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General Surgery
Perspective on Benign Esophageal Disease
Built from Maingot's Abdominal Operations
What’s inside
4 sections · 87 slides
Overview
- Scope of this commentary
- Key terms and abbreviations
The giant (paraesophageal) hiatal hernia
How the stomach climbs into the chest, why it happens, and how it is repaired
- Anatomy of the oesophageal hiatus
- Definition and epidemiology of hiatal hernia
- Predisposing factors for giant hernia in elderly women
- Collagen ultrastructure hypothesis
- Type 1 (sliding) hiatal hernia
- How a sliding hernia weakens the reflux barrier
- Natural history from type 1 to type 3
- Symptom change as the hernia enlarges
- Symptoms of a giant hiatal hernia
- Cameron's ulcers and erosions
- Type 2 hiatal hernia
- Parahiatal hernia
- Classification of hiatal hernia
- Stomach lying inside the chest on computed tomography
- Indications for repair of a giant hiatal hernia
- Laparoscopic versus open repair
- Oesophageal lengthening by wedge Collis gastroplasty
- Recurrence after giant hiatal hernia repair
- Bioprosthetic mesh for crural reinforcement
- Current stance on mesh after the late trial data
- Selective oesophageal lengthening to reduce recurrence
- Clinical significance of a small recurrence
- Operating room setup for laparoscopic repair
- Three early technical problems in laparoscopic repair
- Crural-focused dissection
- Closure of a large crural defect
- Why anterior crural sutures are avoided
Esophageal motility disorders
Achalasia, the Heller myotomy, its failures, and the other named motor disorders
- Achalasia as the surgeon's motility disorder
- Epidemiology of achalasia
- Proposed cause of myenteric nerve loss
- Status of the herpes virus hypothesis
- Dilated oesophagus with distal tapering on barium swallow
- High-resolution oesophageal manometry in achalasia
- Laparoscopic Heller myotomy with partial fundoplication
- Pneumatic dilation versus Heller myotomy
- Anterior (Dor) versus posterior (Toupet) fundoplication
- Rationale for the anterior wrap
- Consequences of an incomplete myotomy
- Intraoperative endoscopy after myotomy
- Muscle layers divided over the lower oesophagus and cardia
- Preparation of the oesophagus before myotomy
- Handling the epiphrenic fat pad and anterior vagus
- Entering the submucosal plane
- Extending the myotomy up the oesophagus
- Dividing the gastric portion of the sphincter
- Checking the completed myotomy
- Evaluation of a failed Heller myotomy
- Managing the diverticulum at a myotomy site
- Balloon dilation versus remyotomy after failure
- Sphincter pressure guides the redo decision
- Oesophagectomy for end-stage achalasia
- Nutcracker oesophagus and diffuse oesophageal spasm
- Leak after distal oesophageal diverticulectomy
- Three steps that prevent diverticulectomy leak
- Thoracoscopic access for diverticulectomy
Gastroesophageal reflux disease
Who needs surgery, which tests to use, which wrap to choose, and how long it lasts
- Four questions addressed in this commentary
- Mechanism of gastro-oesophageal reflux
- Reflux disease in the population
- Persistent symptoms despite acid suppression
- 40%
- Symptom response by type
- Two groups poorly served by medical therapy
- Indications for laparoscopic antireflux surgery
- Laryngopharyngeal reflux
- Tests for laryngopharyngeal reflux
- Direction of travel in LPR testing
- When 24-hour pH testing can be omitted
- Who still needs a pH study
- Total versus partial fundoplication
- Cross-section through a completed total fundoplication
- Completed fundoplication in the upper abdomen
- Oesophageal motility and choice of wrap
- Randomised European data on wrap choice
- Practical conclusion on wrap choice
- Durability of laparoscopic fundoplication
- Failure pattern after fundoplication
- Surgery compared with medical therapy in randomised trials
- Key points: hiatal hernia
- Key points: motility disorders
- Key points: reflux disease
- References
- References (continued)
- References (continued)
- References (continued)
- Maingot's Abdominal Operations, 12th Edition