SURGERY FOR BENIGN ESOPHAGEAL DISEASE · surgery for benign esophageal disease daniel t. dempsey,...
Transcript of SURGERY FOR BENIGN ESOPHAGEAL DISEASE · surgery for benign esophageal disease daniel t. dempsey,...
SURGERY FOR BENIGN ESOPHAGEAL DISEASE
Daniel T. Dempsey, MD
Professor of Surgery
University of Pennsylvania
SURGICAL BENIGN ESOPHAGEAL DISEASE
• GERD
• HIATAL HERNIA
• ACHALASIA
• DIVERTICULA (ZENKER’S AND EPIPHRENIC)
• PERFORATION/CAUSTIC INGESTION
• TUMORS/CYSTS
PREOPERATIVE EVALUATION
• History and physical examination
• EGD
• Manometry
• R/O gastrinoma and h.pylori
• pH testing*
• Gastric emptying scan*
• Upper GI series*
• Gastroenterologist and surgeon team
LAPAROSCOPIC FUNDOPLICATION
NISSEN TOUPET
Dor Fundoplication
Catarci: Ann Surg, Volume 239(3).March 2004.325-337
PARTIAL VS TOTAL FUNDOPLICATION
INCIDENCE AND SEVERITY OF HEARTBURN, LAF v LNF
5 YEAR FOLLOW UP. BROEDERS ET AL, ANN SURG, 2013
DYSPHAGIA AFTER FUNDOPLICATION (LAF v LNF)
5 YEAR DILATION AND REOPERATION: LAF v LNF
LONGTERM HEARTBURN: LAF vs LPR
Broeders et al , Annals of Surgery, 2011
LONGTERM REOPERATION: LAF vs LPF
Jamieson, Ann Surg 2008
LAPAROSCOPIC FUNDOPLICATION:PREDICTORS OF SUBOPTIMAL OUTCOME
• Abnormal esophageal motility
• No heartburn or regurgitation
• Age > 65 years
BMI and GERD in ADULT WOMEN
Jacobson, NEJM, 2006
Inpatient Mortality
0.0%
0.1%
0.2%
0.3%
0.4%
0.5%
0.6%
0.7%
0.8%
0.9%
1.0%
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Year
Inp
atie
nt m
ort
ality
Antireflux Surgery Gastric Bypass Surgery
PARAESOPHAGEAL HIATAL HERNIA
Oelschlager: Ann Surg, Volume 244(4).October 2006.481-490
HIATAL REINFORCEMENT WITH BIOPROSTHESIS
Primary (39) SIS (33)
Symptom⁎ Mean ± SD p Value† Mean ± SD p Value†
Heartburn −3.6 ± 4.0 <0.001 −3.2 ± 4.6 0.002
Regurgitation −4.3 ± 3.5 <0.001 −4.2 ± 4.0 <0.001
Dysphagia −1.0 ± 4.3 0.200 −2.0 ± 3.2 0.009
Chest pain −3.2 ± 4.1 <0.001 −3.8 ± 3.6 <0.001
Abdominal pain
−1.9 ± 3.8 0.007 −1.8 ± 3.5 0.020
Bloating −1.6 ± 3.6 0.020 −2.7 ± 3.2 0.000
Postprandial pain
−2.9 ± 3.3 <0.001 −3.6 ± 3.7 <0.001
Early satiety
Recurrent hernia
−1.2 ± 2.7
59%
0.020 −2.6 ± 3.1
54%
<0.001
Biologic Prosthesis to Prevent Recurrence after Laparoscopic Paraesophageal Hernia Repair: Long-term Follow-up from a Multicenter, Prospective, Randomized Trial (5 years)
Journal of the American College of SurgeonsVolume 213, Issue 4, October 2011, Pages 461-468
Smith: Ann Surg, Volume 241(6).June 2005.861-871
REVISIONAL ANTIREFLUX OPERATION
Pennathur et al, Ann Thor Surg, 2010
PATTERNS OF FAILURE AFTER FUNDOPLICATION
SHORT ESOPHAGUS
• Contributes to recurrent HH and wrap slippage
• Most common in type 3 and 4 HH
• Incidence 0%-20%
• Esophageal Length Index (ELI)<19.5
– Endoscopic length (cm) divided by
– Patient height (M)
– Yano et al, Surg Endosc, 2009
Transthoracic Hiatal Hernia Repair with Collis
WEDGE FUNDECTOMY
COLLIS-NISSEN FOR SHORT ESOPHAGUS
Achalasia: “Northwestern Classification”
Kaplan–Meier Curves for the Rate of Treatment Success.
Boeckxstaens GE et al. N Engl J Med 2011;364:1807-1816.
HELLER DOR PRCEDURE FOR ACHALASIA
Richards, Ann Surg, 2004
Kurian…..Swanstrom, JAMA Surgery, 2013
ESOPHAGOMYOTOMY FOR ACHALASIA
• Abdominal approach w/hemiwrap
• Laparoscopic >95%
• Good results: 85-90% @ 5 years
• End stage disease may do worse
• Life long acid suppression
Zenker’s Diverticulum
Question 1
A 68-year-old man presents due to symptoms of heartburn and regurgitation. He has a history
of numerous abdominal surgeries, including a recent exploratory laparotomy for bowel
obstruction that was notable for significant adhesions. After workup with barium swallow and
esophagogastroscopy, he is diagnosed with a hiatal hernia. Due to his significant operative
history, a transthoracic hiatal hernia repair is planned.
Which of the following is true?
A) The short gastric arteries must be divided along both the greater and the lesser curvature to
mobilize the stomach
B) If there is tension on the esophagus when the stomach is reduced, Collis gastroplasty should
be performed
C) During dissection of the hernia sac, it should be incised perpendicular to the esophagus
D) Left thoracotomy should be performed with incision in the left fourth or fifth interspace
E) Stitches should be placed so that the crura are approximated tightly around the esophagus
A 50-year-old man is taken to the operating room for laparoscopic Nissen
fundoplication for gastroesophageal reflux disease (GERD).
Which of the following is true regarding operative technique?
A) The wrap should be 2.5 cm or greater in length on completion
B) The body of the stomach is used to form the wrap
C) Division of the short gastric vessels is not necessary
D) Placement of a bougie during wrap creation helps avoid an excessively tight wrap
E) The patient should be placed in the steep Trendelenberg position
Question 3
A 48-year-old woman presents with a history of heartburn that has been only
partially relieved with proton pump inhibitors (PPIs). She has been referred for
possible laparoscopic Nissen fundoplication.
Which of the following is true regarding preoperative assessment of these
patients?
A) All patients with GERD will have evidence of mucosal damage on endoscopy
B) Esophageal manometry can be used to confirm the diagnosis of GERD
C) Patients who have not responded to PPIs are more likely to have significant
and abnormal reflux
D) GERD severity can be assessed using ambulatory pH monitoring
E) Typical symptoms of heartburn and regurgitation are highly sensitive and
specific for the diagnosis of GERD
Question 4
A 65-year-old woman presents for possible fundoplication after
being diagnosed with GERD. Esophageal manometry testing
shows abnormal peristalsis.
Which of the following is true regarding partial and full
fundoplication?
A) The wrap in a partial fundoplication extends 180 to 200° around the esophagus B) Partial and full fundoplication are equally effective for control of reflux C) Patients with weak peristalsis are more likely to have dysphagia if a total fundoplication is performed D) The right and left sides of the wrap are separately sutured to the esophagus during partial fundoplicationE) All patients with abnormal manometry should undergo partial rather than full fundoplication
Question 5
A 60-year-old man presents with persistent heartburn and
dysphagia 8 weeks after laparoscopic Nissen fundoplication.
Which of the following is true regarding persistent postoperative
symptoms?
A) A wrap that is too short can cause postoperative dysphagia B) Persistent heartburn is always indicative of persistent reflux, and PPIs should be restarted C) Revision can be completed without completely taking down the previous wrap D) Dysphagia is an expected postoperative complication that can persist for up to 12 weeksE) Barium swallow should be completed to visualize the anatomy of the esophagogastric junction
A 54-year-old woman presents with severe gastroesophageal reflux disease (GERD) that has been only partially relieved with proton pump inhibitors
(PPIs). She has been referred for possible laparoscopic Nissen fundoplication.
Which of the following is true regarding preoperative evaluation of patients prior to antireflux procedures?
• A) Patients who have not responded to PPIs are more likely to have significant and abnormal reflux
• B) All patients with GERD will have evidence of mucosal damage on endoscopy
• C) Typical symptoms of heartburn and regurgitation are highly sensitive and specific for the diagnosis of GERD
• D) GERD severity can be assessed using ambulatory pH monitoring
• E) Esophageal manometry can be used to confirm the diagnosis of GERD
The patient in the previous question undergoes esophageal manometry testing, which shows abnormal peristalsis.
Which of the following is true regarding partial and full fundoplication?
• A) The wrap in a partial fundoplication extends 180 to 210°around the esophagus
• B) Patients with weak peristalsis are more likely to have dysphagia if a total fundoplication is performed
• C) Partial and full fundoplication are equally effective for control of reflux
• D) The right and left sides of the wrap are separately sutured to the esophagus during partial fundoplication
• E) All patients with abnormal manometry should undergo partial rather than full fundoplication
Instead, the esophageal manometry in the patient in the previous two questions is found to be normal. She is planned for Nissenfundoplication.
Which of the following is true regarding operative technique?
• A) The patient should be placed in the steep Trendelenburgposition
• B) Division of the short gastric vessels is not necessary
• C) The body of the stomach is used to form the wrap
• D) The wrap should be greater than 2.5 cm in length on completion
• E) Placement of a bougie during wrap creation helps avoid an excessively tight wrap
Ten weeks after undergoing laparoscopic Nissen fundoplication, the patient in the preceding questions returns with persistent reflux symptoms and dysphagia.
Which of the following is true regarding complications of antirefluxprocedures?
• A) Dysphagia is an expected postoperative complication that can persist for up to 12 weeks
• B) Persistent heartburn is always indicative of persistent reflux, and PPIs should be restarted
• C) Barium swallow should be completed to visualize the anatomy of the esophagogastric junction in patients with persistent dysphagia
• D) A wrap that is too short can cause postoperative dysphagia
• E) Revision can be completed without completely taking down the previous wrap
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