Future applications of flexible endoscopy in esophageal surgery

Flexible endoscopy has long played a role in esophageal surgery, and procedures like perforation closure, stenting of occluding malignancies, antireflux procedures, and removal of Barretts are increasingly replacing open and laparoscopic procedures. We present early results of a series of acute animal experiments studying the feasibility of using flexible endoscopes for complex esophageal surgery such as Heller myotomy and esophagectomy.

A total of six animals and one human cadaver have been operated on in a series of three protocols. The first study involves extraluminal flexible endoscopy through a cervical incision. The esophagus is dissected to the phrenoesophageal junction and a Heller myotomy performed. The second study involves labeling specific mediastinal node areas using EUS and transesophageal tattooing. Transcervical access is once again obtained, and wide esophageal dissection is performed; sequential identification of the marked nodes is performed. The final study involves full thoracic esophageal mobilization and laparoscopic gastric mobilization for an esophagogastrectomy.

Heller myotomy in five animals was performed via flexible endoscopy. Total operative time was 49 min with mean time for myotomy being 22 min. One animal had hemodynamic compromise from over insufflating the mediastinum with air. The second study involved three animals and one human cadaver. An average of four nodes was marked by EUS, and there was 100% success in identifying all nodes with flexible medistinoscopy. Operative times had a mean of 187 min (147-227) for the animal model and 198 min for the cadaver model.

There is a move to increase the role of flexible endoscopy in GI surgery. This is facilitated by the introduction of novel scopes and instrumentation designed for NOTES. We outline early favorable results from animal studies looking at the use of flexible endoscopy as a surgical tool for Heller myotomy and esophagectomy.