Minimally Invasive Esophageal Procedures

Marco G. Patti, MD, FACS

Disclosures

August 30, 2005

Right Thoracoscopic Myotomy

A right thoracoscopic myotomy extending from the diaphragm to the thoracic inlet is the preferred procedure for patients who have nutcracker esophagus or diffuse esophageal spasm involving the entire length of the esophagus but whose LES function is normal. On the whole, this procedure is technically simpler than a left thoracoscopic myotomy: because there is no need to go through the esophagogastric junction, perforation, postoperative dysphagia, and abnormal gastroesophageal reflux are largely prevented.

Preoperative evaluation of patients being considered for right thoracoscopic myotomy is essentially the same as that of patients being considered for left thoracoscopic myotomy.

Operative planning is similar to that for a left thoracoscopic myotomy. The double-lumen tube is used to deflate the right lung rather than the left, and the patient is placed in the left lateral decubitus position over an inflated bean bag, as for a right thoracotomy. The instrumentation is identical except for the endovascular 30 mm stapler used to transect the azygos vein. A thoracotomy tray should be kept ready in case an emergency thoracotomy is necessary to control bleeding.

Step 1: Insertion of Thoracoports

Only port B is inserted where it would be for a left thoracoscopic myotomy. All the other ports are inserted one intercostal space higher because the myotomy need not be extended all the way to the stomach but must be extended to the thoracic inlet. Usually, only four ports are placed; however, an additional port may be placed in the fourth intercostal space in the anterior axillary line to facilitate the proximal extension of the myotomy.

Step 2: Dissection of Periesophageal Tissues and Division of Azygos Vein

The periesophageal tissues above and below the azygos vein are dissected away from the esophagus. A tunnel is created between the azygos and the esophagus with a dissector or a right-angle clamp. The vein is then transected with an endovascular 30 mm stapler. (Alternatively, the azygos is spared and simply lifted off the esophagus with umbilical tape.)

Troubleshooting. Dissection of the azygos vein is the most critical part of this procedure. I find it easier to transect the azygos vein than to keep the vein lifted away from the esophagus and perform the myotomy under it.

Steps 3, 4, and 5

Steps 3, 4, and 5 of a right thoracoscopic myotomy are virtually identical to steps 4, 5, and 6 of a left thoracoscopic myotomy, with a few minor exceptions. Once the submucosal plane is reached, the myotomy is extended distally to the diaphragm and proximally to the thoracic inlet. The endoscope plays a less critical role than in a left thoracoscopic myotomy because the esophagus is easily identified and because the myotomy is not extended through the esophagogastric junction. Instead, a 52 to 56 French bougie is placed inside the esophagus; this facilitates division of the circular fibers and separates the edges of the myotomy nicely.

A delayed esophageal leak is the most common postoperative complication. It should be handled as described earlier (see "Laparoscopic Heller Myotomy with Partial Fundoplication, Complications").

The postoperative course of patients who have undergone this procedure is usually identical to that of patients operated on for achalasia.

Long-term follow-up has confirmed the excellent results initially obtained for diffuse esophageal spasm with either a thoracoscopic or a laparoscopic approach.[26,33] The results for nutcracker esophagus, however, have been disappointing: a number of patients have experienced postoperative dysphagia and recurrent chest pain. In my view, the optimal treatment of nutcracker esophagus remains uncertain. The results of operative management are less predictable with nutcracker esophagus than with other esophageal disorders, and chest pain often is not alleviated.[33]

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