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10 Management of Esophageal Disease
INDICATIONS
Disabling bile reflux symptoms after esophageal surgery
PREOPERATIVE PREPARATION
Confirm bile reflux by visual inspection at endos- copy, radionuclide scan, or 24-hour pH monitoring.
Insert a nasogastric tube.
PITFALLS AND DANGER POINTS
Injury to liver, pancreas, or stomach
Damaging blood supply to residual gastric pouch
OPERATIVE STRATEGY Bile Diversion after Failed Antireflux Procedures
Bile diversion is considered only after multiple failed antireflux procedures. Generally vagotomy and antrectomy with bile diversion via a Roux-en-Y recon- struction (Figs. 10–1, 10–2) is the procedure of choice. If transabdominal vagotomy does not appear feasible because of excessive scar tissue around the abdominal esophagus,transthoracic or thoracoscopic vagotomy is an alternative.
Fig. 10–1 Fig. 10–2
Bile Diversion after Esophagogastrectomy
Bile diversion after esophagogastrectomy is used when bile reflux complicates otherwise successful esophageal resection with esophagogastrectomy.
Perform the dissection with extreme care to avoid traumatizing the blood supply to the residual stomach.
Generally, the gastric remnant is supplied only by the right gastric and right gastroepiploic vessels.A varia- tion of this procedure, the duodenal switch proce- dure, is also illustrated.
OPERATIVE TECHNIQUE Vagotomy and Antrectomy with Bile Diversion
Incision and Exposure
Ordinarily a long midline incision from the xiphoid to a point about 5 cm below the umbilicus is adequate for this operation. Divide the many adhe- sions and expose the stomach. Evaluate the difficulty of performing a hemigastrectomy, rather than other available operations. Insert an Upper Hand or Thompson retractor and determine if a transabdomi- nal vagotomy is feasible.
Vagotomy
If dissecting the area of the esophagogastric junction appears too formidable a task, thoracoscopic or trans- thoracic vagotomy is an option.
Hemigastrectomy
Close the duodenal stump by stapling or suturing.
Roux-en-Y Gastrojejunostomy
Create a Roux-en-Y limb of jejunum and then perform an end-to-side gastrojejunostomy using sutures or staples. Position this anastomosis so it sits about 1 cm proximal to the stapled closed end of the jejunum.
Complete construction of the Roux-en-Y segment by anastomosing the proximal cut end of the jejunum near the ligament of Treitz to the side of the descend- ing segment of jejunum at a point 60 cm distal to the gastrojejunostomy. Close the defect in the jejunal mesentery with interrupted sutures.
Closure
Close the abdominal wall without drainage in the usual fashion.
Bile Diversion Following Esophagogastrectomy Incision and Exposure
Make a midline incision from the xiphoid to a point somewhat below the umbilicus. Divide the various adhesions subsequent to prior surgery and expose the pyloroduodenal region. Because of the previous surgery (esophagogastrectomy)(Fig. 10–3) this area is now located 5–8 cm from the diaphragmatic hiatus.
Dividing the Duodenum,
Duodenojejunostomy, Roux-en-Y Reconstruction
Divide the duodenum at a point 2–3 cm beyond the pylorus. Be careful not to injure the right gastric or right gastroepiploic vessels, as they constitute the entire blood supply of the residual gastric pouch.To divide the duodenum, first free the posterior wall of the duodenum from the pancreas for a short distance.
If possible, pass one jaw of a 55/3.5 mm linear stapler behind the duodenum, close the device, and fire the stapler. Then divide the duodenum flush with the stapling device. Lightly cauterize the everted mucosa
Fig. 10–3
and remove the stapler, which leaves the proximal duodenum open. Leave 1 cm of the posterior wall of the duodenum free (Fig. 10–4, point A) to construct an anastomosis with the jejunum.
Develop a Roux-en-Y limb of jejunum then bring the open distal end of the divided jejunum (Fig. 10–
4, point D) to the level of the duodenum. Generally it most comfortably assumes an antecolic position, but occasionally it is feasible to bring it through an incision in the mesocolon (retrocolic).
Establish an end-to-end duodenojejunostomy (Fig.
10–5, point A to point D) utilizing one layer of inter- rupted 4-0 silk for the seromuscular layer and con- tinuous or interrupted sutures of atraumatic 5-0 PG for the mucosal layers.
Complete the construction of the Roux-en-Y segment by creating an end-to-side jejunojejunos- tomy at a point 60 cm distal to the duodenojejunos- tomy. Close the defect in the jejunal mesentery with interrupted sutures.
Fig. 10–4
Fig. 10–5
Bile Diversion by
Duodenojejunostomy Roux-en-Y
Switch Operation Incision and Exposure
Make a midline incision from the xiphoid to a point about 3–4 cm below the umbilicus.
Duodenojejunostomy
Perform a thorough Kocher maneuver, freeing the head of the pancreas and duodenum anteriorly and posteriorly. Place a marking suture on the anterior wall of the duodenum precisely 3 cm distal to the pylorus.This represents the probable point at which the duodenum will be transected. Now approach the point at which the duodenum and pancreas meet.
Divide and carefully ligate the numerous small vessels emerging from the area of the pancreas and entering the duodenum on both anterior and posterior sur- faces until a 2 cm area of the posterior wall of duode- num has been cleared. Do not dissect the proximal 2–3 cm of duodenum from its attachment to the pan- creas. Dissecting the next 2 cm of duodenum free of the pancreas provides enough length to allow stapled closure of the duodenal stump and a duodenojejunal end-to-end anastomosis. Be careful not to injure the pancreatic segment of the distal common bile duct or the duct of Santorini, which enters the duodenum at a point about 2 cm proximal to the papilla of Vater.
After this step has been completed, make a 2 cm transverse incision across the anterior wall of the duodenum near the marking suture (Fig. 10–6).
Fig. 10–6
Insert an index finger and palpate the ampulla.
Confirm its location by compressing the gallbladder and liver, observing the influx of bile into the distal duodenum. Now use a 55/3.5 mm linear stapler to occlude the duodenal stump just distal to the mark- ing suture. Complete the transection of the duo- denum after the stapler has been fired by cutting along the stapling device with a scalpel, cauterize the mucosa and check the staple line in the usual fashion.
At a point 20 cm distal to the ligament of Treitz, transect the jejunum and incise its mesentery down to, but not across, the arcade vessel (Fig. 10–7, C and D). Limiting the incision in the mesentery to 3 cm helps preserve the innervation of the intestinal pace- maker in the upper jejunal mesentery. Bring the distal transected end of the jejunum through a small incision in the mesocolon and make an end-to-end anasto- mosis between the proximal transected duodenum to the jejunum using 4-0 interrupted silk sutures for the seromuscular layer and 5-0 Vicryl sutures for the mucosa (Fig. 10–8, A and C). Then perform an end-to-side jejunojejunostomy to the descending limb of jejunum (Fig. 10–8) at a point 60 cm distal to the duodenojejunostomy. Eliminate any defect in the mesocolon or the jejunal mesentery by suturing.
Irrigate the abdominal cavity and abdominal wound and close the abdomen in the usual fashion without drainage.
Fig. 10–7
COMPLICATIONS
Intestinal obstruction Anastomotic leak
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Fig. 10–8
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