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158
Research
T. Zohourian et al.
Reference Findings
Slater BJ, Dirks RC, McKinley SK, Ansari MT, Kohn GP, Thosani
N, Qumseya B, Billmeier S, Daly S, Crawford C, P Ehlers A,
Hollands C, Palazzo F, Rodriguez N, Train A, Wassenaar E, Walsh
D, Pryor AD, Stefanidis D.SAGES guidelines for the surgical
treatment of gastroesophageal reux (GERD). Surg Endosc.
2021;35(9):4903–17. https://doi.org/10.1007/s00464- 021- 08625- 5.
Epub 2021 Jul 19
Laparoscopic or robotic fundoplication is
endorsed by the Society of American
Gastrointestinal and Endoscopic Surgeons
(SAGES) over open interventions due to its
safety, efcacy, patient satisfaction, length of
stay, recuperative time, and incidence of
incisional hernia
Complications of fundoplication and their management
Complications Characteristics Management
Dysphagia
Gas bloat syndrome
A liquid diet is needed for approximately 1week
with the slow introduction of solids
Diagnose with upper gastrointestinal series
Recurrent abdominal pain and distention
secondary to air trapping
Diagnosis. Obtain a plain abdominal x-ray if the
patient is symptomatic (e.g., burping, belching). If
the stomach is lled with air but the small bowel
is without distention, this is diagnostic
Intervene if symptoms persist beyond
12weeks
Serial dilation or revision if needed
Reduce carbonated beverages and
reduce aerophagia
Most patients require conversion to a
partial wrap, which reduces bloating
Research
Reference Findings
Sobrino-Cossio S, Soto-Perez JC, Coss-Adame E, etal.
Post-fundoplication symptoms and complications: diagnostic
approach and treatment. Revista de Gastroenterologia de
Mexico (English edition). 2017;82(3):234–247
Postoperative dysphagia and dyspeptic symptoms
are very frequent after Nissen fundoplication and
require an integrated approach to determine the
best possible treatment
5 Esophagus
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Esophageal Perforation andRepair
Esophageal perforation and repair
159
Pathophysiology
Etiology
Presentation Epigastric, chest pain, or dysphagia
Diagnosis
Esophagus lacks a serosal layer➔more susceptible to perforation
Iatrogenic Most common site is cricopharyngeus
Trauma Blunt is more common mechanism of injury than penetrating
Post-emesis
(Boerhaave
syndrome)
Diagnostic
modality
CXR Pleural effusion,
Most common site is on the left side of the distal third of esophagus
Findings Radiology images
pneumomediastinum,
and subcutaneous
emphysema
PA chest radiograph demonstrates
pneumomediastinum (outlined arrows) and
subcutaneous emphysema (arrow), ndings which
can be seen in esophageal perforation
160
Esophageal perforation and repair
T. Zohourian et al.
Esophagogram
with watersoluble
contrast
CT scan with
oral contrast
If
leak➔management
If no leak➔Barium
esophagogram
Left anterior oblique upper GI static image
demonstrates contrast leakage (arrows) from the
esophagus (e), traversing along the diaphragm and
external to the patient through a surgical tract. Also
note the left-sided chest tube (arrowheads)
Air or collection in
mediastinum
Endoscopy Helps inlocalizing
the perforation
Axial chest CT image with IV and oral contrast
demonstrate air and oral contrast outside of the
esophageal lumen, extending into the mediastinum
(arrow)
5 Esophagus
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Esophageal perforation and repair
1. Resuscitate, NPO, antibiotics (including antifungals)
2. Control of the leak
3. Debridement of devitalized tissues
4. Repair of injury if possible
5. Buttress
6. Wide drainage
7. Nutritional support
161
Management
Esophageal
injury
Acute
esophageal
injury (<24h
from injury)
Delayed
recognition of
esophageal
injury
Small
esophageal
injuries
Destructive
injuries that
cannot be
repaired
primary
Destructive
injuries with
signicant
necrosis
Perforations
contained in the
neck or
mediastinum
with no contrast
extravasation
Management
Primary repair
Resuscitate and control contamination
Debride and repair primarily
Repair over T tube to create a controlled stula
Diversion with cervical esophagostomy
Conservative management
Contained
perforation in
patients that are
poor surgical
candidates
Esophageal stents
162
posterolateral
Esophageal perforation and repair
Debride all devitalized tissue
Extend myotomy to inspect mucosa because mucosal defect is usually more extensive than
Key steps to repair
of esophageal
perforation
muscularis injury
Repair in two absorbable layers (closure of mucosa and muscle in separate layers)
Buttress: Intercostal muscle, pericardial fat, pleura, omentum
Wide drainage
Surgical approaches to repair esophageal injuries
Figure
T. Zohourian et al.
Buttress
options
Cervical
esophagus
(from cricoid to
suprasternal
notch)
Upper thoracic
(suprasternal
notch to the
carina)
Distal third
(carina to the
gastroesophageal
junction)
Right
thoracotomy
Left
cervical
incision
Left
thoracotomy
Left collar incision or
incision along the
anterior border of the
sternocleidomastoid
muscle
Divide the omohyoid
muscle, perform blunt
posterior tracheal
dissection to avoid
injury of recurrent
laryngeal nerve
Right posterolateral
thoracotomy at the fth
intercostal space
Left thoracotomy at the
seventh intercostal
space
Omohyoid,
sternocleidomastoid,
and strap muscles
Pericardium,
intercostal, anterior
serratus
Thal patch, partial
fundoplication,
omentum, and
diaphragm
iculum
Cr
phar
di
5 Esophagus
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Cricopharyngeal Myotomy withZenker Diverticulum-Excision
Epiphrenic
Zenker Diverticulum Traction diverticulum
Location Proximal esophagus Mid esophagus Distal third of
diverticulum
esophagus
163
Characteristics
Presentation
Posterior diverticulum, proximal to the
cricopharyngeal muscle, resulting from
inadequate relaxation of the cricopharyngeus
with swallowing
Pulsion diverticulum
Anatomic borders of Killian triangle.
Inferiorly by the upper border of the
cricopharyngeal muscle; Laterally by the
oblique bers of the inferior constrictor
muscles of the pharynx
Dysphagia, halitosis and globus sensation,
regurgitation, aspiration pneumonia, cough,
halitosis, neck pain, weight loss lump in neck
Thyropharyngeus
Zenker’s
divert
ico-
yngeus
Esophagus
Usually caused by an
inammatory condition in a
mediastinal lymph node
(histoplasmosis, tuberculosis)
Pulling force on the outside of
the esophagus
Asymptomatic
Dysphagia, regurgitation
Zenker
diverticulum
Traction
verticulum
Epiphrenic
diverticulum
A pulsion
diverticulum, it is
usually associated
with an
esophageal body
motility disorder
Occurs from
increased pressure
during esophageal
peristalsis against
closed lower
esophageal
sphincter
Asymptomatic
Dysphagia,
regurgitation
Diagnosis
Barium swallow➔distinguish oropharyngeal
Barium swallow Barium swallow
dysphagia from Zenker’s diverticulum
Management Surgical or endoscopic repair is the gold
standard of management
Treatment of underlying
infection
Treatment of
esophageal
dysmotility
disorder
164
Open cricopharyngeal myotomy versus endoscopic cricopharyngomyotomy
Open cricopharyngeal myotomy
Approach
Indications
with diverticulectomy or
diverticulopexy
Diverticula <3cm Approach advocated for larger diverticula
Endoscopic cricopharyngomyotomy
(Dohlman approach)
(diverticula between 3 and 5cm)➔risk of
incomplete myotomy for diverticula <3cm
Requires maximal extension of the neck (cannot
be performed in patients with cervical stenosis)
T. Zohourian et al.
Advantages Complete removal of pouch (carcinoma can be
excluded)
Low recurrence rate
Incision over the anterior border of the left
sternocleidomastoid muscle
Myotomy of the proximal and distal
thyropharyngeus as well as the
cricopharyngeus muscles is performed
Key steps
Complications Mediastinitis, wound infection, stula, or
The posterior surfaces of the pharynx and
esophagus are exposed with blunt dissection
and the diverticulum is exposed
For small diverticula (<2cm)➔myotomy
For large sac (>5cm)➔excision of sac
perforations, pneumomediastinum, vocal cord
paralysis, aspiration pneumonia
Postoperative course is slightly shorter than open
approach
The tip of the diverticuloscope is advanced into
the esophageal introitus to engage the
cricopharyngeus muscle
This method divides the distal cricopharyngeus
muscle while obliterating the sac
The stapler is red➔esophagus and
diverticulum form a common channel
Increased risk of incomplete myotomy with small
diverticula➔barium swallow for diagnosis
Esophageal Caustic Ingestion andForeign Bodies
Esophageal foreign bodies
Anatomic
locations
Epidemiology
Presentation If the foreign body causes perforation, then symptoms depend on location
Diagnosis Diagnostic modality
Sites of physiologic narrowing in esophagus: Upper esophageal sphincter, level of aortic arch,
diaphragmatic hiatus
More common in children and adults with psychiatric disorders or intoxication
Food impaction is more common in patients with eosinophilic esophagitis, achalasia, and
structural abnormalities
X-ray of neck and chest (AP and lateral)
Endoscopy
5 Esophagus
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Esophageal foreign bodies
First step in management of esophageal foreign bodies is to secure airway (bronchoscopic
guided intubation if airway compromise)
165
Case Management
Complete esophageal obstruction
Management
Sharp objects or disk batteries
Non-sharp foreign bodies in esophagus
Non-obstructing food impaction
Asymptomatic patient with coins in esophagus Non-urgent endoscopy
Research
Reference Findings
American Society for Gastrointestinal
Endoscopy (ASGE). ASGE Standards of
Practice Committee, Ikenberry SO, Jue TL,
Anderson MA, etal. Management of ingested
foreign bodies and food impactions.
Gastrointest Endosc. 2011;73(6):1085–91
Emergent endoscopy
Urgent endoscopy (within 24h)
Emergent endoscopy:
• Esophageal obstruction (cannot manage secretions)
• Disk batteries
• Sharp objects
Urgent endoscopy:
• Esophageal objects (not sharp)
• Esophageal food impaction (not obstructed)
• Foreign objects in stomach or duodenum (sharp)
• 6cm objects at or above duodenum
• Magnets within endoscopic reach
Non-urgent endoscopy:
• Coins in esophagus (can be observed 12–24h prior to removal if
asymptomatic)
• 2.5cm objects in stomach
Disk and cylindrical batteries in stomach (can be observed for 48h
if asymptomatic)
Esophageal caustic ingestion
In children most common due to accidental small-volume drinking of household product
Epidemiology
In adults most common due to attempted suicide by drinking large volume
Alkali ingestions➔liquefactive necrosis➔extends to mucosa➔more injury than acid
Pathophysiology
Presentation If the foreign body causes perforation, then symptoms depend on location
Diagnosis Endoscopy should be performed within 24h except if patient is hemodynamically unstable or
ingestion
Acid ingestion➔coagulation necrosis➔protective eschar
with high suspicion for esophageal perforation
166
Esophageal caustic ingestion
First step in management of esophageal caustic injuries is to secure airway
Induction of vomiting is contraindicated because it may exacerbate injury
Patient with low-grade caustic injury Resuscitate
Management
Patient with high-grade caustic injury without
perforation or sepsis
T. Zohourian et al.
Case Management
Resuscitate+antibiotics+intensive care
monitoring
Patient with full-thickness injury or diffuse
necrosis causing sepsis
Follow up Patients with high-grade esophageal burns should undergo yearly endoscopy to check for
stricture or malignancy development
Resuscitate+antibiotics+intensive care
monitoring
Operative intervention (debridement and
diversion)
Research
Reference Findings
Hathorn K, etal. Mo1267 treatment of severe, refractory
esophageal strictures with mitomycin c: a systematic review
and meta-analysis. Gastrointest Endoscop. 91(6):AB407–8
Chirica etal. Caustic ingestion. Lancet.
2017;389(10083):2041–52. https://doi.org/10.1016/
S0140- 6736(16)30313- 0. Epub 2016 Oct 26. PMID:
28045663
Standards of Practice Committee of the American Society for
Gastrointestinal Endoscopy. The role of endoscopy in
Barrett’s esophagus and other premalignant conditions of the
esophagus. ASGE Standards of Practice Committee;
Gastrointest Endosc. 2012;76(6):1087–94
Esophageal stricture caused by caustic injury:
For patients with strictures who are undergoing
dilation, mitomycin C has been shown in
randomized trials to provide symptomatic
improvement and reduced frequency of periodic
dilations
Glucocorticoids are still under debate for stricture
prevention. High-dose and long-course steroid use
has been shown to increase the risk of perforation. A
short course (3days) may be of benet for those at
high stricture risk with low perforation risk (grade
2B)
Between 2% and 30% of patients with grade 2B or
higher injuries will develop esophageal malignancy.
The American Society for Gastrointestinal
Endoscopy (ASGE) recommends routine screening
10–20years after the insult
5 Esophagus
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Esophageal Motility Disorders
Esophageal motility disorders
Distal esophageal
Achalasia
spasm
Nutcracker
esophagus
167
Secondary
dysmotility
(Scleroderma,
diabetes, and
alcoholism)
Aperistalsis+incomplete lower esophageal
sphincter (LES)
Characteristics
Pathophysiology
Presentation Dysphagia to solids and
Diagnosis
relaxation
Loss of inhibitory
innervation in the LES
causes the basal
sphincter pressure to
rise and renders the
sphincter muscle
incapable of normal
relaxation
liquids, regurgitation
“Bird’s beak”
appearance, with a sharp
taper of barium at the
gastroesophageal
junction
Esophageal manometry
(gold standard)
Premature and rapid
contractions in the distal
esophagus
Normal amplitude, with
irregular sequence of
contraction
Impaired inhibitory
innervation malfunction
in endogenous nitric
oxide synthesis and/or
degradation
Dysphagia to solids and
liquids, regurgitation,
sensation of food stuck in
esophagus, retrosternal
chest pain
“Corkscrew”
Peristalsis with >20%
simultaneous
contractions
Prolonged duration
contractions
Hypertensive
peristalsis
High amplitudes,
with regular
sequence of
contraction
Excessive excitation
of smooth muscles
with activation of
nerves
Dysphagia to solids
and liquids, severe
chest pain
No regurgitation
Most patients may
have a normal barium
swallow
Increased amplitude
and peristaltic
duration
Hypotensive
peristalsis
Low amplitude, with
regular sequence of
contraction
Neuropathy of
myenteric plexus
Refractory
heartburn,
dysphagia,
odynophagia
(candida),
regurgitation
Dilated esophagus
(+) reux
LES pressure:
Absent or
<30mmHg
Elevated LES pressure
>45mmHg
Incomplete LES
relaxation
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