Thoracotomy versus transhiatal esophageal dissection: which is the best surgical approach to short esophagus?

Abstract

Purpose: To evaluate different approaches performed to obtain a more significant esophageal length. Methods: an experimental model using 28 cadavers was conceived. randomized groups: group a (n=10) underwent laparotomic transhiatal approach; group B (n=9) which differed from the first in the conduction of a wide phrenotomy and Group C (n=9) esophageal dissection was performed through a left anterolateral thoracotomy. Results: Final length variations for group a were 2.12cm and 3.29cm and for group B 3.24 cm and 3.66cm, without and with esophageal traction, respectively. in group c length gain observed was 3.81 cm. the mediastinal dissections conducted through the hiatus was considered the procedure that produced the better esophageal mobilization, and the association of wide phrenotomy significantly improved the results. Conclusions: the mediastinal dissection was the most effective to improving gain in abdominal esophagus. When toracotomy and laparotomy were compared, no significant differences were observed in the outcome.Key words: esophagus. Surgical Procedures, Operative. thoracotomy. laparotomy. Mediastinum. Dissection. cadaver. RESUMOObjetivo: Avaliar diferentes procedimentos realizados para obtenção de um ganho mais significativo no comprimento esofágico.Métodos: Um estudo experimental utilizando 28 cadáveres foi realizado. randomização dos grupos: grupo a (n=10): Submetido à abordagem laparotômica trans-hiatal; grupo B (n=9): Diferente do primeiro apenas pela realização de uma frenotomia ampla; e grupo c (n=9): a dissecção esofágica foi realizada por uma toracotomia anterior esquerda. Resultados: A variação final do comprimento para o grupo a foi 2,2 cm e 3,29 cm e para o grupo B 3,24cm e 2,66cm, medidas na ausência e presença de tração esofágica, respectivamente. no grupo c o ganho de comprimento observado foi de 3,81 cm. a dissecção mediastinal conduzida através do hiato foi considerada o procedimento de melhor mobilização esofágica e a associação de uma ampla frenotomia levou a uma significativa melhora nos resultados. Conclusões: a dissecção mediastinal foi a mais efetiva para promover o aumento do esôfago abdominal.Quando comparadas toracotomia e laparotomia, nenhuma diferença significativa foi observada no desfecho do estudo.Descritores: esôfago. Procedimentos cirúrgicos Operatórios. toracotomia. laparotomia. Mediastino. Dissecção. cadaver. Acta Cirúrgica Brasileira -Vol. 26 (3) 2011 -215Thoracotomy versus transhiatal esophageal dissection. Which is the best surgical approach to short esophagus?

Esophageal Mobilization in the Treatment of Short Esophagus

“…During thoracoscopic mobilization right lung deflation is done, and in about one-quarter of patients is necessary to apply antibiotic treatment for respiratory problems. A small number of previous studies have shown that there is no advantage of the thoracoscopic mobilization compared to the open approach, but some studies showed that the thoracoscopic approach does have a larger number of complications compared to traditional, open technique, although in this study mobilization of the esophagus as a component part of esophagectomy was examined (14,25,29,30). Based on previous studies it was shown that the maximum length of the abdominal part of the esophagus was obtained using thoracic approach (3).…”

“…There are two main types of esophageal mobilization (14). Type 1 is standard for fundoplication, and consists of complete dissection and exposure of diaphragmatic pillars, specially of the right pillar, by means of the opening of the hepatoduodenal and hepatogastric ligaments, side by side with the release of the gastric end of the diaphragm (15,16).…”

“…Also, the peritoneum and the phrenoesophageal membrane should be lifted, thus mobilizing the esophagus in the posterior mediastinum and keeping the baseline morphology of the esophageal hiatus. Type 2 implies transhiatal large mediastinal dissection, with separation of the esophageal body from surrounding mediastinal structures (14).…”

“…Within them are considered laparotomy and thoracotomy, and lately laparoscopic and thoracoscopic approach. These approaches are the subject of many studies that seek to determine whether there is an advantage over others in terms of providing an adequate length of intra-abdominal part of the esophagus with minimal post-operative complications (14,17). As an alternative method mentioned Collis gastroplasty which can be performed via laparotomy and by laparoscopy.…”

“…Laparotomy approach gives good results, although it has been shown that a wide frenotomy can be very important in the implementation of mediastinal dissection, which increases the length of the abdominal part of the esophagus for about 1 cm as compared to patients who never opened diaphragm (the average length of the esophagus obtained during frenotomy is 3.24 cm compared to 2.12 cm in patients with laparotomy only) (14,21). These results indicate that frenotomy, although it is not a routine procedure, can be an alternative approach when, during laparotomy approach, is established that antireflux valve is not able to stay in the abdomen.…”