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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.

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Laparoscopic access for resection of an epiphrenic diverticulum a) the patient is put in a Y-position, b) positioning of the trocars, c) trocars in situ.
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Figure 3: Laparoscopic access for resection of an epiphrenic diverticulum a) the patient is put in a Y-position, b) positioning of the trocars, c) trocars in situ.

Mentions: The position of the patient is equal to the one used in other minimally invasive operations of the stomach and the distal esophagus e. g. fundoplication (Figure 3). We use four trocars. The surgeon stands between the patient's legs, the first assistant on the patient's left and a second assistant on the patient's right hand side. First, the diaphragmatic crura are exposed. The esophagus is then isolated in its distal segment and mobilized in the caudal part of the mediastinum. We use Harmonic® scalpel for dissection. Ideally, the pleural cavity is not affected during preparation. Under intraluminal endoscopic control the diverticle is identified and its neck isolated. Using a linear endostapler the neck of the diverticle is dissected and closed simultaneously with care taken to line up the stapler exactly parallel to the longitudinal axis of the esophagus. The stapler line is protected by approximating the muscular edges of the diverticular gap with single sutures. With the hydro-pneumatic test we verify a sufficient closure. We perform myotomy reaching from 2 cm distally of the cardia to 5-6 cm above the neck of the diverticle. For anti-reflux we then finish the operation with a 360°-Nissen-fundoplication. We perform a barium-swallow five 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)

Laparoscopic access for resection of an epiphrenic diverticulum a) the patient is put in a Y-position, b) positioning of the trocars, c) trocars in situ.
© Copyright Policy
Related In: Results  -  Collection

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

Figure 3: Laparoscopic access for resection of an epiphrenic diverticulum a) the patient is put in a Y-position, b) positioning of the trocars, c) trocars in situ.
Mentions: The position of the patient is equal to the one used in other minimally invasive operations of the stomach and the distal esophagus e. g. fundoplication (Figure 3). We use four trocars. The surgeon stands between the patient's legs, the first assistant on the patient's left and a second assistant on the patient's right hand side. First, the diaphragmatic crura are exposed. The esophagus is then isolated in its distal segment and mobilized in the caudal part of the mediastinum. We use Harmonic® scalpel for dissection. Ideally, the pleural cavity is not affected during preparation. Under intraluminal endoscopic control the diverticle is identified and its neck isolated. Using a linear endostapler the neck of the diverticle is dissected and closed simultaneously with care taken to line up the stapler exactly parallel to the longitudinal axis of the esophagus. The stapler line is protected by approximating the muscular edges of the diverticular gap with single sutures. With the hydro-pneumatic test we verify a sufficient closure. We perform myotomy reaching from 2 cm distally of the cardia to 5-6 cm above the neck of the diverticle. For anti-reflux we then finish the operation with a 360°-Nissen-fundoplication. We perform a barium-swallow five 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