43

Left thoracic approach to esophageal diverticula

ANDRÉ DURANCEAU

PRINCIPLES AND JUSTIFICATION

Pulsion diverticula of the distal esophagus are considered to be complications of abnormal intraesophageal pressures. The work of Cross and colleagues supported the concept that spasm of the inferior sphincter accompanied by increased contraction pressures in the esophageal body is responsible for both the symptoms and the appearance of the diverticulum. Allen and Claggett, and Benacci et al. have reported significantly fewer leaks with secondary sepsis when a myotomy is combined with diverticulectomy than when a diverticulectomy alone is performed. When surgical treatment is indicated for a distal esophageal diverticulum, the diverticulum should be excised if it is large enough and the underlying motor abnormality corrected. After myotomy, a significant weakening of the gastroesophageal junction results, and an antireflux repair is added to the myotomy to prevent reflux damage to the esophageal mucosa. A partial fundoplication is preferred, as a more complete wrap causes functional obstruction to an esophagus made powerless by the myotomy.

While the traditional approach will be discussed in this chapter, newer approaches have been developed in the era of minimally invasive surgery. These are described in detail in the chapters that follow: Chapter 44, “Thoracoscopic management of esophageal diverticula,” and Chapter 45, “Laparoscopic management of epiphrenic diverticula.”

Indications

Significant symptoms related to swallowing and to the presence of the diverticulum constitute the main indication for surgical treatment. Asymptomatic diverticula do not require operative treatment.

PREOPERATIVE ASSESSMENT AND PREPARATION

Assessment

Radiological assessment is important to identify the size and location of the diverticulum. Videoscopic radiography usually allows visualization of the accompanying motor dysfunction. Although optional, radionuclide transit studies using liquid and solid markers quantify esophageal retention.

Esophageal motility studies are essential to characterize the motor disorder accompanying the diverticulum and to determine the extent of dysfunction.

Endoscopy and 24-hour pH monitoring are important to rule out reflux disease and mucosal damage or other mucosal abnormality.

Patient preparation

The patient is put on a liquid diet for 24 hours before the operation. If there is any possibility of significant esophageal retention, lavage of the esophageal cavity is performed with the patient awake on the morning of the operation.

A cephalosporin and antibiotics active against anaerobes (such as metronidazole [Flagyl], 500 mg, or clindamycin, 600 mg) are administered before induction of anesthesia. Subcutaneous heparin sodium, 5000 U, is administered routinely 2 hours before the operation and every 12 hours thereafter until the patient is fully ambulatory and ready to leave the hospital.

OPERATION

1. The esophagus is approached through a left thoracic incision. The pleura is opened at the superior border of the eighth rib, and a small posterior segment of the rib is removed. Anesthesia via a double-lumen endotracheal tube allows exclusion and retraction of the left lung during the operation. (See Figure 43.1.)
   
2. The mediastinum is opened 1 cm anterior to the aorta, from the aortic arch to the diaphragm. At the distal extent, the pleura is incised as an inverted T to provide free access to the hiatus. The inferior pulmonary ligament is divided up to the inferior pulmonary vein.

The esophagus is mobilized proximally and at the level of the hiatus, below the diverticulum. Penrose drains are passed around it to facilitate traction and dissection. (See Figure 43.2.)

3. The esophageal body is freed completely from its fascial and vascular attachments up to the inferior border of the aortic arch.
   Progressive dissection of the diverticulum is then undertaken, with care taken to ensure that the right pleura is protected.
   If the hiatus is small and without a hernia, free access to the peritoneal cavity is obtained through a peripheral diaphragmatic incision 2-3 cm from its insertion at the chest wall. This allows complete and easy dissection of the fundus, gastrosplenic vessels, and hiatal structures. The phrenoesophageal ligament and the peritoneum are opened, and the whole gastroesophageal junction is delivered into the chest through the hiatus. The gastroesophageal fat pad is removed. (See Figure 43.3.)

Stay updated, free articles. Join our Telegram channel

Join