C Palanivelu, MS, FACS, FRCSEd, DSc, R Parthasarathi, MS, FMAS,P Senthilnathan, MS, FMAS, DNB, S Rajapandian, MS, FRCS, FMAS, P Praveen Raj, MS, FMAS, N Ramesh, M Bharath Cumar. GEM Hospital & Research Centre
Background: Peptic esophageal stricture has become uncommon since the introduction of proton pump inhibitors (PPI’s). Endoscopic dilatation along with PPI is the standard treatment. However, surgery is required for refractory or recurrent strictures which fail multiple attempts at endoscopic therapy. This is a video presentation of laparoscopic vagal sparing transhiatal esophago-gastrectomy with stapled esophagogastrostomy for recurrent peptic stricture of esophagus.
Methods: Case history and pre-operative evaluation: 40 years male, a known case of peptic esophageal stricture, presented with complaints of dysphagia for solids. He had undergone CRE balloon dilatation 4 times over a period of 3 years followed by bio-degradable self-expandable stent placement. However, symptoms recurred each time. On evaluation, there was a 4cm long stricture with severe luminal narrowing in the lower esophagus, starting from 35 cm onwards upto GE junction.
Surgical details: Patient was placed in supine with leg split position. Following port placement, stomach, and GE junction mobilized preserving both Vagi and vascular arcades by staying close to stomach wall. Transhiatal mobilization of lower esophagus was done upto 2cm above the stricture under intra-operative endoscopic guidance. Peristrictural fibrosis was noted with pleura and vagi densely adherent which were dissected away carefully. Esophagus transacted by firing linear stapler above the stricture and gastric conduit was made by serial firing of staplers from incisura to fundus. Anvil of 25mm circular stapler introduced through mouth and brought out through transected end of proximal esophagus. Specimen extracted through 1.5cm transverse incision in left lumbar region and stapler head introduced through same incision. End-to-side stapled esophago-gastric anastomosis done.
Results: Post-operative hospital stay was 6 days, ICU stay was 2 days. Orals commenced on 3rd post-op day after oral gastrograffin study confirmed no leak and good gastric emptying. Patient was symptom free at 3 months and OGD scopy showed patent anastomosis and no evidence of reflux esophagitis.
Discussion: Recurrent or refractory strictures which fail endoscopic management require surgical intervention. Minimal invasive surgery in these patients is associated with early recovery, early resumption of diet, short hospital stay and minimal morbidity.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 79479
Program Number: V167
Presentation Session: Foregut 3
Presentation Type: Video