Esophageal myotomy

Esophageal myotomy is the most widely used procedure for the treatment of achalasia. In 1913, He11er designed to cut the anterior and posterior walls of the esophagus to make the food pass smoothly. Later, Zaaijer changed to cut the anterior wall muscle layer of the esophagus and achieved the same effect. Surgery can be performed via the left chest or abdominal cavity. The transthoracic approach is generally considered to be better. However, in elderly or infirm patients, the risk of transabdominal approach is less and the operation is faster. If a longer myometrial incision or simultaneous anti-reflux surgery is required, it is suitable for the application of the thoracotomy. If the patient's esophagus has undergone surgery, or other operations must be performed at the same time (such as resection of the upper iliac crest or repair of hiatal hernia), or suspected of having a cancer, the transthoracic approach is also appropriate. Treatment of diseases: achalasia in children with achalasia Indication 1 severe achalasia, need to perform a better esophageal myotomy to relieve symptoms. 2 long-term conservative therapy is invalid. 3 severe achalasia, esophageal dilatation and severe flexion, dilator placement is difficult and dangerous, can not expand, or expand failure. 4 often have severe inhalation lung infections. 5 infants and young people or patients with strong achalasia can get good long-term results. 6 patients can not tolerate or do not want to repeat the expansion therapy. Contraindications 1 has severe cardiopulmonary insufficiency. 2 complicated with advanced esophageal cancer. Preoperative preparation 1 Correct the water and electrolyte disorders. 2 adequately treat pulmonary complications until the acute phase subsides. 3 When there is severe retention esophagitis, the mucosa and submucosal tissues are fragile and easy to cause perforation. It takes 3 to 4 weeks for medical treatment. Esophagoscopy is followed by mucosal healing and then surgery. 4 3 days before the operation, give metronidazole 0.2g, orally 3 times a day, clean the esophagus. 5 Before the operation, 1 day before the operation and on the morning of the operation, a stomach tube without a side hole was placed to clean the food, residue and secretions in the esophagus, and the stomach tube was preserved to reduce the risk of aspiration during anesthesia induction. 6 Before going to bed one night before surgery, intramuscular sedatives. Surgical procedure Selection of incisions: The entry path of esophageal myotomy is a transthoracic approach and a transabdominal approach. Sometimes the transthoracic approach is good, sometimes through the abdominal approach, and sometimes both. Proper selection of the incision is very important to the success of the procedure. 1 transthoracic approach: transthoracic incision is better than the abdominal incision. It is easier and more sufficient to cut and peel the muscle layer. It can be used for a long range of myotomy. The upper segment of the muscular layer is not restricted, and the mucosa is damaged. There are few opportunities, especially for those with weak and scar tissue at the lower end of the esophagus. The hiatus of the esophagus is not damaged, which can avoid the occurrence of postoperative delirium, and can choose a suitable anti-reflux technique more widely, and also can combine the diseases. Such as esophageal leiomyoma, diverticulum and cancer, etc. for surgical treatment. 2 transabdominal approach: abdominal incision has the advantages of simple operation, small injury and quick recovery after surgery. It is less dangerous to the elderly and frail and the patient through the abdominal route, and the operation is also faster. The abdomen can also be examined. The lesion can be treated with surgery. The disadvantage is that the exposure problem is especially fat in patients. Need extensive anatomy in the Tuen Mun area does not provide sufficient visual field. Due to the limitation of the upper section of the muscular layer, the anatomy of the cardia has to be performed, the structure of the cardia is damaged, and reflux may occur. Therefore, Nissen fundoplication should be considered. Backflow, however, in the absence of achalasia in the absence of achalasia, the obstruction caused by total fundoplication is too much. Surgical methods 1 transthoracic esophageal myotomy: surgery through the 7th or 8th intercostal posterior lateral thoracic, push the lungs forward and upward, cut the lower pulmonary ligament to the lower pulmonary vein, longitudinally cut the mediastinal pleura, carefully protect the vagus nerve The proximal end reaches the aortic arch and the distal end reaches the diaphragm, which is exposed and freed from the esophagus and lifted around the gauze. A small section of the ventral esophagus and gastroesophageal junction is pulled into the chest, and generally no need to cut the hole. There are also a few that can not pull the gastroesophageal junction into the chest, and a small incision can be made in the anterolateral part of the hole. However, after the muscle layer is cut, it must be sutured to prevent the contents of the abdomen from entering the chest. Hold the esophagus with your left hand, cut a small opening of the esophageal muscle layer longitudinally between the left and right vagus nerves, and reach the submucosal layer. Then, blunt dissection is performed with the blunt forceps upward and downward to extend the myometrial incision, proximal end. Should exceed 2cm of the esophageal stricture, distal to the esophagogastric junction and extend to the stomach wall, the longest is no more than 1cm, a few millimeters. There is a transverse venule at the junction of the esophagus and stomach, which is used as a marker. The incision must not rise over the vein, otherwise it will be concurrently refluxed. After the incision of the muscle layer is completed, the incision muscle edge is released to both sides to reach half or more of the esophagus circumference, and the free esophageal mucosa can naturally bulge from the incision, thereby reducing the postoperative scar formation. The muscles that are cut open are likely to get together again. Some authors have advocated the removal of a free muscle flap. Always pay attention to the protection of the vagus nerve and avoid cutting the mucosa during the operation, and perforation occurs. When the muscle layer is incision free, and then infiltrated through the gastric tube to detect whether the mucosa is damaged. After confirming that there is no leak, carefully stop bleeding, even if there is a small bleeding point, the blood should be fully stopped, so as to avoid the narrowing of the blood clot. After completing the above procedure, the esophagus is placed back into the mediastinum to restore the esophagogastric junction to the normal abdominal cavity position. The mediastinal pleural interrupted suture, the conventional closed drainage tube, closed the chest cavity. 2 transabdominal esophagus myotomy: take the upper abdomen xiphoid and umbilical longitudinal midline incision or left median side incision, cut the triangular ligament, push the left left lobe of the liver to the lower right, to expose the cardia and sacral holes. Cut the peritoneum covering the abdominal segment of the esophagus, free the esophagus, wrap the gauze at the distal end of the esophagus and pull down, expose the esophageal muscle layer between the vagus nerve, and the transthoracic esophagus muscle layer, method and transthoracic esophagus Myometrial incision is roughly the same. Due to the deep position of the esophagus, the exposure is not good. If it is necessary to extend to the proximal end of the esophagus, it is more difficult to cut the muscle layer for a longer period. 3 Transthoracic esophageal incision with anti-reflux surgery: After the esophageal myotomy is completed, the gauze around the esophagus is pulled up, so that the esophagus is lifted from the posterior mediastinum, and the hiatal adhesion of the gastroesophageal junction is cut off. At the site, the anterior esophageal membrane reflexed, retroperitoneal fat and abdominal cavity, free the gastroesophageal junction to the attachment point of the diaphragm, cut and ligation of the left branch of the left gastric artery and the branch of the infraorbital artery. At this point, the entire gastroesophageal junction and part of the fundus can be introduced into the chest cavity, and the fat pad of the gastroesophageal junction is removed. Establishing Mark IV anti-reflux surgery: the front part of the reaming hole reveals the ankle of the right foot of the diaphragm, and the suture is sutured with a thick thread at the back of the esophagus. The needle is not tied, and the distal part of the esophagus is 5 cm. Around the 2/3 circumference, the gastric fundus is divided into two rows at 2cm and 5cm from the gastroesophageal junction. After the second cable is ligated, the line is not cut off. From the abdominal cavity to the thoracic cavity surface, the anti-reflux mechanism is placed under the armpit, and the two needle sutures are contracted and ligated. Finally, the 4-needle suture stitching is ligated, and the gap is required to pass through the gap of one finger width, and the closed drainage tube is used to close the chest layer by layer. 4 transabdominal esophageal muscle incision and anti-reflux surgery: After completing the esophageal myotomy, the right foot of the diaphragm is sutured 3 to 4 needles with a thick thread behind the esophagus. Complete fundus wrapping: the fundus is folded through the distal end of the esophagus and wrapped around 360°, limited to 3 cm distal to the esophagus. The width of the fundus tunnel after completion of wrapping should be appropriate, not too loose or too tight, too loose and no anti-reflux effect, too tight will cause blockage, in order to be able to accommodate a 50F dilator or a finger passed smoothly. Incomplete fundus wrapping: The fundus is folded, wrapped around the lower end for 2/3 weeks, and the length is 5 cm. The specific method is to fix the anterior and posterior walls of the stomach on the right side wall of the esophagus, which is just the uninjured part of the esophageal muscle layer. complication It is a safe operation. The ideal surgical outcome should be esophageal emptying without gastroesophageal reflux and long-term relief of symptoms. In addition to the surgical technique, factors affecting the effect are also the natural mitigation phase of the disease itself and the progressive aggravation of the neuromuscular progressive deterioration. In addition, the operation only relieves the cardia obstruction, and the effective movement of the esophagus is not treated and recovered, so there may still be symptoms after rapid swallowing. The severity of the disease also affects the curative effect. The esophagus is over-expanded, the myometrial fibrosis is severe, and the submucosal adhesion is tight. After the muscle layer is cut, although the cardia blockage is relieved, the enlarged esophagus cannot return to the original caliber and is still distorted. In the absence of effective peristalsis to push the pump, there are still emptying obstacles, and the appearance of symptoms is not surprising. Therefore, although the symptoms of the advanced patients have improved, the effect is mostly not very good, and the patients with mild symptoms rarely fail, so early surgical treatment is very beneficial to improve the surgical results.