Limits...
MIS approach for diverticula of the esophagus.

Laubert T, Hildebrand P, Roblick UJ, Kraus M, Esnaashari H, Wellhöner P, Bruch HP - Eur. J. Med. Res. (2010)

Bottom Line: Operating time was 205, 135 and 141 minutes.We performed intraoperative intraluminal endoscopy in all patients.There were no intraoperative complications and although no surgical complications occured postoperatively one patient developed pneumonia which advanced to sepsis and lethal multi organ failure.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Surgery, University of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23552 Lübeck, Germany. tlaubert@googlemail.com

ABSTRACT

Purpose: diverticula of the esophagus represent a rare pathological entity. Distinct classifications of the disease imply different surgical concepts. Surgery should be reserved for symptomatic patients only. Minimally invasive surgery (MIS) for treatment of esophageal diverticula encompasses rigid and flexible intraluminal endoscopy, thoracoscopy and laparoscopy. We here give an overview on the pathogenesis of esophageal diverticula, the minimally invasive surgical techniques for treatment and the recent literature. Additionally, we present our own experience with MIS for midthoracic diverticula.

Methods: we analyzed the cases of patients who underwent MIS for midthoracic diverticula with regard to preoperative symptoms, perioperative and follow-up data.

Results: three patients (two female, one male, age 79, 78 and 59 years) received thoracoscopic surgery for midthoracic diverticula. All patients reported of dysphagia and regurgitation. In two patients pH-investigation showed pathological reflux but manometry was normal in all patients. Operating time was 205, 135 and 141 minutes. We performed intraoperative intraluminal endoscopy in all patients. There were no intraoperative complications and although no surgical complications occured postoperatively one patient developed pneumonia which advanced to sepsis and lethal multi organ failure. Upon follow-up the two patients did not have recurrent diverticula or a recurrence of previous symptoms.

Conclusions: surgery for diverticular disease of the esophagus has been associated with high rates of morbidity and mortality. Despite the lethal non-surgical complication we encountered, with regard to recent publications minimally invasive apporaches to treat patients with symptomatic esophageal diverticula entail lower rates of complications with better long term results in comparison to open surgery.

Show MeSH

Related in: MedlinePlus

Thoracoscopic resection of a para bronchial diverticulum (Patient No. 1) a) exposure of the neck of the diverticulum, b) intraluminal view with the light source of the camera (‡) within the thorax shining through the esophageal wall, c) application of the linear stapler at the neck of the diverticle, d) intraluminal control of the stapling line.
© Copyright Policy
Related In: Results  -  Collection


getmorefigures.php?uid=PMC3351906&req=5

Figure 2: Thoracoscopic resection of a para bronchial diverticulum (Patient No. 1) a) exposure of the neck of the diverticulum, b) intraluminal view with the light source of the camera (‡) within the thorax shining through the esophageal wall, c) application of the linear stapler at the neck of the diverticle, d) intraluminal control of the stapling line.

Mentions: The patient is put in a prone position. Surgical access is performed from the patient's right hand side. The use of a double lumen tubus allows a collapse of the right lung which facilitates the procedure. The esophagus is mobilized dorsally taking care not to injure the azygos vein, the bronchial system or the descending aorta. If necessary, small arterial vessels from the aorta to the esophagus are clipped. The neck of the diverticulum has to be fully exposed (Figure 2a, b). The dissection and simultaneous closure of the midthoracic pouch is achieved by using an endostapler (Figure 2c). The perfect alignment of the stapler to the longitudinal axis of the esophagus and the complete resection of the diverticulum is verified by endoscopic control. As most midthoracic diverticula are true diverticula, the endostapler closes the esophageal wall in its full thickness. For safety reasons, adding single sutures that grasp the esophageal wall laterally of the closed resection-line are performed to cover the stapler-line. Care is taken not to create a stenosis of the esophagus when applying these extra sutures and this step should also be carried out under endoscopic intraluminal vision (Figure 2d). Two chest tubes are placed apically and basally. We perform a barium-swallow three days postoperatively before the patient is started on oral intake.


MIS approach for diverticula of the esophagus.

Laubert T, Hildebrand P, Roblick UJ, Kraus M, Esnaashari H, Wellhöner P, Bruch HP - Eur. J. Med. Res. (2010)

Thoracoscopic resection of a para bronchial diverticulum (Patient No. 1) a) exposure of the neck of the diverticulum, b) intraluminal view with the light source of the camera (‡) within the thorax shining through the esophageal wall, c) application of the linear stapler at the neck of the diverticle, d) intraluminal control of the stapling line.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC3351906&req=5

Figure 2: Thoracoscopic resection of a para bronchial diverticulum (Patient No. 1) a) exposure of the neck of the diverticulum, b) intraluminal view with the light source of the camera (‡) within the thorax shining through the esophageal wall, c) application of the linear stapler at the neck of the diverticle, d) intraluminal control of the stapling line.
Mentions: The patient is put in a prone position. Surgical access is performed from the patient's right hand side. The use of a double lumen tubus allows a collapse of the right lung which facilitates the procedure. The esophagus is mobilized dorsally taking care not to injure the azygos vein, the bronchial system or the descending aorta. If necessary, small arterial vessels from the aorta to the esophagus are clipped. The neck of the diverticulum has to be fully exposed (Figure 2a, b). The dissection and simultaneous closure of the midthoracic pouch is achieved by using an endostapler (Figure 2c). The perfect alignment of the stapler to the longitudinal axis of the esophagus and the complete resection of the diverticulum is verified by endoscopic control. As most midthoracic diverticula are true diverticula, the endostapler closes the esophageal wall in its full thickness. For safety reasons, adding single sutures that grasp the esophageal wall laterally of the closed resection-line are performed to cover the stapler-line. Care is taken not to create a stenosis of the esophagus when applying these extra sutures and this step should also be carried out under endoscopic intraluminal vision (Figure 2d). Two chest tubes are placed apically and basally. We perform a barium-swallow three days postoperatively before the patient is started on oral intake.

Bottom Line: Operating time was 205, 135 and 141 minutes.We performed intraoperative intraluminal endoscopy in all patients.There were no intraoperative complications and although no surgical complications occured postoperatively one patient developed pneumonia which advanced to sepsis and lethal multi organ failure.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Surgery, University of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23552 Lübeck, Germany. tlaubert@googlemail.com

ABSTRACT

Purpose: diverticula of the esophagus represent a rare pathological entity. Distinct classifications of the disease imply different surgical concepts. Surgery should be reserved for symptomatic patients only. Minimally invasive surgery (MIS) for treatment of esophageal diverticula encompasses rigid and flexible intraluminal endoscopy, thoracoscopy and laparoscopy. We here give an overview on the pathogenesis of esophageal diverticula, the minimally invasive surgical techniques for treatment and the recent literature. Additionally, we present our own experience with MIS for midthoracic diverticula.

Methods: we analyzed the cases of patients who underwent MIS for midthoracic diverticula with regard to preoperative symptoms, perioperative and follow-up data.

Results: three patients (two female, one male, age 79, 78 and 59 years) received thoracoscopic surgery for midthoracic diverticula. All patients reported of dysphagia and regurgitation. In two patients pH-investigation showed pathological reflux but manometry was normal in all patients. Operating time was 205, 135 and 141 minutes. We performed intraoperative intraluminal endoscopy in all patients. There were no intraoperative complications and although no surgical complications occured postoperatively one patient developed pneumonia which advanced to sepsis and lethal multi organ failure. Upon follow-up the two patients did not have recurrent diverticula or a recurrence of previous symptoms.

Conclusions: surgery for diverticular disease of the esophagus has been associated with high rates of morbidity and mortality. Despite the lethal non-surgical complication we encountered, with regard to recent publications minimally invasive apporaches to treat patients with symptomatic esophageal diverticula entail lower rates of complications with better long term results in comparison to open surgery.

Show MeSH
Related in: MedlinePlus