Considerations for Esophageal Lengthening Procedures

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It is essential that the gastroesophageal junction lie tension free in the abdomen before creating a fundic wrap. The length of tension-free intraabdominal esophagus should be measured after closing the crural defect. When the crura are closed from the caudal condensation of the crural fibers toward the anterior margin of the hiatus, the hiatal orifice is effectively displaced cephalad. This transposition of the hiatal orifice lengthens the intraabdominal segment of esophagus because the anterior portion of the hiatus is cephalad to the posterior portion of the hiatus. If the gastroesophageal junction lies at the level of the hiatal closure, one must do something to achieve an adequate intraabdominal segment of esophagus. The first step should be esophageal mobilization. This can be done tran-shiatally or transthoracically. If the segmental arteries to the esophagus are divided to the level of the aortic arch and the vagal branches to the hilum of the lungs are divided, one can generally gain 2 cm of esophageal length. If the intraabdominal esophageal segment is still inadequate, there are several methods for lengthening the intraabdominal segment (see Chapter 14).

The Collis gastroplasty is the most widely used technique to lengthen the esophagus. First described in conjunction with transthoracic hiatal hernia repairs, the Collis gastroplasty can also be performed with minimally invasive approaches. Although some have reported outstanding long-term results with the Collis gastroplasty,17 the neoesophagus may contain acid-secreting mucosa causing concern that patients with Barrett's esophagus may continue to be exposed to acidic irritation. In the current era wherein most reoperations follow failed laparoscopic Nissen fundoplication, the proximal end of the Collis gastroplasty may become ischemic because the short gastric vessels have been previously divided. This may result in a stricture that is very difficult to treat by dilation.

In 1996, Swanstrom et al.18 described a minimally invasive transthoracic Collis gastroplasty technique (see Chapter 13). For this approach, a 12-mm trocar is placed in the right anterior axillary line in the third or fourth intercostal space. A 35-mm tissue stapler is introduced into the right chest and passed along the posterior medial sulcus until it can be seen laparoscopi-cally from the abdomen indenting the medi-astinal pleura. The pleura is incised and the stapler is advanced parallel to the esophagus. A 46- to 48-French bougie is advanced into the stomach along the lesser curvature. While the fundus is retracted laterally, the stapler is advanced along the bougie, adjacent to the angle of His. The stapler is fired creating a 3-cm

TECHNICAL SURGICAL FAILURES: PRESENTATION, ETIOLOGY, AND EVALUATION

gastric tube. The crura are closed in standard manner and a fundoplication is performed (Figure 8.6).

A Collis gastroplasty can also be performed laparoscopically without violating the thoracic cavity (see Chapter 12). An esophageal bougie is advanced along the lesser curvature. A circular stapling device is used to create a "buttonhole" in the gastric fundus adjacent to the bougie. A 35-mm tissue stapler is passed into the "buttonhole" and advanced parallel to the bougie toward the angle of His. The linear stapler is then fired creating a neoesophagus19 (Figure 8.7). The introduction of roticulating endo-scopic staplers has greatly simplified laparo-scopic esophageal lengthening procedures. Many surgeons now resect a wedge-shaped segment of the fundus to create a neoesophagus rather than using the buttonhole technique described above. Once the short gastric vessels have been divided and with a bougie in the esophagus, a linear stapler is fired across the

Foreshortened Esophagus

Figure 8.7. This laparoscopic method of addressing the foreshortened esophagus requires two types of staplers.The anvil of a circular stapler is brought through and through the body of the stomach, following a stitch on a straight needle (A). The stapler is fired, creating an aperture through the stomach (B). A linear cutting stapler is fired from this aperture to the gastroesophageal junction, completing the lengthening gastroplasty. (Reprinted from Horvath et al.,22 with permission.)

Collis Transthoracic

Figure 8.6. A minimally invasive transthoracic method of creating a Collis gastroplasty entails visualization of the hiatus from above. After the proximal stomach is mobilized, a linear stapler is brought through the thoracic port and fired alongside a bougie in the stomach (B). This creates a lengthening gastroplasty (C) that is used to form a fundoplication (D). (Reprinted from Horvath et al.,22 with permission.)

Figure 8.6. A minimally invasive transthoracic method of creating a Collis gastroplasty entails visualization of the hiatus from above. After the proximal stomach is mobilized, a linear stapler is brought through the thoracic port and fired alongside a bougie in the stomach (B). This creates a lengthening gastroplasty (C) that is used to form a fundoplication (D). (Reprinted from Horvath et al.,22 with permission.)

Figure 8.7. This laparoscopic method of addressing the foreshortened esophagus requires two types of staplers.The anvil of a circular stapler is brought through and through the body of the stomach, following a stitch on a straight needle (A). The stapler is fired, creating an aperture through the stomach (B). A linear cutting stapler is fired from this aperture to the gastroesophageal junction, completing the lengthening gastroplasty. (Reprinted from Horvath et al.,22 with permission.)

fundus near the gastroesophageal junction, perpendicular to the esophagus. This then permits the surgeon to divide the fundus adjacent to the dilator and parallel to the esophagus creating the neoesophagus. A fundoplication is then performed.

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Responses

  • Medhanie
    How is the esophagus lengthened?
    8 years ago
  • sara helenius
    What is esophageal lengthening?
    7 years ago
  • SISKO AHOLA
    What is esopageal lengthening?
    6 years ago
  • cheryle grant
    How do surgeon lengthen esophagus?
    9 months ago
  • bell
    How long does it take for esophagael lengthening?
    4 months ago
  • brigitte zimmer
    What is involved in a esophageal lengthening surgery for a hiatal hernia procedure?
    3 months ago
  • Martha
    What is esophageal lengthening called?
    5 days ago

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