with near loss of lumen,
dilations may need to be performed more frequently and for longer durations.
Recurrence of dysphagia also triggers repeat endoscopy and dilation. Strictures that
recur and require multiple dilations despite adequate initial expansion are considered
refractory. These are usually anastomotic strictures after esophageal or gastric surgery,
radiation therapy, or endoscopic ablation; or corrosive esophagitis-related strictures.
Patients with such strictures are good candidates for training for independent self-
dilations using the Maloney dilators. This requires careful evaluation, education, and
instruction of the patient by the surgeon or endoscopist.11
Complications
The main complications of esophageal stricture dilation are perforation, bleeding, and
aspiration. The perforation rate for esophageal stricture dilation has been reported to
be 0.1% to 2.6% with a mortality rate of 1%.4,12 Perforation is more common with
LWBK1254-ch35_p401-412.indd 409 19/02/14 7:05 PM

malignant strictures (6.4% with a mortality of 2.3%) compared with benign strictures
(1.1% with a mortality of 0.5%).13 The risk of perforation is higher with complex
strictures, or when the patients are elderly, nonguided bougies are used or if the
endoscopist is inexperienced. Perforation rates may be higher in the treatment of
achalasia (up to 7% risk) and usually occur during the first dilation.4 Some experts
feel that the perforation rate is higher in peptic strictures than in other benign stric-
tures. However, no definitive data exists to support this claim when careful standards
of safe dilation are met. As always, starting with a smaller caliber dilator using the
Seldinger technique with endoscopic or fluoroscopic guidance is usually the safest
method. However, even with the best intentions, perforation can occur even with a
small-caliber dilator or a guidewire. The site of perforation is usually at the area of
the stricture and may be cervical, intrathoracic, or intra-abdominal. The diagnosis is
made primarily on clinical grounds, with the additional help of imaging studies (chest
x-ray, water-soluble contrast study, computed tomography). Treatment can range from
antibiotic therapy only, to endoscopic management with covered stents or clips, to
surgery depending on the location and severity of the perforation. Future dilations in
the setting of a perforated esophagus should be considered with caution. Subsequent
dilation attempts will depend on the extent of perforation, the patient’s symptoms,
and the time from the perforation event. In these circumstances, esophageal stenting
may be indicated.
Bleeding after dilation is usually minimal and self-limiting. More pronounced
bleeding can be encountered in patients taking anticoagulants and may require endo-
scopic control with clipping or ablation techniques. Aspiration is another potential risk
with upper endoscopy and dilation, particularly in patients with long-lasting obstruc-
tions or inadequate preparation. It is imperative to attempt evacuation of the esophagus
and stomach endoscopically prior to the dilation. Protection of the airway should be a
priority during sedation for the intervention or during induction of general anesthesia
with endotracheal intubation. Transient bacteremia has also been reported after dilation6
and, therefore, antibiotic prophylaxis should be offered to patients at risk of cardiac or
systemic infection as already discussed.
Results
Esophageal dilation is usually successful although the rate of success and the long-
term duration of symptom relief depend on the underlying pathology. Overall, benign
strictures are successfully dilated in 85% to 95% of the cases.4,14 Anastomotic and
peptic strictures are more easily dilated compared with the relatively more resilient
corrosive and postradiation strictures. The anatomic complexity of the strictures
(length, angulation, degree of stenosis) may also affect adversely the expected success
rate.
Studies have been performed comparing push dilators with balloon dilators. No
clear benefit of one type over the other has been demonstrated.2,15 Success rates and
risk of complications are similar and, therefore, decisions are based on the endoscopist’s
experience and the morphology of the stricture intended to be dilated.
Recurrence of dysphagia after dilation warrants endoscopic reassessment and redi-
lation. Several factors have been identified as predictive of the need for repeated dila-
tions: Nonpeptic benign strictures (e.g., radiation or corrosive-induced strictures),
fibrous strictures, and postdilation diameter <14 mm.2,4 Occasionally, tight strictures
may require scheduled repeated dilations in short intervals (i.e., weekly) to achieve
optimal results before recurrence of symptoms. The combined use of esophageal dila-
tion with endoscopic injection of steroids has been suggested as an effective strategy
for recurrent benign strictures and is commonly used in some clinical practices.16,17
However, the reported success rates vary widely.
The treatment of the underlying pathology, when possible, is of paramount signifi-
cance in preventing the recurrence of the strictures. Addressing gastroesophageal reflux
either by optimizing medical management or performing antireflux surgery should be
LWBK1254-ch35_p401-412.indd 410 19/02/14 7:05 PM

integrally linked to the treatment of peptic strictures. Careful surgical planning is

needed when antireflux surgery is considered in the presence of recurrent or difficult
to manage lower esophageal stricture, since recurrence of the stricture in the setting of
a fundoplication can severely aggravate dysphagia. In general, an aggressive regimen of
serial dilations (e.g., weekly for 1 to 3 weeks) followed by antireflux surgery or high-
dose PPIs will maximize success in difficult peptic strictures. Surgical resection may
be required in extreme situations, where the stricture does not improve with dilation
or recurs after multiple previous dilations.
Most malignant strictures can be dilated with a higher risk of perforation.5 There-
fore, these strictures should be dilated with caution over a guidewire with fluoroscopic
guidance. However, they uniformly recur rather rapidly. Chemotherapy or radiation
therapy can reduce stricture recurrence, if tumor response is noted. The short-lived
results of malignant stricture dilation can be prolonged with the use of esophageal
stents.18,19 The main clinical applications of dilation in the setting of a primary esopha-
geal malignancy are the enlargement of the lumen for passage of the EUS probe during
staging and the relief of dysphagia with a palliative intent. Following esophageal dila-

tion and possible esophageal stenting, induction systemic therapy, with or without local
radiation therapy, can often be accomplished while the patient is able to maintain
adequate oral nutrition. Maintenance of the patient’s nutritional and functional status
can reduce the risks of a future surgical resection (esophagectomy), when indicated,
Procedures
after this combination therapy.
Extrinsic esophageal compression by secondary tumors does not respond well to
esophageal dilation. Primary pathologic processes resulting in extrinsic esophageal
compression include aortic aneurysms, congenital aberrant subclavian arteries and vas-
cular rings, substernal thyroid goiters, lymphomas, and vertebral osteophytic processes.
Treatment of the underlying cause of the extrinsic compression should be the primary
concern.
Conclusions
n Esophageal dilation is used for a multitude of obstructing esophageal patholo-
gies. Most commonly, it is used in the management of iatrogenic strictures (e.g.,
anastomotic strictures), peptic strictures, corrosive strictures, and esophageal
malignancies.
n Several types of dilators are available, which are usually classified as push (Maloney,
Savary-Gilliard) or balloon (TTS) dilators. Although different dilators are commonly
used for specific indications in clinical practice, comparative studies have not dem-
onstrated a benefit of one type over the other.
n The passage of push dilators over a guidewire and the advancement of balloon dila-
tors under endoscopic vision have increased the safety of the procedure. The risk of
perforation is further reduced with the selective use of contrast and fluoroscopy,
which is usually reserved for difficult situations.
n The most common risks of esophageal dilation are perforation, bleeding, and aspira-
tion during the procedure.
n Success rates vary depending on the pathology. Peptic strictures are successfully
dilated in 85% to 95% of the patients. Corrosive or radiation-induced strictures are
harder to dilate. Recurrence may be managed with repeated dilations and endoscopic
injection of steroids. It is important to address the underlying pathology (e.g., GERD,
paraesophageal hernia, fibrous stricture, important esophageal motor disorders) in
order to decrease the risk of recurrence.
n Malignant strictures may be dilated but carry a higher risk of iatrogenic perforation.
The effect of dilation is usually short-lived and repeated dilations with potential
placement of a stent may be needed. The need of passage of the EUS probe through
a malignant esophageal lesion is a common clinical indication for dilation of a
malignant stricture.
LWBK1254-ch35_p401-412.indd 411 19/02/14 7:05 PM

Recommended References and Readings 11. Dzeletovic I, Fleischer DE. Self-dilation for resistant, benign
esophageal strictures. Am J Gastroenterol. 2010;105:2142–
1. Rice TW. Dilation of peptic esophageal strictures. In: Pearson 2143.
FG, Cooper JD, Deslauriers J, Ginsberg RJ, Hiebert CA, Patterson 12. Hernandez LV, Jacobson JW, Harris MS. Comparison among the
GA, Urschel HC Jr. (eds). Esophageal Surgery. Churchill Living- perforation rates of Maloney, balloon, and Savary dilation of
stone 2002;306–317. esophageal strictures. Gastrointest Endosc. 2000;51:460–462.
2. Standards of Practice Committee, Egan JV, Baron TH, et al. Higher perforation with Maloney.
Esophageal dilation. Gastrointest Endosc. 2006;63(6):755–760. 13. Quine MA, Bell GD, McCloy RF, et al. Prospective audit of per-
3. Patterson EJ, Herron DM, Hansen PD, et al. Effect of an esopha- foration rates following upper gastrointestinal endoscopy in two
geal bougie on the incidence of dysphagia following nissen fun- regions of England. Br J Surg. 1995;82(4):530–533.
doplication: A prospective, blinded, randomized clinical trial. 14. Pereira-Lima JC, Ramires RP, Zamin I Jr, et al. Endoscopic dila-
Arch Surg. 2000;135(9):1055–1061; discussion 1061–1062. tion of benign esophageal strictures: Report on 1043 procedures.
4. Riley SA, Attwood SEA. Guidelines on the use of oesophageal Am J Gastroenterol. 1999;94(6):1497–1501.
dilation in clinical practice. Gut. 2004;53(suppl 1):i1–i6. 15. Saeed ZA, Winchester CB, Ferro PS, et al. Prospective rand-
5. Lew RJ, Kochman ML. A review of endoscopic methods of omized comparison of polyvinyl bougies and through-the-scope
esophageal dilation. J Clin Gastroenterol. 2002;35(2):117–126. balloons for dilation of peptic strictures of the esophagus.
6. Nelson D, Sanderson S, Azar M. Bacteremia with esophageal Gastrointest Endosc. 1995;41(3):189–195.
dilation. Gastrointest Endosc. 1998;48:563–567. 16. Vasilopoulos S, Shaker R. Defiant dysphagia: Small-caliber
7. Rees CJ, Fordham T, Belafsky PC. Transnasal balloon dilation of the esophagus and refractory benign esophageal strictures. Curr Gas-
esophagus. Arch Otolaryngol Head Neck Surg. 2009;135(8):781–783. troenterol Rep. 2001;3(3):225–230.
8. Maple JT, Petersen BT, Baron TH, et al. Endoscopic management 17. Kochhar R, Ray JD, Sriram PV, et al. Intralesional steroids aug-
of radiation-induced complete upper esophageal obstruction ment the effects of endoscopic dilation in corrosive esophageal
with an antegrade-retrograde rendezvous technique. Gastroin- strictures. Gastrointest Endosc. 1999;49:509–513.
test Endosc. 2006;64:822–828. 18. Xinopoulos D, Bassioukas SP, Dimitroulopoulos D, et al. Self-
9. Bueno R, Swanson SJ, Jaklitsch MT, et al. Combined antegrade expanding plastic stents for inoperable malignant strictures of
and retrograde dilation: A new endoscopic technique in the the cervical esophagus. Dis Esophagus. 2009;22(4):354–360.
management of complex esophageal obstruction. Gastrointest 19. Van Heel NC, Haringsma J, Spaander MC, et al. Esophageal
Endosc. 2001;54:368–372. stents for the relief of malignant dysphagia due to extrinsic com-
10. Fadoo F, Ruiz DE, Dawn SK, et al. Helical CT esophagography pression. Endoscopy. 2010;42(7):536–540.
for the evaluation of suspected esophageal perforation or rupture.
AJR Am J Roentgenol. 2004;182(5):1177–1179.
LWBK1254-ch35_p401-412.indd 412 19/02/14 7:05 PM

36 Esophageal Perforation
Christian G. Peyre and Thomas J. Watson
Introduction
Esophageal perforation is a serious and potentially life-threatening medical emergency.
Given the variability in its presentation and clinical manifestations, esophageal rupture
demands considerable judgment on the part of the treating physician to achieve an optimal
outcome. In 1947, Barrett1 published the first report of a successfully repaired perforation
of the esophagus, ushering in an era when surgical therapy became the standard of care.
Over the next half-century, the principles in the management of esophageal perforation
were elucidated and management was refined. Despite decades of experience with surgical
therapy, as well as improvements in antibiotics, anesthesia, critical care, radiologic imaging,
and percutaneous interventions, mortality and morbidity rates following esophageal
perforation remain high.2 More recently, nonoperative and endoscopic approaches have
gained popularity as alternatives to surgery in appropriately selected patients, further
advancing the ability to treat this condition.3 Today, the esophageal surgeon needs to be
knowledgeable in the treatment principles, as well as the full spectrum of related diag-
nostic and therapeutic alternatives, to best manage this challenging problem.
In 1724, the Dutch physician Hermann Boerhaave published the first treatise on spon-
taneous esophageal perforation, describing the demise of Baron de Wassenaer, the Grand
Admiral of the Dutch fleet, after an episode of self-induced vomiting. Boerhaave syndrome
is due to an acute rise in intraluminal pressure in the esophagus during emesis resulting
in transmural rupture of the esophageal wall. Fortunately, Boerhaave syndrome is uncom-
mon and represents only 15% of esophageal perforations today.2 The most common con-
temporary cause of esophageal perforation is iatrogenic injury following esophageal
instrumentation, accounting for nearly 60% of all perforations. With increasing use of
flexible upper endoscopy for diagnostic evaluation and therapeutic intervention, such as
esophageal dilation or endoscopic resection, and the widespread utilization of trans-
esophageal echocardiography for the assessment of cardiac function, the incidence
of esophageal perforation is likely to rise (Fig. 36.1). Other common etiologies of esophageal
perforation include foreign body ingestion, trauma, operative injury, and malignancy.
Presentation
The clinical manifestations of esophageal perforation are variable and depend on the
size of the perforation, the extent of mediastinal, pleural, or abdominal contamination,
413
LWBK1254-ch36_p413-424.indd 413 19/02/14 10:33 PM

Figure 36.1 Chest radiograph demon-

strating extravasation of oral contrast
into the mediastinum following a
cervical esophageal perforation
sustained during transesophageal
echocardiography. The patient had a
history of chronic bronchiectasis
involving the left lung. The perforation
was successfully managed by left
cervicotomy and laparotomy with
placement of drains into the neck as
well as into the mediastinum via the
neck and the hiatus.
the time interval since perforation, associated esophageal pathology, and patient comor-
bidities. The most common presenting symptom is chest pain, often accompanied by
odynophagia, dyspnea, fevers, and chills. If the perforation is relatively recent, symp-
toms may be mild and subtle. Careful assessment of heart rate, urine output, and white
blood cell count may be helpful in determining if systemic sepsis is evolving. Twenty-
four to forty-eight hours after injury, frank sepsis with tachycardia, hypotension, altered
mental status, and respiratory failure can become evident. It is important during the
initial evaluation to perform a thorough history, focusing on pre-existing dysphagia,
heartburn, or regurgitation, as well as any prior esophageal surgery or endoscopic find-
ings, as concomitant esophageal pathology may influence the ultimate treatment strategy.
A high clinical suspicion for esophageal perforation is necessary in any patient present-
ing to the emergency room with upper gastrointestinal symptoms and a history of
esophageal disease or recent esophageal instrumentation.
The initial diagnostic examination to evaluate a patient with a suspected esophageal
perforation is a chest radiograph. It is a quick and inexpensive test that may reveal a
pleural effusion (frequently unilateral), pneumothorax, pneumoperitoneum, subcutane-
ous or mediastinal emphysema, or mediastinal widening. A normal chest radiograph,
however, does not exclude the diagnosis of an esophageal perforation, especially when
contained or in the early time period after the suspected insult.
The most widely utilized radiologic test for esophageal perforation has been a con-
trast esophagogram (Fig. 36.2). Traditional teaching has been to commence the study
with a water-soluble contrast agent, such as Gastrografin (Bracco Diagnostics Inc.,
Princeton, NJ), out of concern for exacerbating mediastinal, pleural, or abdominal con-
tamination should barium be leaked. This examination requires an alert and cooperative
patient who is able to swallow without aspirating, because Gastrografin has the potential
to induce a severe chemical pneumonitis. Judgment must be exercised in considering
LWBK1254-ch36_p413-424.indd 414 19/02/14 10:33 PM

Chapter 36 Esophageal Perforation 415
Figure 36.2 Contrast esophagogram

demonstrating contained leakage of
oral contrast due to perforation of a
midesophageal stricture sustained
during attempted esophageal dilation.

Procedures
this study for the elderly patient or others at high risk for aspiration, as any resultant
pulmonary injury can be a significant additional insult. The study typically provides a
reasonable assessment of esophageal anatomy, the location and extent of the perforation
(contained vs. free pleural or peritoneal rupture), and the presence of coexisting condi-
tions such as an esophageal stricture, malignancy, diverticulum, or motility disorder. A
negative study with Gastrografin should be followed by the use of thin barium to
increase the sensitivity of the examination. Films also should be taken with the patient
in both the left lateral and right lateral decubitus positions. A negative esophagogram,
however, does not exclude the diagnosis, as the false-negative rate is 10% to 38%.4,5
More recently, computed tomography (CT) has proven an extremely useful diagnostic
modality for assessing the various manifestations of esophageal rupture (Figs. 36.3 and
36.4). The CT findings suggestive of perforation include pneumomediastinum, pneu-
moperitoneum, subcutaneous emphysema, mediastinal fluid collection or inflammatory
changes, pleural effusion, or abdominal abscess. The definitive finding of frank leakage
of oral contrast is not always seen and should not be relied upon to prove or disprove
the diagnosis. Importantly, CT provides critical information regarding the extent and
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 pneumomedi-
astinum resulting from the contained
perforation.
LWBK1254-ch36_p413-424.indd 415 19/02/14 10:33 PM

A B
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.
location of any extraesophageal fluid collections that may require operative intervention
or percutaneous drainage.5,6
Finally, upper endoscopy serves a critical role in the assessment of the full spec-
trum of esophageal pathology including perforations. Not only can endoscopy deter-
mine the location and size of a mucosal injury, but it also allows identification of
concomitant mucosal ischemia, inflammation or ulceration, as well as more chronic or
subacute pathology such as a stricture, diverticulum, or malignancy. While concern may
exist about the safety of flexible endoscopy, with its need for insufflation, in the setting
of acute perforation, the examination typically can be completed in experienced hands
without impact on the extent of injury and provides invaluable information. Insufflation
should be kept at the minimum level necessary for adequate visualization of the entire
mucosa. Consideration should be given to placement of a chest tube prior to the pro-
cedure if concern exists about the potential to induce or exacerbate a pneumothorax.
Some perforations are subtle and may not demonstrate an obvious tear, but rather only
an ecchymotic and slightly disrupted mucosa that flutters with insufflation. As a thera-
peutic maneuver, endoscopy can be utilized for irrigation and suctioning of contained
extraluminal fluid collections, and may even assist with guidance of chest tube place-
ment by advancement of the flexible endoscope through a transmural perforation into
the pleural space.
Unfortunately, no diagnostic examination is perfect in the evaluation of esophageal
perforation. Esophagography is limited by its false-negative rate and the risk of aspira-
tion, as well as the relative inability to assess mucosal detail. CT is poor at localizing
perforations and detecting pre-existent esophageal pathology. Endoscopy is invasive
and does not usually allow determination of the extent of extraesophageal contamina-
tion. Considerable judgment, therefore, is required in deciding the order and number of
diagnostic studies based upon the clinical suspicion, information desired, patient toler-
ance, and possible therapeutic considerations. A point worthy of emphasis is that the
location and extent of perforation must be determined prior to any surgical interven-
tion, in that the planning of incisions and the type of procedure performed will depend
critically on the diagnostic findings.
LWBK1254-ch36_p413-424.indd 416 19/02/14 10:33 PM

Treatment
Principles of Initial Management

The major sequelae of esophageal perforation are sepsis and death resulting from leak-
age of gastrointestinal contents. Accordingly, the mainstays of treatment are: (1) Elimi-
nating the source of sepsis by repairing or otherwise controlling the leak, and (2)
drainage of extraluminal fluid collections. Any treatment strategy, whether nonopera-
tive, endoscopic or operative, must address these two fundamental principles.
Initial therapy should include avoidance of food by mouth, administration of intra-
venous fluids, and initiation of broad-spectrum antibiotics. Leaked enteric contents
incite a chemical burn in the mediastinum, pleural space, or peritoneal cavity and may
lead to sequestration of large amounts of fluid, further exacerbating hypotension from
developing sepsis. Antibiotics should be directed toward a polymicrobial infection

including gram-positive, gram-negative, and anaerobic bacteria. In addition, antifungal
agents should be considered in those individuals with a history of long-standing proton
pump inhibitor use, due to the increased risk of fungal colonization in the stomach.7
Chest tube thoracostomy should be considered early to drain large pleural effusions
Procedures
while preparations are made for definitive intervention.
Determining the Treatment Plan

The overall treatment plan must be individualized, considering the spectrum of nonopera-
tive, endoscopic, and operative alternatives. The criteria for nonoperative management have
been elucidated, though considerable judgment may be required in deciding when to utilize
or abandon such an approach. Available endoscopic therapies include fully covered stents
or mucosal clips. Surgical options include primary repair of the perforation, esophagectomy,
wide drainage, and esophageal exclusion or diversion. If endoscopic therapy is pursued,
one must consider drainage and/or debridement of any periesophageal collections which
might be accomplished percutaneously, thoracoscopically or with open surgery. As multiple
treatment strategies exist, the decision regarding how best to intervene may not be an easy
one. Important questions to guide decision making include the following.
n What is the etiology of the perforation?
n Where is the perforation located (cervical, thoracic, or abdominal esophagus)?
n Is it a contained perforation or free perforation into the pleural or peritoneal space?
n How extensive is the extraluminal soilage?
n What is the time interval since the perforation?
n What is the clinical condition of the patient and what are their comorbidities?
n Is there pre-existing esophageal pathology?
n Is the esophagus worth salvaging?
n Does the patient meet criteria for nonoperative management?
Nonoperative Management
For decades, surgery was the preferred treatment modality for esophageal perforation, but
was associated with high rates of morbidity and mortality. In carefully selected patients,
a nonoperative approach has proven successful and has avoided the potential complica-
tions of esophageal surgery in the emergent setting. The criteria for nonoperative manage-
ment were initially described by Cameron et al. and modified by Altorjay (Table 36.1).14,15
The initial experience was in management of patients sustaining a spontaneous perfora-
tion, though the data have been extrapolated to other causes of perforation as well. In
general, patients selected for nonoperative management have limited perforations with
minimal extraluminal contamination that is contained by adjacent tissues (Fig. 36.3).
Other important considerations include absence of sepsis, no associated distal obstruc-
tion, and an esophagus worth salvage (i.e., no malignancy or end stage benign disease).
Patients who meet these criteria can be treated with intravenous antibiotics and nothing
LWBK1254-ch36_p413-424.indd 417 19/02/14 10:33 PM

T ab l e 3 6 . 1 Suggested Criteria for Nonoperative Management of an Esophageal

Perforation
Limited intraluminal dissection
Contained transmural perforation with drainage back into the esophagus
No associated distal obstruction
Perforation not into abdominal cavity
No evidence of sepsis
Esophagus worth salvaging (e.g.,. no malignancy or end-stage benign disease)
Adapted from: Altorjay A, Kiss J, Voros A, et al. Nonoperative management of esophageal perforations. Is it justified?
Ann Surg. 1997;225(4):415–421.
by mouth. The duration of such therapy is predicated by the patient’s overall condition.
Repeat endoscopy or radiographic imaging is useful in determining the response to treat-
ment and when to resume a diet. The development of sepsis mandates repeat investiga-
tion and strong consideration of more invasive therapeutic measures.
Endoscopic Management
Advances in endoscopic therapies have created new ways to manage esophageal perfo-
rations and their sequelae. As an alternative to surgical repair in those patients not
deemed candidates for nonoperative management, esophageal stents are increasingly
being used to occlude the perforation and prevent ongoing soilage of extraesophageal
tissues (Fig. 36.5).3,8 Stents traditionally were utilized for palliation of dysphagia or
occlusion of fistulae in patients with end-stage esophageal malignancy and a short life
expectancy. With the introduction of fully covered, self-expanding, removable, plastic,
metal, and hybrid stents, the indications for stenting have increased to include nonma-
lignant conditions. A stent should be selected that provides adequate coverage of the
entire length of the perforation, ideally with several centimeters of overlap both above
and below the esophageal injury. Endoscopy with fluoroscopy is used to mark the
proximal and distal extent of the perforation. A guidewire is advanced into the stomach
and the stent is deployed over the guidewire with fluoroscopic guidance to assess
proper positioning. Repeat endoscopy is performed to ensure adequate sealing of the
perforation. The final stent position can be manipulated with biopsy forceps.
Figure 36.5 Contrast upper gastrointesti-

nal radiograph demonstrating a fully
covered stent placed to occlude a
cervical esophagogastric anastomotic
leak following esophagectomy.
LWBK1254-ch36_p413-424.indd 418 19/02/14 10:33 PM

Some perforations are not amenable to stenting, such as those high in the cervical
esophagus where a stent would extend into the pharynx or cause significant patient
discomfort, or those spanning the gastroesophageal junction that are difficult to com-
pletely occlude due to the bulbous nature of the gastric cardia and minimal distal
overlap of the perforation. The timing of stent removal is a matter of controversy,
because it is difficult to know when the perforation has healed and long-term stent
placement increases the risk of complications such as erosion into surrounding struc-
tures. Additional complications from esophageal stenting include stent migration, lumi-
nal obstruction and potential inability to remove the stent at a later date.8
While a stent may be effective at controlling the leak, endoscopic management will
fail if extraluminal contamination is not addressed by appropriate drainage of the medi-
astinum, pleural space, or peritoneum.9 The surgeon endoscopist also must be alert to the
possibility of isolating an extraluminal fluid collection and preventing it from draining
back into the esophagus. Chest tubes or CT-guided pigtail catheters can be placed into
small- to moderate-sized collections. Alternatively, a thoracotomy or minimally invasive
VATS approach can be used to debride the pleural space, decorticate the lung, and place

drains under visual guidance while avoiding the potential morbidity and mortality of
extensive esophageal surgery.
Operative Management
Procedures
Primary Surgical Repair
While endoscopic and nonoperative therapy of selected patients with esophageal per-
foration has gained in popularity, the gold standard therapy has been surgical repair.
One must remember to move to open surgical repair should the patient become septic
and further endoscopic or CT directed approaches appear to be futile.10
Primary repair is best accomplished by a two-layer closure, the first of the mucosa
and submucosa and the second of the overlying smooth muscle layers of the esopha-
gus.11 A key principle underlying successful repair is that the deeper mucosal defect
commonly extends beyond the more superficial muscular one, such that a proximal and
distal myotomy is necessary to identify the edges of the mucosa and to facilitate com-
plete closure. The mucosal edges, once adequately exposed, should be debrided back
to healthy, noninflamed tissue and reapproximated with absorbable or nonabsorbable
sutures (Fig. 36.6). A stapled technique has also been described to close the mucosal
Figure 36.6 A: Mucosa pouting

A B through a muscular defect in the
esophagus and grasped with Allis
clamps. A proximal and distal esopha-
geal myotomy is necessary to visual-
ize the full extent of the mucosal
perforation. B: The entirety of the
Extent of mucosal and submucosal perforation
mucosa tear is visualized in preparation for debri-
dement and closure.
Pouting
mucosa
LWBK1254-ch36_p413-424.indd 419 19/02/14 10:33 PM

layer using a linear GIA or TA stapler, though care must be taken to prevent luminal
narrowing; stapling over an esophageal bougie is recommended.12 The muscular layer
can then be closed independently with interrupted nonabsorbable sutures.
Depending upon the quality of tissues involved in closure and the extent of sur-
rounding contamination, consideration should be given to buttressing the repair with
adjacent viable tissue such as intercostal muscle, parietal pleura, pericardial fat,
omentum, or gastric fundus (Fig. 36.7). At the time of repair, washout, debridement,
and wide drainage of the contaminated spaces are also important. A drain should be
placed adjacent to, but not directly abutting, the suture line in case a recurrent leak
develops in the early postoperative period. In addition, a feeding tube should be
placed to facilitate nutritional support while the esophagus heals. Whether the feed-
ing tube is placed into the stomach, such as with percutaneous endoscopic gastros-
tomy, or more distally into the jejunum is a matter of judgment based on the clinical
circumstances.
Pleural flap
raised
A Pleural flap B
raised
Figure 36.7 A: Mobilization of a parietal pleural flap for buttressing of a distal esophageal perforation. B: The pleural flap is
wrapped around the perforated esophagus. C: Numerous fine sutures are used to tack the pleural flap to the healthy esophageal
muscle, isolating the perforation.
LWBK1254-ch36_p413-424.indd 420 19/02/14 10:34 PM

T ab l e 3 6 . 2 Factors That May Mandate Esophagectomy Over Primary Repair or

Endoscopic Stenting
Inability to surgically repair the perforation (e.g., perforated malignancy)
High likelihood of repair failure (e.g., high-grade distal obstruction, delayed presentation)
Persistent esophageal disease with high likelihood of poor functional outcome (e.g., recalcitrant esophageal
stricture, end-stage achalasia)
Esophagectomy
If the decision is made that esophageal repair or stenting is futile, or the esophagus is
deemed not worth salvaging (e.g., end-stage achalasia), esophagectomy may be required
(Table 36.2). In general, a transthoracic approach is best, as it allows the removal of the
perforated esophagus and irrigation and wide drainage of the infected pleural and medi-

astinal spaces. A transhiatal resection may be appropriate in selected cases. Classically,
the thoracotomy or thoracoscopic incisions are made on the side of a pleural effusion,
as this pleural space will need to be washed out and the ipsilateral lung decorticated.
During the abdominal phase of the operation, it is important to provide nutritional
Procedures
access with a gastric or jejunal feeding tube.
If the patient is septic or at risk for becoming hemodynamically unstable in the
early postoperative period, foregut reconstruction should be delayed due to concern of
inducing conduit ischemia if esophageal replacement were completed. In this situation,
a cervical end esophagostomy is fashioned for drainage of oral secretions. Important
surgical principles include a left neck incision to dissect out the cervical esophagus,
protection of the recurrent laryngeal nerves, and preservation of as much proximal
esophagus as possible to aid in future reconstruction. A longer length of proximal
esophageal remnant also permits placement of the esophagostomy on the chest wall
rather than in the neck, facilitating secure application of an external drainage bag
and increasing patient comfort. In such cases, the esophagus should be tunneled super-
ficial to the clavicle to reach the skin on the anterior chest.
Esophageal Diversion
The most complete method to divert the flow of gastrointestinal contents from the
mediastinum is esophagectomy with end esophagostomy. Some surgeons, however,
have advocated esophageal diversion without esophagectomy to facilitate an easier
reconstruction after recovery. Proximal diversion is most commonly accomplished by
end cervical esophagostomy, although esophageal T-tube and side cervical esophagos-
tomy have been described.13 Distal diversion can be achieved by surgical division at
the gastroesophageal junction using a linear cutting stapler or, alternatively, using a TA
stapler without division of tissues. This latter technique for distal diversion has been
touted to make future reconstruction easier, though it should be used with caution.
Early recanalization of the stapled, undivided esophagus can occur, resulting in ongo-
ing soilage if the perforation has not healed. In general, esophageal diversion rarely
should be necessary.
Special Considerations
Location of the Perforation

Most perforations occur in the thoracic esophagus, though rupture of the cervical or
intra-abdominal portions may occur as well. Cervical perforations are generally well
tolerated. Fascial investments surrounding the esophagus in the neck often contain
cervical perforations, facilitating nonoperative therapy with antibiotics alone. However,
deteriorating clinical condition which may manifest by worsening neck swelling or
tenderness, increasing cervical cellulitis or subcutaneous emphysema or development
of a cervical abscess or mediastinitis warrants surgical exploration with irrigation,
LWBK1254-ch36_p413-424.indd 421 19/02/14 10:34 PM

debridement and wide drainage through a cervical incision. In most situations, such
drainage is sufficient and attempts at direct visualization and repair of the perforation
may prove difficult, unsuccessful and unnecessary. Careful physical examination and
CT scans of the chest and neck are important studies to rule out undrained collections
and early abscess formation that can lead to ascending or descending mediastinitis.
As there are typically only a few centimeters of intra-abdominal esophagus, perfo-
rations into the peritoneal cavity are less common than those occurring into the thorax.
Such perforations can occur, however, with endoscopic interventions aimed at the
lower esophageal sphincter, such as pneumatic dilation or per oral endoscopic myot-
omy (POEM) for achalasia, balloon or rigid dilation for benign strictures or tumors, or
any variety of endoscopic mucosal resective or ablative technologies. An important
anatomic consideration in patients with sliding or paraesophageal hernias is that the
hernia sac is bounded cranially by the phrenoesophageal ligament, rendering the herni-
ated distal esophagus an intra-abdominal structure. As a result, a distal esophageal
perforation may be best addressed by laparotomy or laparoscopy. Preoperative CT imag-
ing may assist in the decision as to whether a distal perforation is optimally approached
through the chest or through the abdomen. When repair is performed below the dia-
phragm, the stomach can be used as a buttress by fashioning a partial or complete
fundoplication to cover the repair site. While placing such a fundoplication above the
hiatus in the chest has been described, conventional wisdom holds that such repairs
lead to the problems inherent in any recurrent hiatal hernia including the potential for
ischemia, pain, obstruction, or postoperative gastroesophageal reflux.
Pre-existing Esophageal Pathology

Esophageal perforation may occur in the face of pre-existing esophageal disease, and both
must be considered when devising a treatment plan. The concomitant pathology may influ-
ence the type of primary repair, or may tip the decision toward esophagectomy (Table 36.2).
The classic example is the patient with achalasia who experiences an iatrogenic
esophageal perforation at time of pneumatic dilation. Repair of the perforation alone
will not ameliorate the symptoms of achalasia. Equally important, the unrelieved distal
esophageal obstruction imposed by a poorly relaxing or hypertensive lower esophageal
sphincter may increase the risk of postoperative leak from the repair site. In this cir-
cumstance, the best approach is to close the perforation in two layers, perform a distal
esophageal (modified Heller) myotomy on the contralateral side of the esophagus away
from the perforation, and create a partial fundoplication that serves as both an antireflux
valve and a buttress of the mucosal repair. In patients with end-stage achalasia or recal-
citrant esophageal strictures, repair alone may lead to ongoing dysphagia or regurgita-
tion; such individuals may benefit from esophagectomy. In addition, patients with
esophageal malignancy should be considered for definitive surgical resection of their
cancer at the time of treatment of the perforation.
Complications and Results

The results following treatment of esophageal perforation historically were poor with
significant morbidity and mortality. A recent meta-analysis of 726 patients revealed a
mortality rate of 18%.2 Nonoperative management in carefully selected patients (Table
36.1) has been shown to be safe and effective. Altorjay reported on a series of 20 patients
treated with an initial nonoperative approach. Sixteen patients (80%) were successfully
managed, while four (20%) required operative intervention of which two (10%) died.
The morbidity rate was 20%. The authors commented that the mortalities were failures
of the decision to manage nonoperatively and were negatively impacted by the delayed
operative intervention, underscoring the importance of appropriate patient selection.15
More recently, Keeling et al.16 reported on a series of 25 patients treated nonoperatively
using strict criteria similar to those described in Table 36.1. Their treatment algorithm
resulted in a mortality of 8% and morbidity of 48%, with the two deaths in patients
with metastatic esophageal cancer who refused operative intervention.
LWBK1254-ch36_p413-424.indd 422 19/02/14 10:34 PM

In patients undergoing surgical treatment for the management of esophageal perfora-

tion, the results have been quite varied. In a meta-analysis of 572 patients, collective
mortality ranged from 0% to 80% among the case series reviewed. For patients undergo-
ing primary repair (n = 322), the average mortality was 12% (0% to 31%), while after
esophagectomy it was 17% (0% to 43%, n = 129), following esophageal exclusion it was
24% (0% to 80%, n = 34) and following surgical drainage alone it was 36%
(0% to 47%, n = 88).2 Care must be exercised in interpreting these data as straightforward
cases treated early after perforation may have been selected for primary repair, while more
complicated or delayed perforations likely mandated resection, diversion, or drainage.
Traditional dogma warned against attempting primary surgical repair in patients
whose treatment was delayed beyond 24 hours from the time of perforation; resection
or drainage procedures historically were recommended for such cases. In a recent meta-
analysis, the mortality of primary repair was 4% when surgery occurred less than
24 hours after the perforation, compared with 14% for those patients whose treatment
was delayed longer. Of note, when all treatment modalities including primary repair,
esophagectomy, drainage, and exclusion procedures were examined, the mortality was

14% for those treated in less than 24 hours and increased to 27% for those treated
beyond 24 hours from perforation. These data highlight the increased risk associated
with delayed treatment regardless of the surgical therapy rendered.2
Whyte et al. reported a series of 22 patients, 9 of which were treated beyond
Procedures
24 hours with an overall mortality of 5%. Of the nine patients, three had a recurrent
leak compared with only one who underwent early repair. All postoperative leaks were
successfully managed with drainage alone. Their experience suggests that primary
repair of perforations beyond 24 hours can be accomplished successfully in selected
cases with acceptable mortality.12
With the introduction and popularization of self-expanding esophageal stents,
enthusiasm for their application in the treatment of esophageal perforation has been
increasing. Results from endoscopic treatment strategies compare favorably with surgi-
cal repair. A recent meta-analysis of 267 patients treated with esophageal stenting found
a success rate of 85% at managing the leakage. Concurrent drainage of an extraesopha-
geal fluid collection was necessary in 59% of cases. Mortality for these patients was
13%, similar to patients who underwent surgical repair. Thirty-four percent of patients
suffered a stent-related complication including stent migration in 29%, bleeding in 2%,
and tissue overgrowth in 5%. Other complications included erosion, failure to achieve
a functional seal, and inability to remove the stent at a later date. Surgical intervention
for incomplete sealing or a stent-related complication was necessary in 13% of patients.8
Patients at increased risk for failure of endoscopic management include those with
perforations of the cervical esophagus or gastroesophageal junction and those with
esophageal injuries longer than 6 cm.17
Conclusions
Esophageal perforation remains a serious and challenging clinical problem that requires
considerable skill, judgment, and creativity to manage. While the treatment tools within
the surgeon’s armamentarium continue to evolve, the principles underlying therapy
remain constant and guide decision making. The basic tenets of managing the esopha-
geal defect, draining extraluminal fluid, and alleviating distal esophageal obstruction,
while treating infection and providing supportive care including nutrition, are critical
whether an operative, endoscopic, or nonoperative therapy ultimately is rendered. A
treatment plan must not only consider the details of the perforation, including size, site,
time interval from onset, and extent of contamination, but also the presence of con-
comitant esophageal disease and the clinical condition of the patient, including comor-
bidities and performance status. The introduction of fully covered and potentially
removable self-expanding esophageal stents has increased the utilization of endoscopy
for definitive therapy, avoiding the need for surgery in many patients for whom previ-
ously there was no other alternative. It must be continually emphasized that successful
LWBK1254-ch36_p413-424.indd 423 19/02/14 10:34 PM

stenting of esophageal perforations will only occur if all periesophageal collections of

any significance are drained simultaneously or as soon as they develop; thus, mandat-
ing careful follow-up of any patient who is stented. The decision to proceed with an
operation, whether it is for attempted primary repair and drainage or for esophageal
extirpation, can be a difficult one, weighing the magnitude of the procedure against the
risk to the patient of persistent leakage and sepsis going unabated. The esophageal
surgeon must be well versed in the treatment principles and the full spectrum of diag-
nostic and therapeutic modalities, including endoscopic techniques and operations
involving the neck, thorax, and abdomen, to manage the various manifestations of
esophageal perforations in an optimal manner.
Recommended References and Readings mortality. Ann Surg. 2005;241(6):1016–1021; discussion 1021–
1023.
1. Barrett NR. Report of a case of spontaneous perforation of the 10. Abbas G, Schuchert MJ, Pettiford BL, et al. Contemporaneous
oesophagus successfully treated by operation. Br J Surg. 1947;35 management of esophageal perforation. Surgery. 2009;146(4):
(138):216–218. 749–755; discussion 755–756.
2. Brinster CJ, Singhal S, Lee L, et al. Evolving options in the man- 11. Wright CD. Primary repair for delayed recognition of esophageal
agement of esophageal perforation. Ann Thorac Surg. 2004;77 perforation. In: Ferguson MK, ed. Difficult Decisions in Thoracic
(4):1475–1483. Surgery: An Evidence-Based Approach. London: Springer;
3. Sepesi B, Raymond DP, Peters JH. Esophageal perforation: surgi- 2007:298–304.
cal, endoscopic and medical management strategies. Curr Opin 12. Whyte RI, Iannettoni MD, Orringer MB. Intrathoracic esophageal
Gastroenterol. 2010;26(4):379–383. perforation. The merit of primary repair. J Thorac Cardiovasc
4. Swanson JO, Levine MS, Redfern RO, et al. Usefulness of high- Surg. 1995;109(1):140–144; discussion 144–146.
density barium for detection of leaks after esophagogastrectomy, 13. Linden PA, Bueno R, Mentzer SJ, et al. Modified T-tube repair
total gastrectomy, and total laryngectomy. AJR Am J Roentgenol. of delayed esophageal perforation results in a low mortality rate
2003;181(2):415–420. similar to that seen with acute perforations. Ann Thorac Surg.
5. Fadoo F, Ruiz DE, Dawn SK, et al. Helical CT esophagography 2007;83(3):1129–1133.
for the evaluation of suspected esophageal perforation or rup- 14. Cameron JL, Kieffer RF, Hendrix TR, et al. Selective nonoperative
ture. AJR Am J Roentgenol. 2004;182(5):1177–1179. management of contained intrathoracic esophageal disruptions.
6. White CS, Templeton PA, Attar S. Esophageal perforation: CT Ann Thorac Surg. 1997;27,404–408.
findings. AJR Am J Roentgenol. 1993;160(4):767–770. 15. Altorjay A, Kiss J, Voros A, et al. Nonoperative management of
7. Elsayed H, Shaker H, Whittle I, et al. The impact of systemic esophageal perforations. Is it justified? Ann Surg. 1997;225(4):415–
fungal infection in patients with perforated oesophagus. Ann R 421.
Coll Surg Engl. 2012;94(8):579–584. 16. Keeling WB, Miller DL, Lam GT, et al. Low mortality after treat-
8. van Boeckel PG, Sijbring A, Vleggaar FP, et al. Systematic ment for esophageal perforation: a single-center experience. Ann
review: temporary stent placement for benign rupture or anasto- Thorac Surg. 2010;90(5):1669–1673; discussion 1673.
motic leak of the oesophagus. Aliment Pharmacol Ther. 2011;33 17. Freeman RK, Ascioti AJ, Giannini T, et al. Analysis of unsuc-
(12):1292–1301. cessful esophageal stent placements for esophageal perforation,
9. Vogel SB, Rout WR, Martin TD, et al. Esophageal perforation in fistula, or anastomotic leak. Ann Thorac Surg. 2012;94(3):959–
adults: aggressive, conservative treatment lowers morbidity and 964; discussion 964–965.
LWBK1254-ch36_p413-424.indd 424 19/02/14 10:34 PM

37 Congenital Diaphragmatic
Hernia Repair: Open and
Thoracoscopic
Kevin P. Lally
In general, the presence of a congenital diaphragmatic hernia (CDH) is an indication for
repair (Figs. 37.1 and 37.2). Most patients with CDH will present in the first 24 hours of
life although, they can present as late as adulthood. The first reported survivor from
repair in the first 24 hours of life was by Gross in 1946. It required advances in anesthe-
sia, neonatal critical care, and mechanical ventilation before a number of infants would
survive. By the late 1960s, centers were reporting the survival of ∼50% in infants with
CDH. Surgical repair was traditionally performed via a laparotomy or thoracotomy until
the advent of minimally invasive surgery in infants. The timing of repair was generally
considered a surgical emergency until the late 1980s when reports of delayed repair were
first seen. It is now rare that a CDH is repaired in the first 6 to 12 hours of life, and many
are repaired after 5 days of life. Contraindications to repair would include fatal chromo-
somal anomalies such as trisomy 13 and 18. While not an absolute contraindication,
survival in infants with single ventricle physiology is so poor that many would not rou-
tinely offer surgical correction to these patients.1 Prematurity is not a contraindication
and successful repair has been performed on infants who were 26 weeks’ gestational age.2
Operative repair of a CDH should be performed when the patient is medically stable.
This definition varies amongst centers. In the patient who is not on extracorporeal life
support (ECMO), we plan for operation when the patient does not require significant
ventilator support (peak inspiratory pressures <25, FiO2 < 0.5) with preductal oxygen
saturations over 90. Ideally, the pulmonary hypertension has resolved, but this may not
always occur. If the patient is on ECMO, we will usually operate within the first 24 to
48 hours on ECMO unless the patient is significantly edematous in which case we delay
until the infant is at dry weight.3
425
LWBK1254-ch37_p425-432.indd 425 20/02/14 1:40 PM

Figure 37.1 External view of a con-

genital diaphragmatic hernia in a
newborn. Note the barrel-shaped
chest and scaphoid abdomen.
The location for repair will depend on the patient’s stability. If the patient is not
on ECMO or high-frequency oscillatory ventilation (HFOV), we will often plan for
repair in the operating room. If the patient is on ECMO, repair is performed in the
intensive care unit as transport on ECMO can be difficult. Patients on ECMO receive
aminocaproic acid as a loading dose 1 hour before operation, and this is continued
for 36 to 48 hours after repair.4 We also make liberal use of the argon cautery when
doing repair on ECMO.
Planning
• Repair on minimal ventilator support
• Repair ideally when pulmonary hypertension is resolved
• Early repair with aminocaproic acid if on ECMO
Surgery
There are several operative approaches to the repair of a CDH. Repair can be done via
an open laparotomy or thoracotomy or using minimally invasive techniques via lapa
roscopy or thoracoscopy. We approach the open repair via a subcostal incision and a
minimally invasive repair via thoracoscopy.
Figure 37.2 Chest x-ray of a congenital

diaphragmatic hernia in a newborn.
Bowel loops are noted in the left chest
(arrow).
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Chapter 37 Congenital Diaphragmatic Hernia Repair: Open and Thoracoscopic 427
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.

Open Repair
Positioning
Procedures
Patients are placed in the supine position with a small shoulder roll on the side of the
defect. It is important to assure the chest is in the sterile field in the rare instance when
a thoracotomy may be needed to help reduce the contents. This is more likely to occur
with right-sided defects.
Technique
We use a broad subcostal incision approximately 2 cm below the costal margin. Once
the abdomen is entered, the bowel is carefully manipulated from the chest into the
abdomen. It may occasionally be difficult to get the spleen down. In that instance, using
a vein retractor on the anterior edge of the diaphragm and gentle traction on the stom-
ach can be helpful. In patients who are not on ECMO, the posterior lip of the diaphragm
is mobilized (Fig. 37.3). This dissection is minimized in patients on ECMO due to the
bleeding risk.
Primary repair can be performed using pledgeted 2-0 polyester suture or silk sutures
(Fig. 37.4). We use the 1 mm polytetrafluoroethylene (PTFE) soft tissue patch for those
patients who require a patch repair. We create a cone-shaped patch by taking pleats in
the patch as it is sewn to the edges of the diaphragm or ribs (Fig. 37.5). Alternatively, the
patch can be preformed and then sewn in place.5 This allows for improved pulmonary
compliance postoperatively and a potentially decreased risk of recurrent herniation. The
defect size can be quite variable and very larger defects may be a challenge to repair. The
defect should be characterized into one of four standardized classes (A to D) (Fig. 37.6).
Figure 37.4 Primary repair using silk

suture (pledgeted polyester can be
used as well).
LWBK1254-ch37_p425-432.indd 427 20/02/14 1:40 PM

Figure 37.5 A: Pleating the PTFE

patch. B: Cone folded from PTFE
patch and fixed with stitches.
C: Cone-shaped patch sewn into A’
CDH defect.
B’
A B
A B C
While fascial closure is ideal, it may not be possible to close the abdomen at
the time of CDH repair. If it appears that the closure will be tight, we will either
sew a patch onto the abdominal wall or perform closure of just the skin.6 The patch
can be slowly reduced and if skin closure is used, the resultant ventral hernia can
be closed at a later date. We do not routinely use a drainage tube in the thorax, but
do use a Silastic Blake or Jackson-Pratt drain if the patient is on ECMO.
Open Repair
• Subcostal approach
• Avoid posterior dissection if on ECMO
• Cone-shaped patch
Minimally Invasive Repair
Positioning
Infants who are candidates for thoracoscopic repair are on low levels of mechanical
ventilator support.7 The patient is placed with the affected side up. These infants are
usually on minimal levels of mechanical ventilation and are transported to the operat-
ing room for repair. The patient is positioned at a right angle to the table at the foot of
the bed. We position the infant in a modified thoracotomy position which allows for
Defect A Defect B Figure 37.6 Classes of CDH defects.
Defect C Defect D
LWBK1254-ch37_p425-432.indd 428 20/02/14 1:41 PM

Anesthesiologist Figure 37.7 Patient and surgeon

positioning for minimally invasive
CDH repair.
Surgical
assistant
Camera
holder
Monitor

Surgeon
Procedures
Scrub nurse
conversion to open repair if necessary. The operating surgeons are positioned at the
patient’s head (Fig. 37.7).
Technique
We place a 5-mm port just below the tip of the scapula. After confirming appropriate loca-
tion, 4 mm Hg of CO2 inflation is used. This facilitates both visualization and reduction
of contents. Two 3-mm ports or stab wounds are then placed on either side of the scapula
(Fig. 37.8). The defect is identified and the bowel is carefully reduced. One must avoid
trying to reduce the contents too rapidly as this can lead to bowel injury. Similar to an
open repair, it can sometimes be a little difficult to reduce the spleen into the abdomen.
Once the contents are reduced, the defect is carefully inspected (Fig. 37.9). If it
appears that a primary repair can be achieved, we will continue with a thoracoscopic
approach. The recurrence rate with this approach is much higher than with the open
Minimally Invasive Repair

• Stable patient • Position the patient with the affected side up
• Not performed in patients on ECMO • Careful manipulation of bowel and spleen
• Position for possible open repair • 3-mm instruments are used for the repair
Figure 37.8 Port placement for mini-

mally invasive CDH repair.
Camera port
Instruments
LWBK1254-ch37_p425-432.indd 429 20/02/14 1:41 PM

Figure 37.9 Inspection of the dia-

phragmatic defect after reduction of
the herniated contents. This repre-
sents an “A” defect.
repair, hence if it appears as if the repair will be under too much tension, we will con-
vert to an open repair. We use 3-0 silk sutures for the repair (Fig. 37.10).
We do not routinely leave a thoracic drainage tube in place with either approach.
Patients are kept on minimal pressures for their ventilator support postoperatively as
they were preoperatively.
Management of infants with CDH will vary depending on the severity of their illness.
In the patients on ECMO, we will continue the aminocaproic acid for 36 hours after
operation. Patients are weaned from ECMO over the course of 7 to 14 days. If the
patient has a patch placed on the abdomen, we do not routinely manipulate it until
off ECMO.
In those patients off ECMO and those who wean from ECMO, we continue to strive
for a minimal ventilation strategy to avoid further lung injury.8 We will tolerate Pco2
levels in the 60s if necessary to avoid higher airway pressures. Management of the
pulmonary hypertension is a cornerstone of caring for these infants. We have a policy
of liberal use of echocardiography to direct appropriate use of nitric oxide, vasopres-
sors, and other pulmonary vasodilators. In the era of preoperative ECMO, the need for
ECMO after operation is infrequent.
Figure 37.10 CDH repaired thoraco-

scopically with 3-0 silk sutures.
LWBK1254-ch37_p425-432.indd 430 20/02/14 1:41 PM

While management of infants with smaller defects is relatively straightforward,

management of those patients in the high risk/large defect group requires close atten-
tion to ventilator and cardiopulmonary management. They may take weeks to stabilize
and adapt to the high pulmonary pressures. We start enteral feedings as soon as there
is evidence of GI tract function. Most infants do not require further operations, but a
percentage will need feeding access, antireflux surgery, and repair of early recur-
rences.
Complications
There are a number of postoperative complications that can occur following the repair
of CDH. Recurrent herniation while in the hospital occurs in just over 2% of infants
with open repair and in almost 9% of infants who have thoracoscopic repair.9 Late recur-
rence is relatively common in those infants with a large defect. Postoperative chylotho-

rax can occur in about 5% of cases. This usually resolves without surgical intervention.
There are also a number of problems that can arise following hospital discharge to
include hearing abnormalities, chest wall deformities, wound hernias, and gastro-
esophageal reflux.10,11
Procedures
Results
Overall survival for infants with CDH approaches 70% on average. Survival of infants
who undergo surgical repair exceeds 80%. Almost all infants with a smaller defect will
survive, but patients with large defects have a survival between 50% and 70%.12 Out-
comes of these patients appear to be improved when cared for in centers seeing more
than 6 to 10 patients per year.13 While recurrent herniation is not uncommon in patients
with very large defects, these can usually be repaired without significant risk of further
reherniation. The role of thoracoscopic repair is unclear. While the approach clearly
offers better cosmesis and reduction of the herniated content is fairly straightforward,
the recurrence rate of almost 9% is worrisome. Others have also shown that the infants
can develop a marked acidosis during operation due to the carbon dioxide insufflation
in the chest.
As mentioned above, long-term follow-up for these patients is quite important.
There are a number of problems that can arise over the course of follow-up. The Amer-
ican Academy of Pediatrics has published guidelines for follow-up.14
Conclusions
n CDH is a spectrum of disease. Some infants with small defects are repaired easily
and do well. Infants with absence of the diaphragm and other anomalies are much
higher risk for both survival and long-term complications
n Repair should be undertaken when the infant has stabilized
n If the infant requires ECMO to stabilize, then repair can be done early in the ECMO run
n Thoracoscopic repair can be attempted in patients on low levels of support
n Large defects should be repaired with a cone-shaped patch to avoid tension
n Open repair can be done via a subcostal incision
n Repair on ECMO should include use of aminocaproic acid to decrease hemorrhage
n Patients with large defects are at the highest risk for mortality
n Careful monitoring of cardiopulmonary function is crucial in the acute phase
n Long-term follow-up is important due to a number of problems that can arise over
time
LWBK1254-ch37_p425-432.indd 431 20/02/14 1:41 PM

Recommended References and Readings 8. Boloker J, Bateman DA, Wung JT, et al. Congenital diaphrag-
matic hernia in 120 infants treated consecutively with permis-
1. Graziano JN. Congenital Diaphragmatic Hernia Study Group. sive hypercapnea/spontaneous respiration/elective repair.
Cardiac anomalies in patients with congenital diaphragmatic J Pediatr Surg. 2002;37(3):357–366.
hernia and their prognosis: A report from the Congenital Dia- 9. Tsao KJ, Lally PA, Lally KP. Congenital Diaphragmatic Hernia
phragmatic Hernia Study Group. J Pediatr Surg. 2005;40(6): Study Group. Minimally invasive repair of congenital diaphrag-
1045–1049. matic hernia. J Pediatr Surg. 2011;46(6):1158–1164.
2. Tsao K, Allison ND, Harting MT, et al. The Congenital Diaphrag- 10. Morini F, Capolupo I, Masi R, et al. Hearing impairment in con-
matic Hernia Study Group. Congenital diaphragmatic hernia in genital diaphragmatic hernia: The inaudible and noiseless foot
the preterm infant. Surgery. 2010;148:404–410. of time. J Pediatr Surg. 2008;43(2):380–384.
3. Harting MT, Lally KP. Surgical management of neonates with 11. Koivusalo AI, Pakarinen MP, Lindahl HG, et al. The cumulative
congenital diaphragmatic hernia. Semin Pediatr Surg. 2007; incidence of significant gastroesophageal reflux in patients with
16:109–114. congenital diaphragmatic hernia-a systematic clinical, pH-metric,
4. Downard CD, Betit P, Chang RW, et al. Impact of AMICAR on and endoscopic follow-up study. J Pediatr Surg. 2008;43(2):
hemorrhagic complications of ECMO: A ten-year review. J Pedi- 279–282.
atr Surg. 2003;38(8):1212–1216. 12. Lally KP, Lally PA, Van Meurs KP, et al; Congenital Diaphrag-
5. Loff S, Wirth H, Jester I, et al. Implantation of a cone-shaped matic Hernia Study Group. Treatment evolution in high-risk
double-fixed patch increases abdominal space and prevents congenital diaphragmatic hernia: Ten Years’ Experience with
recurrence of large defects in congenital diaphragmatic hernia. diaphragmatic agenesis. Ann Surg. 2006;244:505–513.
J Pediatr Surg. 2005;40(11):1701–1705. 13. Bucher BT, Guth RM, Saito JM, et al. Impact of hospital volume
6. Rana AR, Khouri JS, Teitelbaum DH, et al. Salvaging the severe on in-hospital mortality of infants undergoing repair of con-
congenital diaphragmatic hernia patient: Is a silo the solution? genital diaphragmatic hernia. Ann Surg. 2010;252(4):635–642.
J Pediatr Surg. 2008;43(5):788–791. 14. Lally KP, Engle W. American Academy of Pediatrics Section on
7. Arca MJ, Barnhart DC, Lelli JL Jr, et al. Early experience with Surgery; American Academy of Pediatrics Committee on Fetus
minimally invasive repair of congenital diaphragmatic hernias: and Newborn. Postdischarge follow-up of infants with congeni-
Results and lessons learned. J Pediatr Surg. 2003;38(11):1563– tal diaphragmatic hernia. Pediatrics. 2008;121:627–632.
1568.
LWBK1254-ch37_p425-432.indd 432 20/02/14 1:41 PM

Index
Note: Page number followed by f and t indicates figure and table respectively.
A reoperative antireflux surgery, 85–95 GIST and leiomyoma, 331–337, 340,

Ablation of intestinal metaplasia (AIM) trial, Toupet fundoplication, 20–21, 21f, 22f, 346–350
358 37–38, 166–167, 168f, 170 strictures, 402t, 410–411
Achalasia, laparoscopic Heller myotomy transabdominal, Nissen fundoplication Biodegradable stents, 385–386
with fundoplication for, 161–171 36–37 Bloating, 3, 12, 13, 26, 30, 40, 87, 88, 119,
complications, 169 transabdominal, partial fundoplication 121, 122, 130, 132, 134
indications for, 161–162 37–38 Boerhaave’s syndrome, 268, 413
postoperative management, 168–169 transoral incisionless fundoplication Bougienage. See Esophageal stricture
preoperative assessment, 162–164, 163f (TIF), 109–119 dilation
results, 169–171 transthoracic Nissen fundoplication, 43–49 Brachytherapy, 396
surgical procedure, 164–167 Antireflux valves, 385 Bravo pH monitoring system, 2–3. See also
closure, 167 Argon plasma coagulation (APC), 363 Ambulatory pH monitoring;
dissection, 165, 165f 24-hour pH monitoring
Dor fundoplication, 166, 167f
myotomy, 165–166, 166f B
patient positioning, 164 Balloon dilators, 401, 406–408, 407f C
port placement, 164–165, 164f Balloon fiber, 367 CDH. See Congenital diaphragmatic hernia
sigmoid esophagus and, 167 Bariatric Centers of Excellence, 106 (CDH)
Toupet fundoplication, 166–167, 168f Bariatric surgery, 97. See also Gastric bypass Cefazolin, 3, 144, 219
Achalasia, transthoracic approach Barium contrast study, 30, 61, 86, 87, 94, Cervical esophagogastric anastomosis,
for, 173–181 124, 132, 163, 345, 389–390, 392f, 227–230, 228f, 229f
complications, 181 403, 415f Cervical perforations, 422
contraindications to, 174 Barium esophagram. See Barium contrast study Charlson Comorbidity Index (CCI), 123
indications for, 173–174 Barium swallow. See Barium contrast study Chemotherapy, and esophageal stent
outcomes, 181 Barrett’s esophagus (BE), 2, 17, 30, 53, 67, placement, 395–396
postoperative management, 181 72, 77, 78, 78, 87, 89, 110, 124, Chest tube thoracostomy, 417, 419
preoperative assessment, 174 149, 150, 158, 163, 235, 273, 353, Collard anastomosis, modified, 269, 270f
surgical procedure, 174–181 377, 381 Collis gastroplasty, 33, 34f, 58–59, 59f–61f,
esophageal resection and replacement, after endoscopic mucosal resection, 377 65, 75, 76f, 90, 91f. See also Belsey
178–181, 179f, 180f definition of, 353 Mark IV partial fundoplication;
esophagomyotomy, 175, 175f, 176f dysplastic, 368f Laparoscopic Collis gastroplasty
esophagomyotomy with partial (Belsey) incidence of, 353 Collis gastroplasty, open, 75–83
fundoplication, 177, 177f, 178f laser therapy for, 364 complications, 82
extended esophagomyotomy, 177–178, photodynamic therapy for, 367f contraindications to, 77
178f radiofrequency ablation for, 353–362 indications for, 76–77, 77f
reoperative esophagomyotomy, 178 (see also Radiofrequency ablation postoperative management, 80–82
Airway stent, 385 (RFA))BE. See Barrett’s esophagus preoperative planning, 77–78
Alimaxx-E stent, 388, 389f (BE) results of, 82–83
Ambulatory pH monitoring, 31. See also Belsey Mark IV partial fundoplication, 51–62 surgical procedure
Bravo pH monitoring system; complications, 62 and fundoplication procedures, 80, 81f
24-hour pH monitoring indications for, 52 transabdominal Collis gastroplasty,
5-aminolevulinic acid (ALA), 363 postoperative management, 61 78–79, 79f
Antibiotics usage, in esophageal perforation, preoperative planning, 52–53 transthoracic Collis gastroplasty, 79–80,
417 results, 62 81f
Antiemetics surgical procedure Colon interposition, 317–327
after Belsey partial fundoplication, 61 Collis gastroplasty procedure, 58–59, advantages of, 317
after laparoscopic Nissen fundoplication, 59f–61f complications, 325–326
12 esophageal mobilization, 53–54 contraindications to, 318
after laparoscopic partial fundoplication, 25 gastric fundoplication, construction of, dilated/tortuous grafts, 326, 327f
after paraesophageal hernia repair, 157 56–58, 56f–58f disadvantages of, 317–318
after radiofrequency ablation, 357 gastroesophageal junction and cardia, indications for, 318
after transoral incisionless fundoplication, mobilization of, 54–55, 55f postoperative management, 324–325, 325f
118, 119 initial steps, 53 preoperative planning, 318–319
Antireflux procedures, 1 patient positioning, 53 results, 326, 327f
Belsey Mark IV partial fundoplication, thoracotomy, 53 surgical procedure
51–62, 141–144 Belsey, Ronald, 15, 43, 51 colon conduit preparation, 320
Dor repair, 21–22, 166, 23f, 167f Belsey’s artery, 54, 140 left colon interposition, 320–323
Hill repair, 22–25, 24f, 151–156 Benign disease management right colon interposition, 324
laparoscopic Nissen fundoplication esophageal stents in, 396–398, 397f short-segment/long-segment colonic
(LNF), 1–14, 129–131 esophagectomy for, 218, 233, 264, 268, interpositions, 319–320
partial fundoplications, laparoscopic, 15–27 290, 297, 305, 318, 325, 326 vagal-sparing esophagectomy, 324
433
LWBK1254-Ind_p433-438.indd 433 21/02/14 10:18 AM

434 Index
Colonoscopy, 319 esophageal dilation in, 402–403, 402t indications for, 183
Computed tomography (CT), 17, 105, 124, (see also Esophageal stricture postoperative management, 189
236, 274, 290, 298, 325f, 330, 344, dilation) preoperative planning, 184, 184f
390, 415, 416f, 419 intraluminal brachytherapy, 396 results, 190
Congenital diaphragmatic hernia (CDH) self-expanding plastic stents and SEMS, surgical procedure, 185–189, 185f–189f
chest x-ray of, in newborn, 426f 389, 394–395, 397 ESD. See Endoscopic submucosal dissection
defect, classes of, 428f and uncovered metallic stent, 386 Esophageal adenocarcinoma (EAC). See
repair of Dyspnea, 123, 124, 137, 148, 158, 330, 414 Esophageal carcinoma
complications and outcomes of, 431 Esophageal anastomotic leaks, 402–403
indications for, 425 Esophageal carcinoma, 2, 217–219, 235, 263,
minimally invasive, 428–430, E 383, 384t, 396f. See also En bloc
429f, 430f Echocardiography, 430 esophagectomy; Ivor Lewis
open repair, 427–428, 428f EMR. See Endoscopic mucosal resection esophagectomy; Transhiatal
postoperative management, 430–431 En bloc esophagectomy, 251–261 esophagectomy (THE)
preoperative planning for, 425–426, complications, 259–260 Esophageal dilation, 401–411
426f anastomotic leaks, 260 clinical goal of, 402
Constipation, and antireflux surgery, 88 chylothorax, 260 complications of, 409–410
Contrast study. See Barium contrast study conduit ischemia, 259–260 contraindication to, 403
Cricopharyngeal myotomy diaphragmatic herniation, 260 indications for, 402–403, 402t
complications, 209, 210t malrotation of gastric conduit, 260 postoperative management in, 409
contraindications to, 203 recurrent laryngeal nerve injury, 260 preoperative planning in, 403–404
indications for, 203 tracheobronchial injury, 260 results of, 410–411
postoperative management, 209 concept of, 251 surgical procedure for, 404–409
preoperative planning, 204 indications for, 251–252 balloon dilators, 406–408, 407f
results, 209 postoperative management, 259 patient positioning, 404
surgical technique, 205–209, 205f–209f preoperative planning, 252–253 push dilators, 404–406, 405f, 406f
Zenker’s diverticulum and, 203–210 results, 260–261 rendezvous procedure, 408–409, 408f
Cryotherapy, 364 surgical procedure, 253 types of dilators, 401, 402t
complications, 370 abdominal phase, 253–256, 254f–255f Esophageal diversion, 421
contraindications to, 365 anesthetic technique, 253 Esophageal hiatus, 34, 35f
indications for, 364 patient positioning, 253 Esophageal leiomyomas. See Leiomyomas
postoperative management, 370 thoracic phase, 256–259, 257f–258f (LMs)
preoperative planning, 365 Endoscopic appearance, of esophageal stent, Esophageal manometry. See Manometry
results, 371 392f Esophageal neoplasia, endoscopic
technique for, 365, 368 Endoscopic cap resection technique, 376, modalities for, 363–371. See also
376f. See also Endoscopic resection Endoscopic resection;
Endoscopic mucosal resection (EMR), Radiofrequency ablation (RFA)
D 273–274, 353, 374, 376–377, 376f, Esophageal perforations. See also Iatrogenic
DeMeester score, 86 377f. See also Endoscopic resection esophageal perforations;
Diaphragmatic defect, inspection of, 430f Endoscopic resection Intrathoracic esophageal
Diet complications, 380–381 perforations
after gastric bypass, 103–104 indications for, 373–374, 374t, 375t clinical manifestations of, 413–414
after laparoscopic Nissen fundoplication, postoperative management, 380 complications and outcomes of, 422–423
12 preoperative planning, 375 management of, 397, 398
after partial fundoplications, 25 endoscopic ultrasound, 375 partial fundoplications and, 25
after transoral incisionless fundoplication, PET/CT, 375 preoperative planning of, 414–417, 415f,
118 results, 381 416f
Dilation. See Esophageal dilation surgical process, 375 treatment for, 417–422, 418t
Distal diversion, 421 endoscopic mucosal resection, 376–377, Esophageal reconstruction, with colon. See
Distal esophageal diverticula, 193. See also 376f, 377f Colon interposition
Epiphrenic diverticula endoscopic submucosal dissection, Esophageal reconstruction, with jejunum,
Distal esophageal perforation, 422 377–380, 378f–379f 307–316. See also Merendino
Distal myotomy, 419 resected specimens handling, 379f, 380 jejunal interposition
Dor fundoplication, 166, 167f, 170. See also Endoscopic submucosal dissection (ESD), complications, 315
Dor repair 374, 377–380, 378f–379f. See also contraindications to, 308
Dor, Jacques, 15 Endoscopic resection dissection of jejunum, 309
Dor repair, 21–22, 23f, 166–167, 167f. Endoscopic ultrasound (EUS), 219, 290, 345, esophagojejunal anastomosis, 313–314, 314f
See also Partial fundoplications 375, 402, 403 feeding jejunostomy, 315
Drop test, 10 in esophageal perforations assessment, indications for, 308
Drug-eluting stents, 385 416, 418–419 indicator flap, creation of, 313, 313f
Dysphagia, 40 through mouth, 408f intra-abdominal route, 312, 312f
achalasia and, 161 Epiphrenic diverticula, 183, 184, 193 intraoperative and postoperative
after laparoscopic Nissen fundoplication, 13 barium esophagram of, 184f, 195f management, 315
after partial fundoplications, 26 minimally invasive approach for, 193–202 jejunal branches, selection and division
Barrett’s esophagus and, 353–354 (see also complications, 202 of, 310–312, 311f
Barrett’s esophagus (BE)) esophagogastroduodenoscopy, 195 jejunum anatomy, 309
causes of, 384 indications for, 193–194 jejunum delivery through substernal
malignant laparoscopic approach, 199–201, 199f, 200f tunnel, 313
chemotherapy and radiation therapy, patient positioning, 195 manubriectomy and dissection of donor
395–396 postoperative management, 201, 201f vessels, 309–310, 310f
intraluminal brachytherapy, 396 preoperative planning, 194, 195f microvascular anastomosis, 313
treatment of, 395 results, 202 patient positioning, 309
palliation, esophageal stenting in, 383, VATS approach, 195–199, 196f, 198f posterior mediastinal route, 308–309, 308f
384t open esophageal myotomy and resection preoperative planning, 308–309, 308f
scoring system in, 389 of, 183–191 recreating continuity in abdomen, 314–315
treatment of complications, 190 results, 316
LWBK1254-Ind_p433-438.indd 434 21/02/14 10:18 AM

Index 435
substernal route, 308–309, 308f EUS. See Endoscopic ultrasound (EUS) jejunojejunostomy, preparation for, 101,
substernal tunnel, creation of, 310 Expandable metal stents, 384–385. See also 101f
Esophageal shortening, 65, 77 Esophageal stent placement jejunum and mesentery, division of, 100, 100f
definition of, 65 advantage of, 383, 386 leak test, 102
findings associated with, 78 covered, 386f, 387, 388f patient positioning, 99
types of, 65–66, 66f retrospective analysis of, 387 stapled side-to-side jejunojejunostomy,
Esophageal squamous cell carcinoma, 374, and rigid stents, comparison of, 394–395 construction of, 101, 102f, 103f
375t, 381. See also Esophageal risk of, 383 technique, 99–102
carcinoma uncovered, 386f trocar configuration for standard 5-port
Esophageal stent placement Extracorporeal life support, 425, 428, 430–431 technique, 99, 99f
complications of, 393–395, 393t, 394f weight loss prior to, 98
evolution in, 383 Gastric emptying study, 3, 18, 53, 67, 88, 95,
indications for, 383–386 F 149, 204
outcomes of, 394–398 FDA-approved self-expanding stents, in Gastroesophageal junction (GEJ), 3, 22, 51,
in benign disease management, United States, 388t 53, 55f, 56f, 65, 76, 90, 109, 110,
397–398, 397f Fine-needle aspirations (FNAs), 346 121, 124, 128–129, 140–143, 147,
in malignant disease management, Flamingo Wall stent, 388 163, 200, 246, 418, 421
395–396, 396f Flexible bronchoscopy, 385, 390 limited resection of (see Merendino
rigid vs. expandable stents, 395 Fundoplication jejunal interposition)
postoperative management, 391–392 for achalasia, 161–171 tumors, 218, 248, 251, 263, 265f, 273, 338,
preoperative assessment, 389–390 Belsey Mark IV partial, 51–62 (see also 345f
stent design, 386–389 Belsey Mark IV partial Gastroesophageal reflux disease (GERD),
technique, 390–391, 390f, 391f fundoplication) 1–2, 29, 85, 109
Esophageal stricture dilation Dor, 166, 167f, 170 surgery for (see different antireflux
complications of, 409–410 Nissen, laparoscopic, 1–13, 129–131 surgery procedures)
indications of, 402–403, 402t (see also Laparoscopic Nissen Gastrografin, 414–415
origin, 401 fundoplication (LNF)) Gastrointestinal radiograph, 418f
outcomes of, 410–411 Nissen, transthoracic, 43–49 (see also Gastrointestinal stromal tumors (GISTs),
postoperative management, 409 Transthoracic Nissen 338–340, 343
preoperative planning, 403–404 fundoplication) computed tomography of, 345f
surgery, 404–409 open transabdominal approach, 29–41 esophageal, 338
types of, 401, 402t complications, 40 management of, 340, 349–350, 350t
Esophagectomy contraindications to, 30 presentation and diagnosis, 339–340, 339f
en bloc (see En bloc esophagectomy) indications for, 29 tumor markers, 339
Ivor Lewis (see Ivor Lewis gastroesophageal reflux disease, 29–30 Gianturco-Rösch Z stents, 387, 388
esophagectomy) mechanical obstruction, 30 GISTs. See Gastrointestinal stromal tumors
minimally invasive, 217, 243–250, 273 apatient preparation for, 31 (GISTs)
(see also Minimally invasive Ivor postoperative management, 40 GPEH (See Paraesophageal Hernia)
Lewis esophagectomy) preoperative assessment, 30–31
Transhiatal, 217–233 (see also Transhiatal results, 40–41
Esophagectomy) surgical procedure H
Esophagectomy, left thoracoabdominal error and post-fundoplication HALO 360 RFA device, 354–355, 355f
approach for, 263–264 problems, 38, 39f Heartburn. See Gastroesophageal reflux
complications extrinsic sphincter reconstruction, disease (GERD)
cervical infection, 271 34–35, 35f–37f Heller myotomy, for achalasia, 161–171
chylothorax, 271 positioning and instrumentation, Hernia sac, reduction and dissection of, 54, 68,
costal arch dehiscence, 271 31–32 80, 121, 126–127, 138–140, 150–152
contraindications to, 264 reinforcement of intrinsic sphincter, Hiatus hernia (HH), 1, 31, 43, 121, 122f
indications for, 264–265 35–38, 38f High-frequency oscillatory ventilation, 426
postoperative management, 271 restoration of intra-abdominal High-grade dysplasia (HGD), 2, 273, 274,
preoperative planning, 265 esophagus, 32–33, 32f–34f 354, 373, 374t, 381. See also
surgical procedure, 266–271 partial, 15–28 (see also Partial Barrett’s esophagus (BE)
incision closure, 269–271 fundoplications, laparoscopic; Dor Hill esophagogastropexy, 22–25, 24f,
patient positioning, 265, 266f Repair, Toupet fundoplication; Belsey 150–157. See also Partial
thoracoabdominal incision, 266–269, Mark IV partial fundoplication) fundoplications, laparoscopic
267f–270f Toupet, 20–21, 21f, 22f, 37–38, 166–167, Hill, Lucius, 15
Esophagectomy with substernal pull-up, 168f, 170
289–295 transoral incisionless, 109–119
complications and results, 295 (see also Transoral incisionless I
contraindications to, 290 fundoplication (TIF)) Iatrogenic esophageal perforations, 397,
indications for, 289 397f, 402
postoperative management, 292–293 Imatinib, 339
preoperative planning, 290 G Infants, with congenital diaphragmatic
surgical procedure, 290 Gagging, 12 hernia, 426f
position and incision, 290 Gas bloat, 13, 40 complications and outcomes of, 431
substernal route, 290 Gastric bypass, 97–105 open repair, 427–428
surgical techniques, 290–292, 291f–294f complications after, 105, 105t operative approaches for, 426–430
Esophagitis, 30 contraindications to, 97–98 postoperative management, 430–431
Esophagogastric flap valve, 17, 17f indications for, 97 preoperative planning for, 425–426, 426f
Esophagogastric junction (EGJ), 29. See also outcomes, 106 thoracoscopic repair of, 428–429
Gastroesophageal junction (GEJ) postoperative management, 103–104 Intestinal metaplasia (IM), 353. See also
Esophagogastroduodenoscopy (EGD), 2, 30, preoperative planning, 98 Barrett’s esophagus (BE)
87, 212, 332, 390 surgical procedure, 98–103, 104f Intraluminal brachytherapy, single-dose of, 396
Esophagram, 416 antibiotic prophylaxis, preoperative, 98 Intramucosal adenocarcinoma, 373, 374t,
EsophyX device, 109. See also Transoral DVT prophylaxis, preoperative, 98 381. See also Endoscopic resection
incisionless fundoplication (TIF) gastric pouch, creation of, 99–100, 100f Intrathoracic esophageal perforations, 397, 410
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436 Index
Ivor Lewis esophagectomy, 235–236 crus closure, 8–9, 9f, 10f right VATS technique, 346–349, 347f,
contraindications to, 236 esophageal length, assessment of, 8, 9f 348f
indications for, 235–236 esophageal mobilization, 8 surgical process, 346–349
minimally invasive, 243–248, 273–288 fundoplication, 9–12, 10f–12f Ligate-and-cut technique, 376, 376f.
abdominal phase, 244–245, 244f–246f, goal of, 3 See also Endoscopic resection
275–281, 275f-281f hiatal dissection, 5–7, 6f LMs. See Leiomyomas (LMs)
results, 248, 287 peritoneal access, 3–4 LNF. See Laparoscopic Nissen
thoracic phase, 246–248, 246f–248f, positioning, 3, 4f fundoplication (LNF)
282–285, 282f-285f retroesophageal window, creation of, Lower esophageal sphincter (LES), 1, 78
open, 237–243 7–8, 8f Low-grade dysplasia (LGD), 354. See also
abdominal phase, 237–238, 237f–238f room setup, 3, 4f Barrett’s esophagus (BE)
and anastomotic leaks, 241 short gastric vessels division, 7, 7f
complications, 240–242 Laparoscopic paraesophageal hernia repair,
postoperative mortality rates, 241 121–134 M
thoracic phase, 238–240, 240f complications, 133, 133t Malignant disease, esophageal stent
preoperative planning, 236 contraindications to, 123 insertion for, 384f, 395–396, 396f
endoscopic evaluation, 236 indications for, 122–123 Maloney bougies, 141, 141f, 404, 406f
radiologic evaluation, 236 key elements of, 121–122 Manometry, 2, 16, 17f, 31, 52, 67, 88, 90, 110,
postoperative management, 132, 134 124, 138, 149, 163, 163f, 174, 194
preoperative assessment, 123–124 in achalasia, 163, 174
J blood test, 123 McKeown esophagectomy, 273, 274
Jackson-Pratt (JP) drain, 94, 197, 199, 202, 285 esophageal physiology testing, 124 Megaesophagus, 174
Jejunal interpostion. See Merendino jejunal flexible endoscopy, 124 Merendino jejunal interposition, 297–306
interposition history examination, 123 abdomen exploration, 298
Jejunostomy feeding, 219, 224, 230–231, pulmonary function testing, 124 abdominal lymphadenectomy, 301
238, 245, 246f, 259, 279–280, 281f, radiographic evaluation, 124 complications
286, 291, 293, 325, 421 results, 134 anastomotic leakage, 305
Jejunum, reconstruction with. See surgical procedure, 124–132 hemorrhage, 304
Esophageal reconstruction, with antireflux barrier, re-establishing of, respiratory, 304
jejunum; Merendino jejunal 129–131 diaphragmatic hiatus and GEJ, dissection
interposition circumferential floppy Nissen of, 299–300, 299f
fundoplication, 130, 130f distal esophagus, en bloc dissection of,
crural closure, 131–132, 131f 301
K floppy diaphragm sign, 128 distal esophagus, transection of, 300, 300f
Killian’s triangle, 203, 211 hernia sac reduction, 126–128, 127f, 128f esophagojejunostomy and
Kocher maneuver, 224, 224f intra-abdominal esophageal length, jejunogastrostomy, 302–304, 303f
re-establishing of, 128–129, 129f goal of, 298
liver retraction, 126 indications for, 297
L patient positioning, 125 isoperistaltic jejunal conduit, preparation
Laparoscopic Collis gastroplasty, 65–73 port placement, 125–126, 125f of, 301–302, 302f
complications, 72–73 wedge Collis gastroplasty, 129, 129f patient positioning, 298
contraindications to, 66–67 Laparoscopic partial fundoplications, postoperative management, 304
indications for, 65–66, 66f 15–27. See also Partial preoperative planning, 297–298
postoperative management, 71–72 fundoplications, laparoscopic proximal stomach, transection of, 301, 301f
preoperative planning, 67 Laser therapy, 364. See also Argon plasma results, 305
results of, 73, 73t coagulation (APC); ND:YAG laser Mesenteric arteriography, 319
surgical procedure, 68–69 therapy Metabolic syndrome, 106
doughnut hole, creation of, 68 complications, 370 Microvasive Wallstent I, 386–388
EEA and linear stapler, use of, 68, 68f indications for, 364 Midesophageal diverticula, 193. See also
final staple line, 71f postoperative management, 369–370 Epiphrenic diverticula
first staple line, 70f results, 370–371 Minimally invasive esophagectomies
GIA stapler through left subcostal port, technique for, 365, 368 (MIEs), 243–248, 273–288. See also
70f Leiomyomas (LMs), 343, 344f Minimally invasive Ivor Lewis
initial set-up for Collis gastroplasty, 69f computed tomography of, 344f esophagectomy
neoesophagus, final view, 71f incidence and presentation of, 344–345 Minimally invasive Ivor Lewis
positioning, 67 open resection of, 329–338 esophagectomy, 244–249, 273–287
second staple line, 70f anesthesia for, 331 complications, 287, 287t
wedge approach, 68–69, 69f clinical presentation and, 330 indications for, 273–274
Laparoscopic correction of epiphrenic complications, 338 laparoscopic phase
diverticulum, 199–201, 199f, 200f contraindications to, 331 feeding jejunostomy, placement of,
Laparoscopic esophagectomy. See diagnosis and, 330 279–280, 281f
Minimally invasive Ivor Lewis indications for, 330–331 final steps, 281–282, 281f
esophagectomy, laparoscopic phase patient positioning, 331, 332f gastric conduit, creation of, 278–279,
Laparoscopic Nissen fundoplication (LNF), postoperative management, 338 278f, 279f
1, 35–36, 85, 129–131 preoperative planning, 331 port placement, 275–276, 275f
complications results, 338 pyloroplasty, creation of, 279, 280f
intraoperative, 12 surgical technique, 332–337, staging, 276f
postoperative, 12–13 332f–337f stomach, mobilization of, 276–278
contraindications to, 2 thoracoscopic approach for resection of, patient positioning, 275
indications for, 2 343–349 postoperative management, 286
postoperative management, 12 complications, 349 preoperative planning, 273–274
preoperative assessment, 2–3 endoscopic biopsy in, 345–346 results, 287
results, 13 indications for, 345 thoracoscopic phase
surgical procedure, 3 postoperative management, 349 esophageal mobilization, 282–284, 283f
cannula and liver retractor placement, preoperative planning, 345–346 esophagogastric anastomosis, creation
4–5, 5f results, 349 of, 284–285, 284f, 285f
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Index 437
final steps, 285–286, 286f Paraesophageal hernia (PEH), 30, 121, 147, Merendino jejunal interposition, 298
port placement, 282, 282f 148f minimally invasive approach for
Modified Heller esophagomyotomy, 177, repair of epiphrenic diverticula, 195
177f, 178f laparoscopic approach for, 121–134 minimally invasive Ivor Lewis
Myotomy (see also Laparoscopic esophagectomy, 275
Extended, 177–178 paraesophageal hernia repair) open Ivor Lewis esophagectomy, 237
Heller, 161–171, 177 open abdominal approach for, 147–158 open resection of leiomyomas, 331, 332f
laparoscopic, 200 (see also Paraesophageal hernia, paraesophageal hernia, open Hill repair
open cricopharyngeal, 203–210 open Hill repair of) of, 150–151
open esophageal, 183–191 transthoracic approach for, 137–145 paraesophageal hernia, transthoracic
in sigmoid esophagus, 169–170 (see also Paraesophageal hernia, repair of, 138
Transthoracic, 175–176 transthoracic repair of) partial fundoplications, 18, 19f
Thoracoscopic, 197 type II, 121, 122f reoperative antireflux surgery, 89
type III, 121, 122f transhiatal esophagectomy (THE), 219, 220f
type IV, 121, 122f transoral incisionless fundoplication
N Paraesophageal hernia, transthoracic repair (TIF), 113
Nasogastric decompression, 12, 61, 103, of, 137–145 Zenker’s diverticulum, transoral repair of,
189, 240 complications, 144–145 212
Nasogastric suction, after Belsey partial crural sutures, failure of, 145 PDT. See Photodynamic therapy (PDT)
fundoplication, 61 leakage of gastrointestinal content, 144 PEH. See Paraesophageal hernia (PEH)
Nasogastric tube, 49, 59, 61, 69, 71, 92 102, postprandial pain, 145 Peptic strictures, 402
103, 132, 144, 168–168, 177, 178f, vagal nerve injury, 145 Perforations. See Esophageal perforations
179, 181, 189, 201, 209, 209f, 230, contraindications to, 137 pH monitoring, 88
239 240, 252, 259, 265, 304 indications for, 137 Photodynamic therapy (PDT), 353, 363, 383
Nathanson liver retractor, 5, 164f, 165 postoperative management, 144 complications, 370
Nausea, after laparoscopic Nissen preoperative assessment, 137–138 contraindications to, 364
fundoplication, 12 results, 145 indications for, 364
ND:YAG laser therapy. See Neodymium: surgical procedure, 138 postoperative management, 369
yttrium-aluminum garnet (Nd:YAG) anesthesia for, 138 preoperative planning, 365
lasers Belsey fundoplication, 141–144, results, 370–371
Needle knife, 378. See also Endoscopic 142f–144f technique, 365–368, 366f, 367f
resection crural sutures placement, 141, 142f Photofrin, 365
Neodymium: yttrium-aluminum garnet esophageal lengthening procedure, Plastic stents, 388. See also Esophageal stent
(Nd:YAG) lasers, 363, 364, 368, 140–141, 141f placement
371, 393, 395, 396. See also Laser esophagus mobilization, 139 Pneumatic dilation, for achalasia, 162
therapy hernia sac mobilization and resection, Polyflex stent, 388, 389f
Neoesophagus, 58, 65, 82 139–140, 140f Porfimer sodium, 363
Nissen fundoplication incision, 138 Port placement
laparoscopic (see Laparoscopic Nissen patient positioning, 138 for congential diaphragmatic hernia
fundoplication (LNF)) technique, 139–141 repair, 429, 429f
Transabdominal (see fundoplication, open Partial fundoplications, laparoscopic, 15–27 for diverticulum repair, 195, 196f, 199, 199f
transabdominal approach) complications for fundoplication, 3–5, 5f, 18, 19f
transthoracic (see Transthoracic Nissen intraoperative, 25 for Heller myotomy for achalasia,
fundoplication) postoperative, 25–26, 26t 164–165, 164f
Nissen, Rudolf, 43, 51 contraindications to, 16 for minimally invasive esophagectomy,
Nitinol, usage of, 386 indications for, 15–16 244f, 246, 275, 275f, 282, 282f
Niti-S stent, 388–389, 389f postoperative management, 25 for paraesophageal hernia repair, 125–126,
Nonobstructive mesenteric ischemia preoperative assessment, 16–17, 17f, 18t 126f
(NOMI), 315 results of, 26–27 for thoracoscopic resection of LM and
Nonpeptic benign strictures, 410 surgical procedure, 18 GIST, 346
dissection, 18, 20, 20f Positron emission tomography (PET),
Dor repair, 21–22, 23f esophageal cancer and, 219, 290
O Hill repair, 22–25, 24f, 151–156 Postfundoplication dysphagia, treatment of,
Obesity, and gastroesophageal reflux port placement, 18, 19f 402
disease, 30 positioning, 18, 19f Proton pump inhibitors (PPIs), 29, 72, 109,
Obesity Surgery Mortality Risk Score Toupet repair, 20–21, 21f, 22f 354, 357, 391, 402
(OS-MRS), 98 Patient positioning Protoporphyrin IX (PpIX), 363
Ondansetron, 117. See also Antiemetics Belsey Mark IV partial fundoplication, 53 Proximal diversion, 421
Opiate usage, and antireflux surgery, 88 congenital diaphragmatic hernia, minimally Proximal esophageal cancer, esophageal
Oversized stents, complications of, 394. See invasive repair of, 428, 429f stents in, 385
also Esophageal stent placement congenital diaphragmatic hernia, open Proximal myotomy, 419
repair of, 427 Proximal stents, complications of, 393, 394
en bloc esophagectomy, 253 Pseudoachalasia, 162
P esophageal dilation, 404 Pulmonary embolus, after gastric bypass, 105
Paraesophageal hernia, open Hill repair of, esophageal reconstruction, with jejunum, Pulmonary function testing (PFT), 124, 149,
147–158 309 174, 219, 236, 274, 290, 318
advantages of, 150 esophagectomy, left thoracoabdominal Push dilators, 401
complications, 158 approach, 265, 266f
indications for, 148–149 fundoplication, 31–32
postoperative management, 157–158 gastric bypass, 99 R
preoperative assessment, 149–150, Heller myotomy and fundoplication for Radiation therapy, and esophageal stent
149f achalasia, 164 placement, 385, 395–396
results, 158 laparoscopic Collis gastroplasty, 67 Radiofrequency ablation (RFA)
surgical procedure, 150–156 laparoscopic Nissen fundoplication, 3, 4f for Barrett’s esophagus, 353–362
patient positioning, 150–151 laparoscopic paraesophageal hernia complications, 358
technique, 151–156, 151f–157f repair, 125 contraindications to, 354
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438 Index
Radiofrequency ablation (RFA) (Continued) in minimally invasive esophagectomy, historical perspective on, 43
indications for, 354 282–286 indications for, 44
postoperative management, 357–358 for paraesophageal hernia repair, 137–145 postoperative management, 48–49
preoperative planning, 354 for resection of gastrointestinal stromal preoperative planning, 45
results, 358–359 tumors, 343–350 results, 49
surgical procedure, 354–357, 355f–357f for resection of leiomyomas, 343–349 surgical procedure
and surveillance, 359 video-assisted (see Video-assisted access for, 45–47, 46f, 47f
Radiographic appearance, of esophageal thoracoscopic (VATS) approach) Nissen procedure, 47–48, 48f
stent, 392f Through-the-scope (TTS) balloon dilators, 24-hour pH monitoring, 2, 16, 61, 138, 149,
Radionuclide scintigrams, 204 401, 406–408, 407f 170. See also Ambulatory pH
Radio-opaque markers, 390 TIF. See Transoral incisionless monitoring; Bravo pH monitoring
Refractory strictures, 384 fundoplication (TIF) system
Rendezvous procedure, 408–409, 408f Timed barium esophagram (TBE), 30
Reoperative antireflux surgery, 85–95 Toupet, Andre, 15
complications, 94 Toupet fundoplication, 20–21, 21f, 22f, U
indications for, 86–87 36–37, 166–167, 168f, 170. See also Ultraflex uncovered esophageal stent, 386, 387
postoperative management, 94 Partial fundoplications Ultrasonic shears, 126, 244
preoperative planning, 87–88 Tracheoesophageal fistulas management, Undersized stents, complications of, 394.
results, 95 esophageal stents in, 396 See also Esophageal stent
surgical procedure, 88–94 Transhiatal esophagectomy (THE), 217–233 placement
patient positioning for, 89 advantages of, 217 Upper endoscopy, 87
redo fundoplication and, 89–90, 91f, 92f complications, 231 in achalasia, 163
Roux-en-Y near esophagojejunostomy anastomotic leak, 231 Upper esophageal sphincter (UES), 203.
and, 93–94, 93f anastomotic stricture, 232 See also Cricopharyngeal myotomy
selection of, considerations in, 89 chylothorax, 232 Upper gastrointestinal contrast studies, 17
Rigid and expandable stents, comparison of, hemorrhage, 231 Upper hand retractors system, 150–151,
394–395 recurrent laryngeal nerve injury, 231 151f, 219
Rigid plastic conduits, 383 tracheal tears, 231
Rigid stent prostheses contraindications to, 218
disadvantages of, 386 historical perspective, 217 V
and expandable stents, 394–395 indications for, 218 Vagal nerve injury/vagal nerve preservation,
Roux-en-Y (RNY) near esophagojejunostomy, postoperative management, 230–231 26t, 53, 54, 68, 89–90, 145, 177, 300,
85, 86, 88–89, 93–94, 93f preoperative planning, 219 347
principles of, 217–218 Vagal-sparing esophagectomy, 324
results, 232–233 Versaport, 5
S surgical procedure VersaStep Bladeless trocars, 164
Savary-Gilliard dilator, 404–406, 405f abdominal phase, 219–224, 220f–224f Video-assisted thoracoscopic (VATS)
Sedation, in esophageal dilation, 403–404 anesthesia for, 219 approach, 73t, 201, 331, 419
Seldinger technique, 279, 410 cervical esophagogastric anastomosis, for esophageal diverticula, 194, 195–199,
Self-expanding metallic stents, 385, 386 227, 228f–229f, 230 196f, 198f
complications in placement of, 393 cervical phase, 224–225, 224f–225f for leiomyomas, 346–349, 347f, 348f
partially covered, 387f closure, 230, 230f for minimally invasive esophagectomy,
and rigid prostheses, comparison of, 394–395 patient positioning, 219, 220f 246–247, 282–285
and self-expanding plastic stents, transhiatal phase, 225–227, 226f–228f Video esophagography, for achalasia, 174
comparison of, 389 Transient bacteremia, in dilation, 410 Vigorous achalasia, 177–178, 178f
Self-expanding plastic stents, 388, 389 Transoral incisionless fundoplication (TIF),
SEMSs. See Self-expanding metallic stents 109–119
Short esophagus. See Collis gastroplasty; complications, 118–119 W
Esophageal shortening cervical esophageal injuries, 118 Wedge gastroplasty, for esophageal
Sigmoid esophagus, 162, 167 early procedure failure, 119 lengthening, 78–79, 79f, 92f.
laparoscopic myotomy in, 169–170 mediastinal abscess, 119 See also Collis gastroplasty
Skinner, David, 51 postprocedure hemorrhage, 118–119 Weerda laryngoscope, 213, 213f
Small bowel obstruction, after gastric contraindications to, 110 Wireless (Bravo) 48-hour pH monitoring, 2–3
bypass, 105 indications for, 110
S-shaped antireflux valve, 385 postoperative management, 117–118
Stents, usage of. See also Esophageal stent preoperative planning, 110, 111f Z
placement results, 119 Zenker’s diverticulum, 203, 211
complications in, 393 surgical procedure, 110–113 open cricopharyngeal myotomy and,
considerations in, 385–386 anatomy related to, 110, 113f 203–210
designing of, 386–389 anterior plication sets placement, 115, 115f complications, 209, 210t
and esophageal perforation, 418–419 completion endoscopy, 117, 118f contraindications to, 203
placement of, 384 device removal, 117 indications for, 203
selection and effectiveness of, 383 EsophyX device, 110–111, 111f, 112f, postoperative management, 209
Subcutaneous emphysema, 380, 409, 113, 114f preoperative planning, 204
415, 421 greater curve longitudinal plication, results, 209
Supercharged pedicled jejunum (SPJ), 307. 116, 117f surgical technique, 205–209, 205f–209f
See also Esophageal reconstruction, patient positioning and preparation, 113 symptoms of, 211
with jejunum posterior plication sets placement, transoral repair of, 211–215
Supercharging technique, 307 115–116, 116f complications, 214
Superior mesenteric artery (SMA), 319 Transthoracic esophagectomy (TTE), 217. contraindications to, 211–212
See also En bloc esophagectomy; equipment for, 212
Esophagectomy, left indications for, 211
T thoracoabdominal approach for; patient positioning, 212
Temporary stents placement, 384, 385 Esophagectomy with substernal postoperative management, 214
THE. See Transhiatal esophagectomy (THE) pull-up; Ivor Lewis esophagectomy preoperative planning, 212
Thoracoscopic approach Transthoracic Nissen fundoplication, 43–49 results, 214–215
for hernia repair, 428–429 complications, 49 surgical technique, 212–213, 213f, 214f
LWBK1254-Ind_p433-438.indd 438 21/02/14 10:18 AM

1.master Techniques in Surgery - Esophageal Surgery, 1E (2014)

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What are some of the surgical procedures discussed in the document?

What are some of the surgical procedures discussed in the document?

What are some of the complications mentioned for different surgical procedures?

What are some of the complications mentioned for different surgical procedures?

LWBK1254-FM_i-xviii.

indd 1 21/02/14 9:26 PM

Colon and Rectal Surgery: Abdominal Operations

Colon and Rectal Surgery: Anorectal Operations

Hepatobiliary and Pancreatic Surgery

LWBK1254-FM_i-xviii.indd 2 21/02/14 9:26 PM

Edited by: Associate Editors

Josef E. Fischer, MD Arjun Pennathur, MD, FACS

Illustrations by: BodyScientific International, LLC.

© 2014 by WOLTERS KLUWER Health

Library of Congress Cataloging-in-Publication Data

Esophageal surgery / edited by James D. Luketich ; associate editors,

LWBK1254-FM_i-xviii.indd 4 21/02/14 9:26 PM

LWBK1254-FM_i-xviii.indd 5 21/02/14 9:26 PM

I would like to dedicate my contributions to this textbook of esophageal surgery to

I am grateful to God for the Blessings and Grace.

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Rafael S. Andrade, MD Jonathan Daniel, MD

Mara B. Antonoff, MD Gail E. Darling, MD

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André Duranceau, MD Blair A. Jobe, MD, FACS

Hiran C. Fernando, MD Michael Kent, MD, FACS

Haichuan Hu, MD Virginia R. Litle, MD

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Alex G. Little, MD Bryan F. Meyers, MD, MPH

Michael A. Maddaus, MD Christopher R. Morse, MD

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Arjun Pennathur, MD, FACS Lynne A. Skaryak, MD

Kyle A. Perry, MD Brian R. Smith, MD, FACS

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This series of mini-atlases is an outgrowth of Mastery of Surgery. As the series editor,

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Josef E. Fischer, MD, FACS

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dysplasia, as well as in very highly selected patients with intramucosal adenocarci-

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2 Laparoscopic Partial Fundoplications 15

3 Fundoplication: Open Transabdominal Approach 29

4 Transthoracic Nissen Fundoplication 43

5 Belsey Mark IV Partial Fundoplication 51

6 Laparoscopic Collis Gastroplasty 65

7 Open Collis Gastroplasty 75

8 Reoperative Antireflux Surgery 85

10 Endoscopic Antireflux Repair—EsophyX 109

11 Laparoscopic Paraesophageal Hernia Repair 121

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12 Open Paraesophageal Hernia: Transthoracic Approach 137

13 Open Paraesophageal Hernia and Hill Repair: Open Abdominal

15 Transthoracic Approach for Achalasia 173

16 Open Esophageal Myotomy and Resection of Epiphrenic Diverticula 183

17 Minimally Invasive Approach to Resection of

18 Open Cricopharyngeal Myotomy and Correction of Zenker’s

19 Transoral Repair of Zenker’s Diverticula 211

21 Ivor Lewis Esophagectomy 235

Part V: Endoscopic Ablative