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312 Part III Esophagus
52F
A
Bougie
Planned site
of myotomy
B
C
FIGURE 14-23 A. Zenker’s diverticulum, dashed line indicates proposed site of myotomy. B. Isolation of Zenker’s diverticulum, with myotomy.
C. Resection of Zenker’s diverticulum with gastrointestinal anastomosis (GIA) stapler.
Small diverticula are dicult to engage with the stapling
device and diverticuloscope.
endoscopy) are employed. All therapies are associated with
greater than 90% symptom relief. Endoscopic therapies are
associated with shorter length of stay, can be performed as
outpatient procedures, and may avoid general anesthetic
Summary
administration. However, they are associated with higher
recurrence rates, which can often be addressed with repeat
ZD is a rare disorder in which a pulsion-type diverticulum
occurs in the posterior pharyngoesophageal region. Both
surgical and endoscopic treatments (using rigid or exible
endoscopic treatment. ese are important factors to consider as ZD usually presents in elderly patients who are more
likely to be inrm. Both open surgical technique and perioral
Chapter 14 Benign Esophageal Disorders 313
A
Diverticuloscope
Diverticulum
B
Endo GIA
Copyright © 2002, University of Washington. All rights reserved.
FIGURE 14-24 Zenker’s diverticulectomy using diverticuloscope and stapler to perform mucomyotomy.
endoscopic methods are valid treatment methods and the
choice of which to pursue should be based upon anatomic
considerations, available expertise, and patient comorbidities.
disorder. Assuch, these patients may present with symptoms
similar to the aforementioned motility disorders, most commonly to include dysphagia, chest pain, heartburn, and regurgitation. Intermittent nocturnal aspiration is frequently seen
and occurs in nearly 45% of patients.
Epiphrenic Diverticula
patients should include a complete history and examination,
upper GI barium swallow, esophageal manometry and pH
Diverticula present in the distal third of the esophagus, usually
within 10 cm of the GE junction, are referred to as epiphrenic
diverticula (ED). It is a rare condition, and its true incidence
remains unclear as the number of patients with asymptomatic
diverticula is not known. ese are pulsion-type false diverticula, similar to ZD, as they are only outpouchings of mucosa
and submucosa through the muscular wall of the esophagus.
e pathophysiology underlying the disease, rst recognized
85
by Mondiere in 1833,
is assumed to be elevated esophageal
testing, and endoscopy (Fig. 14-25). Some controversy exists
regarding who should be treated surgically. ose with mild
symptoms and small-size diverticula, or those to whom surgery
presents signicant risk, can be safely observed. If symptoms of
GERD are present, they may be controlled with medications.
ese patients should be followed for progression of their symp-
90
ose with severe symptoms who are candidates for sur-
toms.
gery should be treated surgically.
intraluminal pressures, as a result of an underlying esophageal
motility disorder, in conjunction with functional distal obstruction. With the advent of esophageal manometric testing, it is
Treatment
clear that EDs are commonly associated with a heterogeneous
group of motility disorders and LES dysfunction, including
achalasia, DES, Nutcracker esophagus, hypertensive LES, as
well as nonspecic esophageal motility disorders (NSMD),
86,87
although often there is no detectable underlying motility
Surgical treatment focuses on the concepts of resection of
the diverticulum and treatment of the underlying esophageal motility disorder to relieve the functional obstruction,
typically with long esophagogastric myotomy. Historically,
88,89
e workup of these
314 Part III Esophagus
FIGURE 14-25 Upper GI Barium study. Arrows demonstrating
two epiphrenic diverticula. (Used with permission from Saurabh
Khandelwal, MD, University of Washington.)
this was performed through a left thoracotomy to provide
optimal exposure to the distal esophagus, GE junction, and
91
cardia.
is was associated with excellent symptom relief
in 76–94% of patients, but with mortality rates of up to
15% and complication rates of nearly 40%. Leak rates of
92–94
6–18% were observed.
Just as with treatment of achalasia and other benign esophageal disorders, the dominant
operative technique has now shifted to the minimally invasive approach. Both the video-assisted thoracoscopic surgery
(VATS) and laparoscopic approach have been described
95,96
neither these nor the open approach have been compared in
a randomized prospective fashion. When compared to thoracotomy approach, both minimally invasive techniques (VATS
and laparoscopy) are associated with lower perioperative mortality rates (0–7.7%), shorter length of stay, and lower leak
rates (14% cumulative rate); morbidity still ranges as high as
94,97,98
50%.
lent relief of symptoms is seen in 83–100% of patients.
With the minimally invasive approaches, excel-
94
e
laparoscopic approach, which has been the minimally invasive
technique predominantly reported, capitalizes on these advantages and avoids single-lung ventilation and postoperative
chest tubes. In addition, performing fundoplication is technically easier with the laparoscopic approach compared to the
VATS approach. e laparoscopic method is the one we have
adopted, in which we perform stapled resection of the diverticulum, long myotomy, and Toupet fundoplication.
Operative Technique
LAPAROSCOPIC EPIPHRENIC DIVERTICULECTOMY
Patients are placed on a liquid diet for 48 hours prior to
operation to minimize retained food in the diverticulum.
At the time of operation, endoscopy is performed prior to
commencing, while the patient is under general anesthetic,
to remove any retained debris and avoid its incorporation
into the eventual suture line. e standard esophageal
operating position is used, as previously described in this
chapter. A 10-mm, 30-degree laparoscope is used to obtain
the best image, and a liver retractor is placed to visualize the
hiatus. e short gastric vessels are ligated, and the left crus
technique is used to begin the division and dissection of
the phrenoesophageal membrane. A Penrose drain is placed
around the esophagus to aid with retraction. e esophagus
is circumferentially dissected up into the mediastinum. e
diverticulum usually becomes apparent at this time. Most
diverticula are encountered on the right side. e diverticulum is freed from surrounding structures and dissected
using both blunt and sharp dissection, taking care to cleanly
expose the neck. e least obvious, but most important
aspect of this is separating the diverticulum from the surrounding esophagus by dividing adhesions connecting the
two. is is often underappreciated and can lead to incomplete resection of the diverticulum. An appropriately sized
bougie is carefully placed in the esophagus (50–60 F) ensuring it does not enter the mouth of the diverticulum. e
diverticulum is resected using an articulating laparoscopic
stapling device, keeping the stapler parallel to the esophagus and using the bougie for guidance and to help avoid
narrowing (Figs. 14-26A–C). e laparoscopic approach
typically aords better visualization and stapler alignment
than either VATS or open thoracotomy. e stapled edge
is inspected to make sure there is no bleeding or disruption. A myotomy is performed opposite the suture line in
the same fashion as previously described for achalasia, with
extension of 3 cm onto the cardia. e separation of muscle
;
bers from the myotomy allows the suture line to be oversewn in Lembert fashion using interrupted sutures placed in
intracorporeal fashion to protect it. Finally, a Toupet fundoplication is then performed as previously described to complete the operation, which provides protection from GER
and in most cases will buttress the staple line. Endoscopy
is performed to evaluate for leak or narrowing. Patients are
admitted and an UGI barium study is performed on postoperative day 2. If no leak or stricture is seen, the patient is
started on liquids and discharged home.
Summary
Epiphrenic diverticula are a rare type of pulsion diverticula
that occur in the distal third of the esophagus. Treatment
should be oered to those with symptomatic diverticula
who are medically t for surgery. erapy should include
surgical resection of the diverticulum and address the
motility disorder to provide relief of distal obstruction,
typically with long myotomy. Minimally invasive methods with either VATS or laparoscopy have demonstrated
excellent symptomatic relief and lower mortality and morbidity compared to the older approach with thoracotomy.
Chapter 14 Benign Esophageal Disorders 315
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GASTROESOPHAGEAL REFLUX DISEASE AND HIATAL HERNIA (INCLUDING PARAESOPHAGEAL)
Toshitaka Hoppo • Shamus R. Carr • Blair A. Jobe
15
GERD—OVERVIEW
De nition
Gastroesophageal re ux disease (GERD) is a chronic disor-
der related to the retrograde ow of gastric contents into
the esophagus, resulting in a spectrum of symptoms with
or without tissue injury.
absence of esophageal mucosal complications are the hallmarks of nonerosive re ux disease (NERD). Patients with
NERD account for up to 70% of those with GERD in the
community.
long-term therapy. Although various endoscopic approaches
to treat GERD have been introduced, none of them has
been able to achieve an e cacy equivalent to antire ux
surgery.
2
Antire ux surgery is the only e ective and
3,
4
1
Classic GERD symptoms in the
Symptoms
Heartburn (ascending retrosternal burning) and regurgitation are typical GERD symptoms. Epidemiologic studies
have demonstrated that heartburn occurs monthly in as
many as 40–50% of the Western population. e occurrence of heartburn at night and its e ect on quality of life
have recently been highlighted by a Gallup poll conducted
by the American Gastroenterologic Society ( Table 15-1 ).
Regurgitation of gastric contents often occurs when the
patient is supine or with increases in intra- abdominal pressure, and may result in atypical symptoms, including cough,
globus sensation, hoarseness, throat clearing, asthma, aspiration pneumonia, and pulmonary brosis. Dysphagia is a
typical symptom of GERD and can be divided into (1) an
oropharyngeal etiology, which is characterized by di culty
5
transferring food out of the mouth into the esophagus,
and (2) esophageal etiology, which is characterized by the
sensation of food sticking in the lower chest. Dysphagia can
be a sign of underlying malignancy and should be aggressively investigated with upper endoscopy. Chest pain can be
caused by GERD; however, it is very important to exclude
a cardiac etiology. DeMeester and colleagues reported that
nearly 50% of patients with severe noncardiac chest pain
had a positive 24-hour pH study implicating GERD as
the underlying etiology.
occurring at night while supine, nonradiating, responsive
to antacid medication, or accompanied by other symptoms
such as dysphagia and/or regurgitation should trigger an
evaluation for an esophageal cause. Additionally, it should
be noted that the distinction between heartburn and chest
pain can be di cult to make, and the perception of these
symptoms is highly variable between patients.
6
Chest pain precipitated by meals,
7,
PATHOPHYSIOLOGY OF GERD
e antire ux mechanism includes four important components:
(1) lower esophageal sphincter (LES); (2) crural diaphragm;
(3) esophageal peristalsis; and (4) stomach (the reservoir).
Lower Esophageal Sphincter
e gastroesophageal junction (GEJ) is a complex arrange-
ment of specialized muscles composed of both intrinsic
(LES) and extrinsic (crural diaphragm) contractile elements.
e LES, which can be identi ed as a high-pressure zone
located at the GEJ, creates the barrier between the esophagus and stomach that normally prevents re ux. LES relax-
8
319
320 Part III Esophagus
TABLE 15-1: AMERICAN GASTROENTERO-
LOGIC ASSOCIATION GALLUP POLL ON
NIGHTTIME GASTROESOPHAGEAL REFLUX
DISEASE SYMPTOMS
•
•
both day and night
•
work the next day
•
•
symptoms
ation occurs in two situations: (1) immediately following a
swallow, when it momentarily relaxes to allow passage of food
into the stomach, and (2) when the fundus is distended with
gas, it is eliminated to allow venting of the gas (a belch)—transient LES relaxation (TLESR). For an LES to be e ective,
it must possess three characteristics: an adequate (1) total
length, (2) intra-abdominal length, and (3) resting pressure
9
( Table 15-2 ).
erefore, a defective LES is identi ed by one
or more of the following characteristics: (1) a high-pressure
zone with an average pressure of less than 6mm Hg, (2) an
average overall length of 2 cm or less, and (3) an average
length exposed to the positive pressure environment of the
abdomen (intra-abdominal length) of 1 cm or less. e most
common cause of a permanently defective LES is an inadequate abdominal length, secondary to the high prevalence of
9
a hiatal hernia in patients with GERD.
A TLESR is an LES
relaxation that occurs without a swallow and accounts for the
physiologic re ux and “venting” of the stomach, particularly
in the postprandial state. Frequent and prolonged TLESR
can be associated with the development of GERD, and this
may explain the etiology of disease observed in the 40% of
patients with a manometrically normal sphincter. A transient
loss of the LES can also occur due to a functional problem of
10
the gastric reservoir and delayed emptying.
In this setting, if
excessive air and food are swallowed, there are gastric distention and an increase in intra-gastric pressure with shortening
of the LES ( Fig. 15-1 ). is process continues until a critical LES length is reached and eventually the pressure drops
precipitously and re ux occurs. is “transient sphincter”
TABLE 15-2: NORMAL MANOMETRIC
VALUES OF THE LOWER ESOPHAGEAL
SPHINCTER, N = 50
shortening occurs in the initial stages of GERD and is the
mechanism for the early complaint of excessive postprandial
re ux. is process is associated with the common complaints of belching and bloating in patients with GERD. To
compound matters, there is an increased frequency of swallowing (air and saliva) observed in GERD patients because
the ingestion of saliva (pH 7) serves to neutralize the acidic
11
uid (pH 1) in the esophagus.
erefore, GERD may
begin in the stomach, secondary to gastric distention due
to overeating and a high-fat diet, which delays gastric emptying. Further, a close relationship between the geometry
of the cardia and one’s propensity to re ux in the face of
10
a given intragastric pressure has been established.
Greater
gastric distension, as re ected by an increasing intragastric
pressure, is necessary to “open” the sphincter in patients
with an intact angle of His compared to those with hiatal
12
hernia ( Fig. 15-2 ).
ese data elucidate why the presence
of a hiatal hernia is often associated with GERD and explain
the loss of the ap valve mechanism (intragastric portion
of LES). In addition, in the presence of a hiatal hernia the
intrinsic portion of the LES is no longer aided by the crural
diaphragm (extrinsic LES).
Esophageal Peristalsis
Esophageal peristalsis is an extremely important component of
the antire ux mechanism and serves to clear physiologic re ux
and thus reduces contact time between the esophageal epithelium and gastric uid. Ine ective esophageal motility can
result in an abnormal esophageal exposure to gastric juice even
in individuals with a mechanically e ective LES and normal
gastric function.
seen in patients with a mechanically defective LES, where distal esophageal body function deteriorates as a direct result of
repetitive in ammation; this e ect further prolongs the esophageal exposure to gastric juice, which creates a vicious cycle
leading to more severe disease. Diener and colleagues reported
that 40–50% of patients with GERD had abnormal esophageal peristalsis.
was prolonged, and gastric uid was in contact with the esophageal mucosa for a longer period of time and traveled more
proximally when compared to GERD patients with intact
esophageal motility. erefore, these patients were prone to
having more severe mucosal injury and extraesophageal symptoms such as cough.
lished that patients with mixed connective tissue diseases such
as scleroderma commonly have an aperistaltic esophagus and
absent LES, which results in the most severe form of GERD.
13
However, ine ective motility is more often
13
In these patients, esophageal clearance time
14,
15 To highlight these points, it is estab-
16
Parameter
Pressure (mm Hg) 13 5.8 27.7
Overall length (cm) 3.6 2.1 5.6
Abdominal length (cm) 2 0.9 4.7
Median
value
2.5th
percentile
97.5th
percentile
Crural Diaphragm
e crural diaphragm provides an extrinsic component to
the gastroesophageal barrier. Mittal and colleagues demonstrated a direct correlation between intraluminal pressure
of the GEJ and integrated electrical activity of the crural
Chapter 15 Gastroesophageal Reux Disease and Hiatal Hernia (Including Paraesophageal) 321
B
A
C
FIGURE 15-1 A graphic illustration of the shortening of the lower esophageal sphincter that occurs as the sphincter is “taken up” by the cardia
as the stomach distends.