transthoracic esophagotomy

Axillary achalasia refers to the absence of peristalsis in the esophageal body during swallowing and poor sphincter sphincter. The disease is more common in 20 to 50 years old. Esophageal myotomy is the most widely used procedure for the treatment of achalasia. 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 Indication Transthoracic esophageal myotomy is applied to: 1. The medical treatment is not effective, the esophageal dilatation and flexion are obvious, or there are other pathological changes, such as supraorbital diverticulum, hiatal hernia or suspected cancer. 2. Have undergone dilatation treatment, or lead to gastroesophageal reflux and esophagitis. 3. The symptoms are severe and do not want to be esophageal dilatation. Contraindications 1. Patients with severe heart and lung function. 2. The nutritional status is low, and the hemoglobin is lower than 6.0g/L. Preoperative preparation 1. People with malnutrition should be corrected before surgery. They can be intubated through central venous, supported by parenteral nutrition or treated with internal medicine or dilatation, so that they can enter the liquid food by mouth. 2. Patients with pulmonary complications should be treated appropriately. 3. Because the food is retained in the esophagus, the esophagus has different degrees of inflammation. The esophagus should be inserted into the stomach tube once a day for 3 days before surgery, and the antibiotic solution is injected after washing. Repeat 1 time before anesthesia to remove the accumulated secretions overnight and leave the stomach tube. Premedication should not be given to pills or tablets. Surgical procedure Incision The posterior lateral incision of the left chest enters the chest through the 7th or 7th intercostal space. 2. Exposed esophagus The lungs were pulled forward and upward, and the lower lung ligament was cut until the level of the lower pulmonary vein. The mediastinal pleura was opened, the esophagus was exposed, and the gauze was bypassed. As a traction, the lower esophagus was lifted, the esophageal ligament ligament was cut, and the gastroesophageal junction was pulled into the chest for a short period of time. It is not necessary to cut the hole attachment portion of the esophagus unless anti-reflux surgery is required. When the esophagogastric junction cannot be pulled into the chest, a short incision can be made in the diaphragm in front of the hole to provide the necessary exposure, after which the incision is repaired with intermittent sutures. 3. Esophageal muscle layer incision Hold the esophagus in the left hand and put the thumb in front. Use a round blade to carefully make the mouth on the anterior wall of the esophagus. Use a blunt-right angle clamp to separate the longitudinal muscles of the outer layer. Continue to open the ring muscle and carefully dissociate. Deep into the submucosa, the visceral incision was used to extend the incision of the myometrium, the proximal to the lower pulmonary vein was horizontal, and the distal end was 1 cm below the esophagogastric junction. Regarding the length of the incision, each family has different opinions, generally not less than 5cm, and there are also those who advocate direct aortic arch level. After completing the myometrial incision, pay attention to hemostasis and use electrocoagulation carefully. 4. Free muscle layer After the muscle layer is cut, the cut muscle edge is released to both sides to half of the circumference of the esophagus, so that the mucosa bulges within the entire length of the incision. 5. Esophageal reduction Place the esophagus in the mediastinum and return to the normal intra-abdominal position, unless there is a hiatus, no need for routine reconstruction and contraction. The incision of the partial mediastinal pleura was sutured. 6. Close the chest Before the chest is closed, the nasogastric tube is sent to the stomach, and the chest tube is drained on the sputum, and the chest wall is additionally made into a slit, and the chest wall is sutured layer by layer. 7.Heller improved The mucosal bulging part of the original esophagus myotomy was not covered. Petrovsky et al. cut the diaphragm adjacent to the esophagus into a lingual flap, and the pedicled iliac muscle flap was transferred upward on both sides of the esophagus cutting edge, and the suture was completed. 8. Anti-reflux surgery In order to reduce reflux esophagitis after esophageal myotomy, some authors advocate adding anti-reflux surgery.