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xii
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Contributors
MohammedAl Mahroos, MD, FRCSC Department of Surgery, St Mary’s Hospital, McGill University, Montreal, QC, Canada
EdwardAuyang, MD, MS, FACS Department of Surgery, Uni­versity of New Mexico School of Medicine, Albuquerque, NM, USA
AlexanderL.Ayzengart Department of Surgery, University of Florida Health, Gainesville, FL, USA
Amy Banks-Venegoni, MD, FACS Spectrum Health Medical Group and Corewell Health West-Department of Surgery, Michi­gan State School of Medicine, East Lansing, MI, USA
NikolaiA.Bildzukewicz University of Southern California, Los Angeles, CA, USA
ShaoxuBing, MD Department of Surgery, UF Health Jackson­ville, Jacksonville, FL, USA
JennaBorys, DO Department of Surgery, Grant Medical Center, Columbus, OH, USA
JosephR.Broucek, MD Division of General Surgery, Depart­ment of Surgery, Vanderbilt University Medical Center, Nash­ville, TN, USA
AndrewM.Brown, MD Department of Surgery, St. Luke’s Uni­versity Hospital, Bethlehem, PA, USA
J.ChristianBrown Department of Surgery, University of Flor­ida Health, Gainesville, FL, USA
FrancisP.Buckley III Dell Medical School, University of Texas at Austin, Austin, TX, USA
MichelleCampbell, MD University of Chicago Medical Center, Chicago, IL, USA
Jennwood Chen Division of Gastroesophageal and Bariatric Surgery, University of Utah, Salt Lake City, UT, USA
PaulD.Colavita Division of Gastrointestinal Surgery, Depart­ment of Surgery, Carolinas Medical Center, Charlotte, NC, USA
Contributors
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xiii
TanujaDamani, MD, FACS NYU Grossman School of Medi­cine, New York, NY, USA
Center for Esophageal Health, NYU Langone Health, New York, NY, USA
S.ScottDavis Jr., MD, FACS Emory Endosurgery Unit, Depart­ment of Surgery, Emory University, Atlanta, GA, USA
D’Artagnan DeBow, MD Division of Minimally Invasive and Bariatric Surgery, Zucker School of Medicine at Hofstra/North­well, Lenox Hill Hospital, New York, NY, USA
GabrielDiazDel Gobbo, MD Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
Abdul-Rahman Fadi Diab, MD Division of Gastrointestinal Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA
Maggie L. Diller, MD Division of General and GI Surgery, Department of Surgery, Emory University, Atlanta, GA, USA
StephanieDoggett Dell Medical School, University of Texas at Austin, Austin, TX, USA
RodrigoDuarte-Chavez, MD Department of Gastroenterology, St. Luke’s University Hospital, Bethlehem, PA, USA
ChristopherDuCoin, MD, MPH, FACS Division of Gastroin­testinal Surgery, Department of Surgery, University of South Flor­ida Morsani College of Medicine, Tampa, FL, USA
JustinEagleston, MD, MHA Trihealth Good Samaritan Hospi­tal, Cincinnati, OH, USA
Carolinas Medical Center, Charlotte, NC, USA
SoaneEl Djouzi Barijuve Surgical, Darien, IL, USA
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Contributors
MichaelT.Fastiggi, MD New Jersey Bariatric Center, Hackett­stown, NJ, USA
University Hospitals Cleveland Medical Center, Cleveland, OH, USA
Case Western University School of Medicine, Cleveland, OH, USA
FilippoFilicori, MD Division of Minimally Invasive and Bariat­ric Surgery, Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, NY, USA
FerminFontan, MD University of Iowa Carver College of Med­icine, Iowa City, IA, USA
Meredith Freeman, MD Tulane University, School of Medi­cine, New Orleans, LA, USA
Gregory Fritz, MD Corewell Health General Surgery Resi­dency, Michigan State School of Medicine, East Lansing, MI, USA
ElisaJ.Furay, MD Dell Medical School, University of Texas at Austin, Austin, TX, USA
CarlosGalvani, MD, FACS, FASMBS Division of Minimally Invasive Surgery and Bariatric, Department of Surgery, Tulane University, School of Medicine, New Orleans, LA, USA
MeredithA.Harrison, MD Department of Surgery, St. Luke’s University Hospital, Bethlehem, PA, USA
Alison Y. Haruta, MD Department of Surgery, University of Washington, Seattle, WA, USA
IvyN.Haskins, MD Esophageal Swallowing Center, MIS/Bar­iatric, Foregut, and Hernia Surgery, Omaha, NE, USA
JustinHenning, MD Center for Esophageal Health, NYU Lan­gone Health, New York, NY, USA
NYU Langone Health, New York, NY, USA
KellyM.Herremans Department of Surgery, University of Flor­ida Health, Gainesville, FL, USA
Contributors
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xv
CharlesHill, MD Dell Medical School, University of Texas at Austin, Austin, TX, USA
Justin Hsu, MD Corewell Health General Surgery Residency, Michigan State School of Medicine, East Lansing, MI, USA
AnnaIbele, MD, FACS Department of Surgery, The University of Utah, Salt Lake City, UT, USA
Hope T. Jackson, MD Department of Surgery, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
TaylerJ.James University of Southern California, Los Angeles, CA, USA
BoraKahramangil, MD Cleveland Clinic Florida, Department of General Surgery, Bariatric and Metabolic Institute, Weston, FL, USA
KshitijKakar, MD, FACS Trihealth Bethesda North Hospital, Cincinnati, OH, USA
Umashankkar Kannan, MD Institute for Bariatric and Mini­mally Invasive Surgery, Mount Sinai Morningside Medical Cen­ter, New York, NY, USA
Angela M. Kao Division of Gastrointestinal Surgery, Depart­ment of Surgery, Carolinas Medical Center, Charlotte, NC, USA
AbdulazizAliKaram Department of Surgery, St Mary’s Hospi­tal, McGill University, Montreal, QC, Canada
SubhashKini, MD Institute for Bariatric and Minimally Inva­sive Surgery, Mount Sinai Morningside Medical Center, New York, NY, USA
IsaacR. Kriley, MD Department of Surgery, UF Health Jack­sonville, Jacksonville, FL, USA
MatthewKroh, MD Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
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Contributors
James Kurtz, DO, FACOS Valley Forge Surgical Associates, Phoenixville, PA, USA
DanuelLaan, MD Division of Minimally Invasive Surgery and Bariatric, Department of Surgery, Tulane University, School of Medicine, New Orleans, LA, USA
Ryan Lamm, MD Department of SurgeryThomas Jefferson University Hospital, Philadelphia, PA, USA
MeganLundgren, MD Department of Surgery, Penn Highlands Healthcare, Dubois, PA, USA
Emanuele Lo Menzo, MD, PhD, FACS, FASMBS Cleveland Clinic Florida, Department of General Surgery, Bariatric and Metabolic Institute, Weston, FL, USA
RonakModi, MD Department of Gastroenterology, St. Luke’s University Hospital, Bethlehem, PA, USA
PeterNau, MD, MS, FACS University of Iowa Carver College of Medicine, Iowa City, IA, USA
KrzystofM.Nowak, MD ENT and Allergy Associates, Yonkers, NY, USA
Dmitry Oleynikov, MD Department of Surgery, Monmouth Medical Center, Long Branch, NJ, USA
FrancescoPalazzo, MD, FACS Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
AbhishekD.Parmar, MD Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
KyleA.Perry Division of General and Gastrointestinal Surgery, Ohio State University, Columbus, OH, USA
JenniferF.Preston, MD College of Medicine Phoenix, Univer­sity of Arizona, Phoenix, AZ, USA
Ruchir Puri, MD, FACS Department of Surgery, UF Health Jacksonville, Jacksonville, FL, USA
Contributors
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xvii
JoelRichter, MD, FACP, MACG Division of Gastrointestinal Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA
MatthewW.Romine, MD Department of Surgery, East Caro­lina University Hospital System, Greenville, NC, USA
RaulRosenthal, MD, FACS, FASMBS Cleveland Clinic Flor­ida, Department of General Surgery, Bariatric and Metabolic Institute, Weston, FL, USA
RamsesA.Saavedra, MD, MS Department of Surgery, Univer­sity of New Mexico School of Medicine, Albuquerque, NM, USA
Sarah Samreen, MD University of Texas Medical Branch, Galveston, TX, USA
StefanScholz, MD, PhD, FACS, FAAP Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
Division of Pediatric General and Thoracic Surgery, UPMC Chil­dren’s Hospital of Pittsburgh, Pittsburgh, PA, USA
LuisSerrano, MD, FACS HCA Florida Osceola Surgical Care Specialists, Kissimmee, FL, USA
FedericoSerrot, MD Department of Surgery, Emory University, Atlanta, GA, USA
ElizabethSharbaugh, MD Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
LindseyC.Shipley, MD Division of Gastroenterology and Hep­atology, University of Alabama at Birmingham, Birmingham, AL, USA
DanielShouhed, MD Cedars Sinai Medical Center, Los Ange­les, CA, USA
VibhaSood, MD Department of Pediatrics, University of Pitts­burgh School of Medicine, Pittsburgh, PA, USA
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Contributors
Division of Pediatric Gastroenterology, Hepatology, and Nutri­tion, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
NathanielJ.Soper, MD College of Medicine Phoenix, Univer­sity of Arizona, Phoenix, AZ, USA
JosephSujka, MD Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA
Samuel Szomstein, MD, FACS, FASMBS Cleveland Clinic Florida, Department of General Surgery, Bariatric and Metabolic Institute, Weston, FL, USA
OscarTalledo, MD University of Iowa Carver College of Medi­cine, Iowa City, IA, USA
TalarTatarian, MD Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
Jeffrey Thomas, DO, MPH Department of Surgery, Doctors Hospital, Columbus, OH, USA
MichaelUjiki, MD NorthShore University HealthSystem, Evan­ston, IL, USA
NatachaWathieu, MD Tulane University, School of Medicine, New Orleans, LA, USA
Michael L. Williford, MD WakeMed Health and Hospitals, Raleigh, NC, USA
AndrewS.Wright, MD Department of Surgery, University of Washington, Seattle, WA, USA
LaurenYoder, MD Trihealth Good Samaritan Hospital, Cincin­nati, OH, USA
MohanadR.Youssef, MD Division of Minimally Invasive Sur­gery and Bariatric, Department of Surgery, Tulane University, School of Medicine, New Orleans, LA, USA
Part I
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Understanding Anatomy
and Physiology
Anatomy andPhysiology
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oftheEsophagus
JereyThomas andJamesKurtz
Anatomy
Topography oftheCervical, Thoracic, andAbdominal Esophageal Segments
Topographically, the cervical portion of the esophagus extends from the pharynx to the suprasternal notch, with an average dis­tance of approximately 5 centimeters. In this region, the esopha­gus is bordered posteriorly by the vertebral column, laterally by the carotid sheaths, and anteriorly by the trachea. The cervical esophagus is adherent to the posterior trachea and the vertebral column via loose connective tissue (anteriorly) and the preverte­bral fascia (posteriorly). The thoracic duct is also found to the left of the sixth cervical vertebra in close proximity to the esophagus.
1
J. Thomas Department of Surgery, Doctors Hospital, Columbus, OH, USA e-mail: Jeffrey.Thomas@ohiohealth.com
J. Kurtz (*) Valley Forge Surgical Associates, Phoenixville, PA, USA e-mail: James.Kurtz@towerhealth.org
© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2023 A. D. Patel et al. (eds.), The SAGES Manual of Physiologic Evaluation of Foregut Diseases,
https://doi.org/10.1007/978-3-031-39199-6_1
3
4
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J. Thomas and J. Kurtz
The primary source of arterial inow to the cervical esophagus is derived from the inferior thyroid arteries, branches of the subcla­vian artery on the right, and the thyrocervical trunk on the left.
The cervical esophagus is notable for its composition of stri­ated muscle, making it distinct from the muscular composition of the remaining 2/3 of the esophagus, which is primarily smooth muscle. The upper esophageal sphincter (UES) is an important high-pressure zone at the inlet of the esophagus that allows bolus passage and protection of the airway during swallowing. The high, constant resting tone (mean 60mmHg) of the UES is accom­plished by the cricopharyngeus muscle, the inferior pharyngeal constrictor, and the musculature of the cervical esophagus (which are arranged in a horizontal orientation). The cricopharyngeus muscle is thought to be the main contributor to the UES and also marks the most proximal of three narrowing points in the esopha­gus that contribute to its hourglass shape. In contrast, the opening of the UES is accomplished by contraction of the suprahyoid superiorly and the thyrohyoid musculature inferiorly, which act together to pull the hyoid bone anterior and inferior to its native position, ultimately displacing the laryngeal complex anteriorly and opening the UES.Posterior musculature including the stylo­pharyngeus, palatopharyngeus, and pterygopharyngeus acts to stabilize the posterior aspect of the UES and increase its diameter on opening.
Also, within the cervical esophagus is an area of relative weak­ness in the wall of the esophagus known eponymously as Killian’s triangle. This triangle represents a common site for the diverticula of the esophagus. This anatomic triangle is formed by the trans­versely oriented bers of the cricopharyngeus and by the obliquely oriented inferior pharyngeal constrictor muscles. The weakest point of this triangle wherein diverticula may be found is known as Killian’s dehiscence and is characterized by its lack of poste­rior esophageal muscularis. In addition to being a frequent site of diverticular formation, this area is subject to iatrogenic injury in routine procedures including esophagogastroduodenoscopy (EGD) secondary to its ease of penetration.
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