19. Paraesophageal Hernia Repair
• Transthoracically
– For who have failed previous open transabdominal repair
• Transabdominally
– Open
– Laparoscopic (Preferred)
Less complications, mortality, reoperation & readmission rate,
Shorter hospital stay.
20. Transabdominally PEHR
Transabdominal PEHR steps:
1. Incision
2. Dissection of the hiatus and hernia sac
3. Esophageal mobilization
4. Closure of hiatal defect
5. Fundoplication
6. Optional Anterior gastropexy
21. Primary Eosphageal motility disorder
• Achalasia
– inflammation & degeneration of neurons in esophageal wall
– loss of peristalsis in the distal esophagus
– incomplete lower esophageal sphincter (LES) relaxation
– excluded cancer at the esophagogastric junction
• 3 Sub-type:
– Type I : esophageal abscent peristalsis
– Type II : pan-esophageal pressurization
– Type III : distal esophageal spastic contractions
26. Characteristics of Achalasia tx
Advantages Disadvantages
Pneumatic dilation
Less invasive
No need GA
Good short term outcome
Need repeated
Risk of perforation
Heller Myotomy
One-off tx
Good long term outcome
Less reflux
More invasive
Longer recovery period
POEM
One-off tx
Less invasive
Good short term outcome
Best option for Type 3
No long term outcome data
More reflux (GERD)
27. Take home message
• Identify Oropharyngeal / esophageal origin
• Symptomatic & large ZD need surgery
• Symptomatic Paraesophageal hernia need
surgical repair.
• Achalasia has 3 definitive therapies.
– Pneumatic dilation
– Heller Myotomy
– POEM
• Heller Myotomy – good outcome/less reflux
28. References
• General Surgery - Principles and International Practice
• Essentials of general surgery and surgical specialties
• Yamadas Textbook of Gastroenterology
• ASGE guideline on the management of achalasia, 2020
• Alice Sfara, The management of hiatal hernia: an update on diagnosis and treatment, Med Pharm Rep.
2019 Oct; 92(4): 321–325.
• World gastroenterology organisation global guidelines: dysphagia--global guidelines and cascades update
September 2014
• A. BIZZOTTO, et al. Zenker's diverticulum: exploring treatment options. Acta Otorhinolaryngol Ital. 2013
Aug; 33(4): 219–229.
• Guidelines for the Management of Hiatal Hernia – SAGES, 2013
Editor's Notes
In this topic we are going to review the physiology of swallowing and introduce dysphagia.
Then we will go though the initial approach of dysphagia and focus on the surgical management of the diseases of non-malignant dysphagia.
Anatomically, the normal swallow is divided into three phases:
Oral phase which also called preparatory phase, is the voluntary part of swallowing. First, food enters mouth, chewing and moistened with saliva, formed a food bolus, then tongue elevate and push it to pharynx. This process is under neural control of several area of cerebral cortex.
Pharyngeal phase starts with stimulation of tactile receptors in oropharynx by food bolus, which is involuntary. The tongue block oral cavity prevent food go back to mouth, soft palate blocks nasal cavity, vocal folds close, larynx elevate with epiglottis flipping over to cover trachea entry. Then the Upper esophageal sphincter relax to allow passage to the esophagus.
Esophageal phase move the food bolus down by peristalsis, and prolong relaxation of Lower esophageal sphincter then bolus enter stomach.
Dysphagia is a disorder define as difficulty in swallowing and needed evaluation to define the exact cause and initiate appropriate therapy, more accurately described in clinical practice as a sensation of food or liquid being stuck in the esophagus or chest.
Early identification and appropriate treatment of dysphagia are important. Some dysphagia patients have limited awareness of their dysphagia and undiagnosed or untreated dysphagia may lead to aspiration, dehydration and malnutrition.
Dysphagia is arising from disorder in the 3 phases we just mentioned, and which can categorize as structural problem, motility problem, or sometimes functional disorder.
To approach dysphagia, a key decision is whether the dysphagia is oropharyngeal or esophageal.
As Oropharyngeal dysphagia can cause by systemic diseases like muscular disease & Central nervous system disorder, and esophageal dysphagia usually result from esophageal diseases.
The 2 different type can be determine by symptoms
The characteristic of Oropharyngeal dysphagia including difficult to initiating swallow, choking, coughing and nasal regurgitation.
And the The characteristic of esophageal dysphagia is difficult swallowing several seconds after initiating a swallow, and sensation that foods are being obstructed in their passage from the upper esophagus to the stomach.
And there are some specific key features should be consider in esophageal dysphagia
Patient has difficulty of swallowing Solid & liquid foods are hints of motility disorder, while Solid food only are hints of structural disorder
Progressive or intermittent are helping to determine diseases like malignancy and achalasia, from others problems like esophageal webs and rings
Some associated symptoms can help us to narrow the ddx field, like malignancy associated with significant weight loss, Neurological problems associated with Hemiparesis, Ptosis of the eyelids etc.
Here is the algorithm of the approach of dysphagia. After the
Here are the representative causes of oropharyngeal dysphagia.
For structural problems there are occupy lesions, Post-cricoid webs, iatrogenic or others.
Functional problems are including neurological disorder like CVA, Parkinson disease, and muscular disorder like myasthenia gravis (oculopharyngeal muscular dystrophy)
Guillain barre syndrome
Amyotrophic lateral sclerosis
Here are the representative causes of esophageal dysphagia.
For structural problems there are esophageal stricture, diverticular, hernia, webs & rings and others.
Motility problem including Achalasia, others primary and secondary motility disorder.
Most esophageal dysphagia patients are needed upper endoscopy for further assessment. Barium study and manometry test are indicated depending on situation.
The therapeutic approach in dysphagia are according to the different disease, severity, patient’s conditions. Method including medical tx, Rehabilitation and nutritional support, endoscopic treatment and surgical treatment.
In those causes of dysphagia, some of them are indicate for the surgical management, we are going to focus on some of these disease and the role of surgical management.
Esophageal Diverticula is a sac-like outpouching of one or more layers of the esophageal wall, most of them consist of mucosa and submucosa only, and which is false diverticula, and that is the feature of pulsion diverticula.
Pulsion diverticula typically occur proximal to a physiologic sphincter or proximal to areas of functional resistance to food passage and are assumed to be caused by excessive intraluminal pressure on the esophageal wall.
Another type of diverticula is True diverticula, it consist all layer of esophageal, and result from traction forces arising from outside the esophageal wall. Usually occur in response to periesophageal inflammation such as chronic lymphadenitis.
The diverticula location in esophagus can divided as Hypopharyngeal, Parabronchial and Epiphrenic.
Zenker diverticula is the most common type of them, results from an outpouching in a weak muscular portion at the posterior hypopharyngeal wall immediately proximal to the upper esophageal sphincter, the so-called Killian’s triangle. The pathogenesis related to a decreased compliance of the cricopharyngeal muscle then increased resistance to pass UES.
Besides of dysphagia, ZD can be associated with mouth bad smelling, food regurgitation, and neck mass.
ZD can be dx by barium swallow and recommended EGD for rule out concurrent malignancy.
Zenker’s diverticula size larger then 1cm or symptomatic is indicated for surgical management
The is the anatomy picture of ZD and other types of Esophageal Diverticula.
. The surgical approach can be transcervical by open / transoral by endoscopy.
The core of procedure is cricopharyngeal myotomy, that will increasing the compliance of the upper esophageal sphincter and solve the underlying cause. In good surgical candidates, accompany with diverticulectomy is prefered. And in high surgical risk patients, can consider accompany with diverticulopexy.
Transcervical approach has lower symptom recurrence rate and failure rate, but associated with higher rate of complication, and longer hospital stay.
Transoral approach is aim to make a channel as overflow tract, at the common wall between the diverticulum and esophagus, and meanwhile perform cricopharyngeal myotomy.
Compare to Open surgery, transoral approach has the advantages including Less invasive, lower rate of complications, shorter hospital stay
But higher symptom recurrence rate & failure rate.
Choosing the approach can be base on the ability to visualize the ZD and septum endoscopically, patient's body habitus and local expertise.
Difficult exposures of the ZD and spectrum require an open approach.
This is the trans cervical approach to zenker’s diverticulum
Diverticulopexy:
involves suspension of the lumen of the diverticulum in the caudal direction such that the orifice is directed away from the hypopharynx, thereby preventing the entry of food and secretions.
On left side is Diverticuloscope and right side is Flexible endoscopy. Both can expose the common wall between the diverticulum and the esophagus.
Transoral approach will use different cutting and coagulation device to divide the spectrum marked with red cross.
Hiatus hernia refers to herniation of elements of the abdominal cavity through the esophageal hiatus of the diaphragm.
And Paraesophageal hernia is the uncommon type of hiatal hernia.
The etiology of Paraesophageal hernia is recognized as a complication of surgical dissection of the hiatus as occurs during anti-reflux procedures, esophagomyotomy, or partial gastrectomy.
It is a true hernia with a hernia sac and is characterized by an upward dislocation of the gastric fundus through a defect in the phrenoesophageal membrane.
As the hernia enlarges, the greater curvature of the stomach rolls up into the thorax. Because the stomach is fixed at the GE junction, the herniated stomach tends to rotate around its longitudinal axis, resulting in an organoaxial volvulus, or infrequently, rotation occurs around the transverse axis resulting in a mesenteroaxial volvulus
Surgical repair is indicated in patients with a symptomatic paraesophageal hernia and Emergent repair is required in patients with a gastric volvulus, uncontrolled bleeding, obstruction, strangulation, perforation, and respiratory compromise secondary to a paraesophageal hernia.
Paraesophageal hernias can be repaired transthoracically or transabdominally.
Transabdominal repairs can be performed open or laparoscopically.
Laparoscopic way is prefer for most patients as compared with open repair, as they have equivalent outcomes, but lap is associated with lower rates of complications, mortality, reoperation, readmission, and shorter hospital stay.
However, the three operative approaches have not been directly compared with one another in randomized trials, and the optimal operative approach remains controversial and varies by surgeon training and preference
The steps of Transabdominal PEHR including:
Incision
Dissection of the hiatus and hernia sac to prevent re-herniation
Sufficient Esophageal mobilization to archive tension-free repair
Closure of hiatal defect
Fundoplication can improve preexisting GERD & reducing the risk of postoperative GERD
Optional Anterior gastropexy can be used to reduce the risk of gastric re-herniation into the thoracic cavity
Primary esophageal motility disorders (PEMD) are relatively rare motor disorders and may occur in the absence of gastroesophageal reflux disease (GERD). They present with specific manometric characteristics and classified as: (I) achalasia (II) Esophagogastric Junction Outflow Obstruction
(III) Jackhammer esophagus (JE) (IV) diffuse esophageal spasm (DES) Absent contractility, and other minor disorder
Primary esophageal motility disorders (PEMD) are relatively rare motor disorders and may occur in the absence of gastroesophageal reflux disease (GERD). They present with specific manometric characteristics.
Achalasia is right now the best-defined primary esophageal motor disorder, it has consensus on pathogenesis, diagnosis and treatment, different from other eosphageal motility disorder.
Therefore we will focusing on achalasia today.
Achalasia has been assumed to result from inflammation and degeneration of neurons in the esophageal wall. But etiology in primary achalasia is unknown
The diagnosis of Achalasia is established by aperistalsis in the distal two-thirds of the esophagus and incomplete lower esophageal sphincter (LES) relaxation on manometry.
And need to rule out Pseudoachalasia due to cancer at the esophagogastric junction.
Achalasia can be classify as 3 subtype according to Chicago Classification.
Type I is characterize as esophageal absent peristalsis
Type II is characterize as pan-esophageal pressurization
Type III is characterize as distal esophageal spastic contractions
Treatment of achalasia is aimed at decreasing the resting pressure in the lower esophageal sphincter (LES) to a level at which the allows the passage of food, although the normal peristalsis is still absent and gravity is the key factor to allow emptying food from esophagus to stomach.
This can be accomplished by mechanical disruption of the muscle fibers of the LES. Like pneumatic dilation, surgical myotomy, or peroral endoscopic myotomy [POEM] or by pharmacological reduction in LES pressure (eg, injection of botulinum toxin or use of oral nitrates).
The choice has to base on the type of achalasia, local expertise, patients condition and willing according to evidence based guideline.
ASGE (American Society for Gastrointestinal Endoscopy)Guideline suggested Pneumatic dilation, Heller myotomy and POEM are both effective definitive therapies, while botulinum toxin injection and nitrates are reserved for who are not candidates for these therapies. We are going to introduce the characteristic of these definitive therapies.
Pneumatic dilation is a technique disrupts the LES fibers through intraluminal dilation of a pressurized balloon and is most commonly performed under fluoroscopic guidance.
Three balloon sizes (30, 35, and 40 mm
diameter) are available for pneumatic dilation. The conventional
approach is to start with the 30-mm balloon in most
patients, progressing to bigger diameter balloons if a
response is not achieved
Heller myotomy is a laparoscopic surgical procedure which weakened the LES by cutting its muscle fibers. Since LES disruption can cause reflux esophagitis, it is frequently combined with an antireflux procedure such as a partial fundoplication (Dor or Toupet fundoplication).
POEM is a form of natural orifice transluminal endoscopic surgery.
Endoscopist will make an incision in the esophageal mucosa, creating a submucosal tunnel that is extended distally into the gastric cardia. A diathermic scalpel then is passed through the endoscope to cut the muscle around the LES.
About the characteristics of these tx.
Pneumatic dilation has advantages of less invasive, no need GA, good short term result in single dilation, and serial dilation has similar outcome compare with Heller myotomy. But it has disadvantages including needs of repeated dilations, risks of esophagus perforation(3-5%), which needed the patient are good candidate for surgical treatment.
Heller Myotomy is one-off treatment, having good long term outcome, and associated with lower post-operation reflux rate , but it is more invasive and require longer recovery period.
POEM is also one-off treatment and having good short term outcome, and it is the first line tx for type 3 achalasia, as it can provide a longer myotomy. However it does no have enough long term outcome data, and POEM includes no antireflux procedure, consequently, can result in severe GERD.
Guidelines recommended Pneumatic dilation and Heller Myotomy for Type 1 & Type 2 achalasia while POEM is also a reasonable option, depending on decision making between patients & doctors.
And POEM is the first line recommended tx for type 3 achalasia as it can provide a longer myotomy.
In dysphagia cases, it is important to identify Oropharyngeal or esophageal origin, which can be accomplish by detailed history taking.
Symptomatic & large ZD is indicated for surgical treatment, besides do not warrant treatment.
Symptomatic Paraesophageal hernia or presented urgent complication like gastric volvulus needs surgical repair.
Achalasia has 3 definitive therapies which is Pneumatic dilation, Heller Myotomy, POEM, the treatment choice has to base on the type of achalasia, local expertise, patients condition and willing according to evidence based guideline.
And Heller myotomy has good long term out come and less complicated with reflux compare to the others achalasia definitive treatment.
