Intraoperative diagnosis of short esophagus in a patient with Barrett's metaplasia

Authors

Abstract

Patients who have Barrett’s esophagus are considered at risk for having a short esophagus.
Routine intraoperative endoscopy and liberal addition of a Collis gastroplasty is a key factor to prevent recurrences.

Classification

basic techniques

Keywords

Intraoperative diagnosis, short esophagus, Barrett\'s metaplasia, Collis gastroplasty, Barrett\'s esophagus

Media type

Duration

12'40''

Publication

2008-12

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E-publication

WeBSurg.com, Dec 2008;8(12).
URL: http://www.websurg.com/doi-vd01en2476.htm

Intraoperative diagnosis of short esophagus in a patient with Barrett's metaplasia

1. Clinical case presentation 00'20''

This is the case of a 50-year-old man with a 10-year history of typical GERD symptoms. Preoperative workup included endoscopy, esophageal manometry and 24 hour pH monitoring, which confimed the diagnosis of GERD, which was associated with Barrett’s esophagus and ineffective esophageal motility.

2. Preoperative endoscopy 00'40''

Before the operation, endoscopy was repeated and showed a short segment Barrett’s esophagus. Four quadrants multiple biopsies were then taken. Trocar placement is the same as for Nissen fundoplication: a 5-trocar technique is used with the patient placed in reverse Trendelenburg.

3. Landmark identification 01'00''

Surgery starts with identification of the anatomical landmarks at the hiatus and dissection of the gastroesophageal junction. This allows the identification of the essential anatomical landmarks, which will guide the following steps of the procedure.

4. Gastroesophageal junction dissection 01'19''

We usually start the dissection on the right side. The pars condensa of the lesser omentum is opened making sure to preserve the left hepatic artery and the hepatic branch of the vagus nerve. This maneuver shows the way to the right crura, which needs to be identified before dissecting the esophagus. Blunt dissection of the cleavage plane internal to the crus allows to identify the esophagus. Once the position of the esophagus is identified, the phrenoesophageal membrane is opened anteriorly along the anterior border of the hiatal orifice towards the left crus. At this point, a retroesophageal window is created with careful identification of the posterior vagus nerve, which is kept along the esophagus.

5. GE junction retraction 02'40''

Once the distal part of the esophagus is fully mobilized, an umbilical tape is placed around the GE junction.

6. Mediastinal dissection 03'05''

Now to the mediastinal dissection. We routinely carry out an extensive mediastinal dissection in order to mobilize the distal esophagus completely. The aim of this step is to bring at least 2cm of the distal esophagus below the hiatus. This dissection is carefully performed in a blunt fashion, posteriorly, laterally, and anteriorly, while manipulating the esophagus with the umbilical tape. The endoscope is advanced to the diaphragmatic hiatus to provide good visualization. A 0 degree scope is used in this case but a 30 degree lens is advantageous here. The anterior and posterior vagus nerves are dissected along the esophagus and it is important to avoid inadvertent injury by excessive traction or cautery. The dissection is carried out up to the level of the inferior pulmonary vein, and higher, in order to gain a maximal length.

7. Division of short gastric vessels 04'40''

To build a floppy valve, the gastric fundus must be completely mobilized by dividing the short gastric vessels up to the posterior fundic artery and all the gastrophrenic attachments. The landmark to look for when starting this division of the short gastrics is a fat fold that is usually found at the level of the upper third of the stomach. Cephalad tension of the fundus and retraction of the body of the stomach to the patient’s right side helps to expose these structures. At the end of this dissection, the left crus should be clearly visible.

8. Intraoperative endoscopy 05'30''

An intraoperative endoscopy is carried out to assess the exact location of the Z line. The GE junction is now checked again. Even after a thorough mediastinal dissection, it does not descend more than 2cm below the diaphragmatic hiatus. A marking suture is placed on the junction to identify this level. At this point, the mediastinal dissection is continued to gain as much esophageal length as possible. In fact, the next step is to determine how much esophageal lengthening is necessary. If only 2 to 3cm are required, then it is possible to proceed with a trans-abdominal Collis gastroplasty such as in this case. If 4 to 5cm are needed, then it is preferable to perform a trans-thoracic Collis gastroplasty. In patients with a long history of GERD, it is usual to find denser adhesions laterally, which can make the dissection more difficult and may result in opening of the pleura as happened in this case, which was easily managed with an increase in PEEP pressures.

9. Collis gastroplasty 07'15''

After a final check of the GE junction in this patient, a trans-abdominal lenghtening procedure is considered sufficient. The cardia and the fundus of the stomach must first be prepared in the following manner: the fat pad at the cardia is excised completely for good visualization of the gastroesophageal junction. The fundus being already completely mobilized by the division of the short gastric vessels, the main 5mm left subcostal working trocar is now changed to a 12mm one to facilitate the passage of the stapling device. The fundus of the stomach is retracted inferiorly and anteriorly and a 45mm endoscopic stapler is placed through the left subcostal port, directed towards the esophagus. The upper part of the fundus is stapled obliquely. The stapler is then re-orientated parallel to the esophagus, with the tip of the stapler directed cephalad. At this time, the stomach is retracted inferiorly and to the left. This maneuver will lengthen the esophagus by 2 to 3cm.

10. Short Nissen fundoplication 08'56''

A short floppy Nissen fundoplication is built. The fundus of the stomach is passed behind the neo-esophagus. Since no oversewing of the staple line is performed, the wrap will also cover it.

11. Intraoperative endoscopy 09'59''

Endoscopy is performed to check the neo-esophagus. During the lengthening procedure, the endoscope served as a bougie to calibrate.

12. Crura re-approximation 10'38''

The crura are now re-approximated with non-absorbable sutures. Two sutures are used making sure not to overtighten the hiatus. A final stitch is placed to anchor the fundoplication to the esophagus. This will allow to keep a good configuration of the wrap. Another stitch is placed to secure the upper part of the wrap to the esophagus. A gastro-graffin swallow was performed on the 1st postoperative day to confirm both the integrity and patency of the Collis gastroplasty and Nissen fundoplication. The patient was then allowed a soft diet and discharged on the 2nd postoperative day. Patients who have Barrett’s esophagus are considered at risk for having a short esophagus. In our opinion, routine intraoperative endoscopy and liberal addition of a Collis gastroplasty is a key factor to prevent recurrences.

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