Supraphrenic esophageal diverticulectomy and esophageal myomyotomy

If you have symptoms in the upper esophageal diverticulum, you can first consider medical treatment, such as body drainage and drinking water to maintain the emptying of the diverticulum after the meal; those with diverticulosis should eat non-irritating soft food; have esophageal fistula and organic stenosis Can do esophageal dilation treatment. If the symptoms are due to combined esophageal fistula, hiatal hernia or other causes, these conditions should be treated first. Surgical treatment is only suitable for cases where the symptoms are progressive and severe. Asymptomatic patients should not be treated if they can rule out other serious illnesses. However, if surgery is required due to other diseases of the esophagus or diaphragm, the upper iliac crest should be removed at the same time. Because the symptoms of the supraorbital diverticulum are often related to the size of the diverticulum, surgical procedures should be considered for patients with mild symptoms and a significant increase in diverticulum volume. In 1927, Clairmont successfully achieved an anterior esophageal diverticulum via the extrapleural approach. Since then, transthoracic or transabdominal resection of the supraorbital diverticulum has been performed, including diverticulagastrostomy, diverticulopexy, diverticular inversion, diverticular placation. And simple excision. Although surgical treatment of esophageal diseases has made great progress, there are still many complications after supracondylar esophageal resection. In recent years, with the emphasis on the diseases associated with the upper iliac crest, clinically, methods for treating related diseases have been continuously sought. For example, the combined hiatal hernia is also repaired during esophageal myotomy, and esophageal dilatation is performed before and after surgery. After simple diverticulum resection, the recurrence rate of the diverticulum was higher and the symptoms could not be alleviated. According to Brugman, of the 4 patients who underwent a simple diverticulectomy, 1 died and 3 failed to resolve. At present, diverticulum resection combined with myotomy is used for the upper esophageal diverticulum, as well as some modified surgery. Treatment of diseases: esophageal diverticulum Indication Upper esophageal diverticulum resection and esophageal myotomy are mainly for symptomatic patients, especially those with progressive exacerbations. 1. The neck of the diverticulum is narrow and cannot be fully emptied. 2. The diverticulum has obvious inflammation or infection. 3. The diverticulum is large and drooping to displace the esophagus. 4. The diverticulum gradually increased. X-ray examination found that there were food residues and fluid retention in the sputum and reached a considerable extent. Surgical treatment should be considered regardless of clinical symptoms or esophageal dysfunction. 5. In the surgical treatment of other associated diseases, even if there is no clear clinical symptoms in the sacral diverticulum itself, diverticulectomy should be performed at the same time. Preoperative preparation 1. Those who have weight loss and systemic malnutrition due to long-term dysphagia should be corrected. It can be used for parenteral nutrition; sometimes, after esophageal dilation, patients can resume oral feeding and improve nutritional status. 2. If lung inflammation occurs due to aspiration, body drainage, antibiotic treatment, and chest therapy should be performed. 3. 2 days before the operation, the patient was given a fluid diet. 4. Before anesthesia, empty the food and secretions in the room to prevent aspiration during the induction period of anesthesia. 5. If accompanied by other diseases that cause esophageal retention, esophageal dilatation can be used to empty the esophagus. It can also be emptied by flushing the esophagus and diverticulum. 6. Indwell the stomach tube before surgery. Surgical procedure 1. Incision: posterior lateral incision of the left chest, through the 8th or 8th intercostal space into the chest. This incision is more satisfactory when it is necessary to surgically treat other esophageal or diaphragmatic diseases. It is also convenient to free and rotate the lower part of the esophagus and remove the diverticulum. 2. Cut the lower lung ligament and pull the lung forward and upward. Cut the mediastinal pleura of the lower esophagus along the esophageal bed, carefully dissipate the lower esophagus and diverticulum, and gently lift the esophagus with a fine gauze strip or rubber strip. At this time, confirm and protect the vagus nerve. In order to fully expose and remove the diverticulum, the lower esophagus can be rotated to the right along with the diverticulum. 3. Use a wide Allis forceps to clamp the bottom of the diverticulum (ie, the diverticulum tip), gently separate the mucosal sac along the diverticulum of the diverticulum, and separate the loose connective tissue around it. At this time, the diverticulum can be seen from the esophagus. The fiber layers protrude outward. Like other bulging diverticulum, the supraorbital sac is mainly composed of the mucosa and submucosa of the esophagus, and sometimes contains a thin muscle layer and fibrous tissue. 4. Accurately clamp the neck of the diverticulum mucosa with a curved vascular clamp (the vascular clamp blade should be parallel to the long axis of the esophagus). Vascular forceps can be used to either tow the diverticulum or as a marker to remove the diverticulum. The diverticulum was sequentially removed and the mucosal incision was sutured by the edge-cutting method. Special attention should be paid to the removal of the esophageal mucosa and the esophageal stricture when removing and removing the diverticulum. 5. The esophageal muscle layer is sutured close to the mucosal suture to embed the mucosal incision in the neck of the diverticulum. Thereafter, the diverticulum incision in the lower part of the esophagus is rotated back to the right. 6. Esophageal muscle layer incision: Make a long longitudinal incision in the left side wall of the lower esophagus, and cut all the ring muscle fibers, but do not damage the mucosal layer and vagus nerve fibers underneath. The visceral separation of the muscular layer and the mucosa layer, the free range must reach at least one and a half of the circumference of the esophageal mucosa, so that the mucosal layer bulges from the muscle layer incision. The distal end of the myometrial incision extends down to the cardia to ensure complete dissection of the entire muscle fibers at the distal end of the esophagus, but does not damage the esophageal hiatus and the esophageal ligament; the proximal end of the myometrial incision is advanced up to the level of the pulmonary vein or aortic arch. Finally, the fundus is folded and sutured. If a hiatus hernia is combined, it should be repaired at the same time. Another method of treating a large hernia sac without neck contraction is diverticulopexy, which is to pull the bottom of the diverticulum upward and suture it with the esophageal muscle layer to facilitate drainage of the cyst. In addition, a deverticular inversion can be used to turn the chamber into the esophageal lumen. The Mayo Clinic performed an esophageal myotomy for all patients with supraorbital diverticulum after resection of the diverticulum, regardless of preoperative or esophageal motor dysfunction. 7. Restore the esophagus to the esophageal bed of the mediastinum; place the gastric tube; install a closed thoracic drainage tube to expand the lungs and close the chest layer by layer. complication The most serious complications are paralysis of the suture site and other serious complications caused by paralysis. In order to reduce the occurrence of sputum, the edge of the original esophageal muscle incision should be sutured at the suture after the diverticulum resection, and another esophageal myotomy should be performed on the side of the diverticulum to reduce the tension, and the pedicled pleural flap or anterior The fascia is covered in the suture to reinforce. If simple diverticulum resection is performed without esophageal myotomy, and there is a disorder of esophageal motor function, it is prone to paralysis after surgery, and severe cases are often fatal. Before restoring oral feeding, the use of the absorbable contrast agent Gastrografin for esophagography can be found in the diverticulum resection site with a seamless sputum and esophageal lumen obstruction. If the angiographic examination confirms sputum or esophageal obstruction, it should be treated promptly. Excessive mucosal resection of the neck of the diverticulum can cause local esophageal stenosis and complicate the treatment of sutures. Patients who have not undergone esophageal myotomy are prone to recurrence after surgery. If the vagus nerve is damaged during surgery, it may lead to dysfunction of iatrogenic esophageal motor function.