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208
Aortic esophageal
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CHAPTER 25
The Esophagus and Diaphragmatic Hernia
Right bronchial
artery
Esophageal branch
Inferior thyroid
artery
Superior left
bronchial artery
Inferior left
bronchial artery
arteries
FIG. 25-1. Arterial blood supply of the esophagus.
(Reproduced with permission from Shields TW: General
Thoracic Surgery, 3rd ed. Philadelphia, PA: Lea &
Febiger; 1989.)
3. All of the following hormones decrease lower esophageal
A. Gastrin.
B. Estrogen.
C. Somatostatin.
D. Cholecystokinin (CCK).
E. Glucagon.
Ascending branches of
left gastric artery
Left gastric artery
Answer: A
neural and hormonal mechanisms. Alpha-adrenergic neurotransmitters or beta blockers stimulate the LES, and alpha
blockers and beta stimulants decrease its pressure. It is not
clear to what extent cholinergic nerve activity controls LES
pressure. The vagus nerve carries both excitatory and inhibitory fibers to the esophagus and sphincter. The hormones
gastrin and motilin have been shown to increase LES pressure; and cholecystokinin, estrogen, glucagon, progesterone,
somatostatin, and secretin decrease LES pressure. The peptides bombesin, l-enkephalin, and substance P increase LES
pressure; and calcitonin gene-related peptide, gastric inhibitory peptide, neuropeptide Y, and vasoactive intestinal polypeptide decrease LES pressure. Some pharmacologic agents,
such as antacids, cholinergics, agonists, domperidone, metoclopramide, and prostaglandin F2, are known to increase LES
pressure; and anticholinergics, barbiturates, calcium channel
blockers, caffeine, diazepam, dopamine, meperidine, prostaglandin E1 and E2, and theophylline decrease LES pressure.
Peppermint, chocolate, coffee, ethanol, and fat are all associated with decreased LES pressure and may be responsible for
esophageal symptoms after a sumptuous meal. (See Schwartz
11th ed., pp. 1015–1016.)
4. The incidence of metaplastic Barrett esophagus (BE)
progressing to adenocarcinoma is:
A. <0.1% per year.
B. 0.2% to 0.5% per year.
C. 1% to 3% per year.
D. 3% to 5% per year.
E. >5% per year.
Answer: B
If reflux of gastric juice is allowed to persist and sustained or
repetitive esophageal injury occurs, two sequelae can result.
First, a luminal stricture can develop from submucosal and
eventually intramural fibrosis. Second, the tubular esophagus
may become replaced with columnar epithelium. The columnar epithelium is resistant to acid and is associated with the
alleviation of the complaint of heartburn. This columnar
epithelium often becomes intestinalized, identified histologically by the presence of goblet cells. This specialized intestinal
metaplasia (IM) is currently required for the diagnosis of
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BE. Endoscopically, BE can be quiescent or associated with
complications of esophagitis, stricture, Barrett ulceration,
and dysplasia. The complications associated with BE may be
due to the continuous irritation from refluxed duodenogastric juice. This continued injury is pH-dependent and may
be modified by medical therapy. The incidence of metaplastic Barrett epithelium becoming dysplastic and progressing
to adenocarcinoma is approximately 0.2% to 0.5% per year.
(See Schwartz 11th ed., p. 1035.)
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CHAPTER 25
5. The histologic hallmark of Barrett esophagus (BE) is:
A. Columnar epithelium.
B. Goblet cells.
C. Parietal cells.
D. Cuboidal epithelium.
6. Squamous cell carcinomas of the esophagus most commonly occur:
A. At the gastroesophageal junction.
B. In the cervical and upper thoracic esophagus.
C. In the lower thoracic esophagus.
D. Evenly distributed throughout the esophagus.
Answer: B
The definition of BE has evolved considerably over the past
decade. Traditionally, BE was identified by the presence of
columnar mucosa extending at least 3 cm into the esophagus. It is now recognized that the specialized, intestinal-type
epithelium found in the Barrett mucosa is the only tissue
predisposed to malignant degeneration. Consequently, the
diagnosis of BE is presently made given any length of endoscopically identifiable columnar mucosa that proves, on
biopsy, to show intestinal metaplasia (IM). Although long
segments of columnar mucosa without IM do occur, they are
uncommon and might be congenital in origin.
The hallmark of IM is the presence of intestinal goblet
cells. There is a high prevalence of biopsy-demonstrated IM
at the cardia, on the gastric side of the squamocolumnar junction, in the absence of endoscopic evidence of a columnarlined esophagus (CLE). Evidence is accumulating that these
patches of what appears to be Barrett in the cardia have a
similar malignant potential as in the longer segments, and
are precursors for carcinoma of the cardia. (See Schwartz
11th ed., p. 1035.)
Answer: B
It is estimated that 8% of the primary malignant tumors of
the esophagus occur in the cervical portion. They are almost
always squamous cell cancer, with a rare adenocarcinoma
arising from a congenital inlet patch of columnar lining.
These tumors, particularly those in the postcricoid area, represent a separate pathologic entity for two reasons: (a) They
are more common in females and appear to be a unique entity
in this regard; and (b) The efferent lymphatics from the cervical esophagus drain completely differently from those of the
thoracic esophagus. The latter drain directly into the paratracheal and deep cervical or internal jugular lymph nodes
(LNs) with minimal flow in a longitudinal direction. Except
in advanced disease, it is unusual for intrathoracic LNs to be
involved. (See Schwartz 11th ed., p. 1685.)
The Esophagus and Diaphragmatic Hernia
7. The preoperative test most heavily correlated with the
ability to tolerate an esophagectomy is:
A. DLCO.
B. FEV1.
C. Ability to climb 1 flight of stairs.
D. FVC.
Answer: B
Patients undergoing esophageal resection should have sufficient cardiopulmonary reserve to tolerate the proposed
procedure. The respiratory function is best assessed with the
forced expiratory volume in 1 second, which ideally should
be 2 L or more. Any patient with a forced expiratory volume
in 1 second of <1.25 L is a poor candidate for thoracotomy,
because he or she has a 40% risk of dying from respiratory
insufficiency within 4 years. In patients with poor pulmonary
reserve, the transhiatal esophagectomy should be considered,
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CHAPTER 25
The Esophagus and Diaphragmatic Hernia
8. Which of the following tests most accurately assesses the
T stage of esophageal cancer?
A. High-resolution CT scan
B. Magnetic resonance imaging (MRI)
C. Echocardiography
D. Endoscopic ultrasound (EUS)
E. Esophagogastroduodenoscopy
as the pulmonary morbidity of this operation is less than is
seen following thoracotomy. Clinical evaluation and electrocardiogram are not sufficient indicators of cardiac reserve.
Echocardiography and dipyridamole thallium imaging provide accurate information on wall motion, ejection fraction,
and myocardial blood flow. A defect on thallium imaging
may require further evaluation with preoperative coronary
angiography. A resting ejection fraction of <40%, particularly
if there is no increase with exercise, is an ominous sign. In
the absence of invasive testing, observed stair-climbing is an
economical (albeit not quantitative) method of assessing cardiopulmonary reserve. Most individuals who can climb three
flights of stairs without stopping will do well with two-field
open esophagectomy, especially if an epidural catheter is used
for postoperative pain relief. (See Schwartz 11th ed., p. 1073.)
Answer: D
For years, clinical staging, contrast radiography, endoscopy,
and computed tomography (CT) scanning formed the backbone of esophageal cancer staging. More recently, preoperative
decision-making is guided by endoscopic ultrasonography
and positron emission tomography (PET) scanning.
EUS provides the most reliable method of determining
depth of cancer invasion. In the absence of enlarged lymph
nodes (LNs), the degree of wall invasion dictates surgical
therapy. (See Schwartz 11th ed., p. 1073.)
9. Which of the following patients would not be considered
a candidate for esophagectomy?
A. A 55-year-old man with gastroesophageal junction
(GEJ) adenocarcinoma confined to the muscularis
mucosa
B. A 47-year-old woman with mid-esophageal cancer
and an involved cervical lymph node (LN)
C. A 60-year-old man with a large GEJ carcinoma with
invasion into the pleura without a malignant effusion
D. A 70-year-old woman with a small GEJ cancer and
three pathologic LNs nearby on EUS
10. Patients with dysphagia secondary to esophageal cancer
treated with radiation can expect the benefit to last:
A. <1 month.
B. 2–3 months.
C. 6–12 months.
D. >12 months.
Answer: B
If the tumor invades in to the submucosa, without visible
LN involvement, most individuals would suggest esophagectomy with LN dissection, as positive nodes can be found in
20% to 25% of those with cancer limited to the mucosa and
submucosa. If EUS demonstrates spread through the wall of
the esophagus, especially if LNs are enlarged, then induction chemoradiation therapy (neoadjuvant therapy) should
be strongly considered. Lastly, when the EUS demonstrates
invasion of the trachea, bronchus, aorta, or spine, then surgical
resection is rarely indicated. If there is invasion into the pleura
(T4a), then surgical resection can be considered in the absence
of a malignant effusion. Thus, it can be seen that the therapy
of esophageal cancer is largely driven by the findings of an
endoscopic ultrasonography. It is difficult to provide modern
treatment of esophageal cancer without access to this modality. (See Schwartz 11th ed., pp. 1070–1072.)
Answer: B
Primary treatment with radiation therapy does not produce
results comparable with those obtained with surgery. Currently, the use of radiotherapy is restricted to patients who are
not candidates for surgery, and is usually combined with chemotherapy. Radiation alone is used for palliation of dysphagia
but the benefit is short-lived, lasting only 2 to 3 months. Furthermore, the length and course of treatment are difficult to
justify in patients with a limited life expectancy. Radiation is
effective in patients who have hemorrhage from the primary
tumor. (See Schwartz 11th ed., p. 1074.)
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11. The optimal treatment of an incidentally discovered
3 cm leiomyoma of the upper esophagus in a 45-year-old
otherwise healthy man is:
A. Observation.
B. Esophagectomy.
C. Enucleation.
D. Endoscopic resection.
12. Following a night of heavy drinking, a 43-year-old otherwise healthy man has sudden onset of severe chest
pain after vomiting. Esophagram confirms esophageal
rupture just proximal to the GEJ. What is the preferred
operative exposure?
A. Right thoracotomy
B. Right thoracotomy with laparotomy
C. Left thoracotomy
D. Left thoracotomy with laparotomy
E. Midline laparotomy
Answer: C
Despite their slow growth and limited potential for malignant
degeneration, leiomyomas should be removed unless there
are specific contraindications. The majority can be removed
by simple enucleation. If, during removal, the mucosa is
inadvertently entered, the defect can be repaired primarily.
After tumor removal, the outer esophageal wall should be
reconstructed by closure of the muscle layer. The location
of the lesion and the extent of surgery required will dictate
the approach. Lesions of the proximal and middle esophagus require a right thoracotomy, whereas distal esophageal
lesions require a left thoracotomy. Videothoracoscopic and
laparoscopic approaches are now frequently used. The mortality rate associated with enucleation is low, and success in
relieving the dysphagia is near 100%. Large lesions or those
involving the gastroesophageal junction (GEJ) may require
esophageal resection. (See Schwartz 11th ed., p. 1081.)
Answer: C
The key to optimum management is early diagnosis. The most
favorable outcome is obtained following primary closure of
the perforation within 24 hours, resulting in 80% to 90% survival. The most common location for the injury is the left lateral wall of the esophagus, just above the GEJ. To get adequate
exposure of the injury, a dissection similar to that described
for esophageal myotomy is performed. A flap of stomach is
pulled up and the soiled fat pad at the GEJ is removed. The
edges of the injury are trimmed and closed primarily. The
closure is reinforced with the use of a pleural patch or construction of a Nissen fundoplication. (See Schwartz 11th ed.,
pp. 1084–1085.)
CHAPTER 25
The Esophagus and Diaphragmatic Hernia
13. A 34-year-old man presents to the emergency
department (ED) after an episode of hematemesis.
Esophagogastroduodenoscopy (EGD) confirms a
Mallory-Weiss tear with no residual bleeding. Treatment
should consist of:
A. Esophagectomy.
B. Observation.
C. Proximal gastrectomy with esophago-jejunostomy.
D. Injection of botulinum toxin.
Answer: B
Mallory-Weiss tears are characterized by arterial bleeding,
which may be massive. Vomiting is not an obligatory factor,
as there may be other causes of an acute increase in intraabdominal pressure, such as paroxysmal coughing, seizures,
and retching. The diagnosis requires a high index of suspicion, particularly in the patient who develops upper gastrointestinal (GI) bleeding following prolonged vomiting or
retching. Upper endoscopy confirms the suspicion by identifying one or more longitudinal fissures in the mucosa of the
herniated stomach as the source of bleeding.
In the majority of patients, the bleeding will stop spontaneously with nonoperative management. In addition to
blood replacement, the stomach should be decompressed and
antiemetics administered, as a distended stomach and continued vomiting aggravate further bleeding. A SengstakenBlakemore tube will not stop the bleeding, as the pressure
in the balloon is not sufficient to overcome arterial pressure.
Endoscopic injection of epinephrine may be therapeutic if
bleeding does not stop spontaneously. Only occasionally will
surgery be required to stop blood loss. The procedure consists
of laparotomy and high gastrotomy with oversewing of the
linear tear. Mortality is uncommon, and recurrence is rare.
(See Schwartz 11th ed., p. 1085.)
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Left vagus nerve
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14. Which of the following disorders involves simultaneous
nonperistaltic contractions of the esophagus?
A. Achalasia
B. Diffuse esophageal spasm (DES)
C. Hypertensive lower esophageal sphincter
D. Nutcracker esophagus
CHAPTER 25
The Esophagus and Diaphragmatic Hernia
15. Damage to the recurrent laryngeal nerves could result in
the following EXCEPT:
A. Function of vocal cords.
B. Function of cricopharyngeal sphincter.
C. Motility to cervical esophagus.
D. Increase risk of aspiration.
E. Innervation of stylopharyngeus muscle.
Answer: B
The classic manometric findings in these patients are characterized by the frequent occurrence of simultaneous waveforms and multipeaked esophageal contractions, which may
be of abnormally high amplitude or long duration. Key to the
diagnosis of DES is that there remain some peristaltic waveforms in excess of those seen in achalasia. A criterion of ≥30%
peristaltic waveforms out of 10 wet swallows has been used
to differentiate DES from vigorous achalasia. However, this
figure is arbitrary and often debated.
The lower esophageal sphincter (LES) in patients with DES
usually shows a normal resting pressure and relaxation on
swallowing. A hypertensive sphincter with poor relaxation
may also be present. In patients with advanced disease, the
radiographic appearance of tertiary contractions appears
helical, and has been termed corkscrew esophagus or pseudodiverticulosis. Patients with segmental or diffuse esophageal
spasm can compartmentalize the esophagus and develop an
epiphrenic or midesophageal diverticulum between two areas
of high pressure occurring simultaneously. (See Schwartz
11th ed., pp. 1056–1057 and Table 25-9.)
Answer: E
The parasympathetic innervation of the pharynx and esophagus is provided mainly by the vagus nerves. The constrictor
muscles of the pharynx receive branches from the pharyngeal
plexus, which is on the posterior lateral surface of the middle
constrictor muscle, and is formed by pharyngeal branches of
the vagus nerves with a small contribution from cranial nerves
IX and XI (Fig. 25-2). The cricopharyngeal sphincter and the
cervical portion of the esophagus receive branches from both
recurrent laryngeal nerves, which originate from the vagus
nerves—the right recurrent nerve at the lower margin of the
subclavian artery and the left at the lower margin of the aortic
FIG. 25-2. Innervation of the esophagus.
(Reproduced with permission from Shields TW.
General Thoracic Surgery, 3rd ed. Philadelphia, PA:
Lea & Febiger; 1989.)
Right vagus nerve
Right recurrent
laryngeal nerve
Anterior esophageal
plexus
Right or posterior
vagal trunk
Recurrent
laryngeal
nerves
Left recurrent
laryngeal nerve
Thoracic chain
Left or anterior
vagal trunk
arch. They are slung dorsally around these vessels and ascend
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in the groove between the esophagus and trachea, giving
branches to each. Damage to these nerves interferes not only
with the function of the vocal cords but also with the function of the cricopharyngeal sphincter and the motility of the
cervical esophagus, predisposing the individual to pulmonary
aspiration on swallowing. (See Schwartz 11th ed., p. 1014.)
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16. Primary tumors in the thoracic esophagus tend to
metastasize:
A. In the submucosal lymph plexus.
B. Into regional nodes.
C. In a transverse direction.
D. Directly into the muscle layer.
E. In a hematogenous fashion.
Answer: A
The lymphatics located in the submucosa of the esophagus are
so dense and interconnected that they constitute a single plexus
(Fig. 25-3). There are more lymph vessels than blood capillaries in the submucosa. Lymph flow in the submucosal plexus
runs in a longitudinal direction, and, on injection of a contrast
medium, the longitudinal spread is seen to be about six times
that of the transverse spread. In the upper two-thirds of the
esophagus, the lymphatic flow is mostly cephalad, and, in the
lower third, caudad. In the thoracic portion of the esophagus,
the submucosal lymph plexus extends over a long distance in
a longitudinal direction before penetrating the muscle layer to
enter lymph vessels in the adventitia. As a consequence of this
nonsegmental lymph drainage, a primary tumor can extend
for a considerable length superiorly or inferiorly in the submucosal plexus. Consequently, free tumor cells can follow the
submucosal lymphatic plexus in either direction for a long
distance before they pass through the muscularis and into the
regional lymph nodes (LNs). The cervical esophagus has more
direct segmental lymph drainage into the regional nodes, and,
as a result, lesions in this portion of the esophagus have less
submucosal extension and a more regionalized lymphatic
spread. (See Schwartz 11th ed., pp. 1014–1015.)
CHAPTER 25
The Esophagus and Diaphragmatic Hernia
Superior
paraesophageal nodes
Pulmonary hilar
nodes
Left gastric artery nodes
Hepatic artery
nodes
FIG. 25-3. Lymphatic drainage of the esophagus.
Internal jugular
nodes
Paratracheal
nodes
Subcarinal nodes
Inferior paraesophageal
nodes
Parahiatal nodes
Celiac artery nodes
Splenic artery
nodes
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17. The antireflux mechanism is composed of the following
EXCEPT:
A. A mechanically effective lower esophageal sphincter
(LES).
B. Efficient esophageal clearance.
C. An adequately functioning gastric reservoir.
D. Secondary peristalsis.
E. Intact vagal function.
CHAPTER 25
The Esophagus and Diaphragmatic Hernia
18. On upper endoscopy, a patient is found to have erosions
in the esophagus limited to the mucosal folds that are
>5 mm in longitudinal extent. What classification does
he fall under according to the Los Angeles (LA) grading
system?
A. Grade A
B. Grade B
C. Grade C
D. Grade D
E. Grade E
Answer: D
If the pharyngeal swallow does not initiate a peristaltic contraction, then the coincident relaxation of the LES is unguarded and
reflux of gastric juice can occur. This may be an explanation for
the observation of spontaneous lower esophageal relaxation,
thought by some to be a causative factor in gastroesophageal
reflux disease (GERD). The power of the worm-drive pump
of the esophageal body is insufficient to force open a valve that
does not relax. In dogs, a bilateral cervical parasympathetic
blockade abolishes the relaxation of the LES that occurs with
pharyngeal swallowing or distention of the esophagus. Consequently, vagal function appears to be important in coordinating the relaxation of the LES with esophageal contraction.
The antireflux mechanism in human beings is composed
of three components: A mechanically effective LES, efficient
esophageal clearance, and an adequately functioning gastric
reservoir. A defect of any one of these three components can
lead to increased esophageal exposure to gastric juice and
the development of mucosal injury. (See Schwartz 11th ed.,
pp. 1016–1017, 1032.)
Answer: B
When endoscopic esophagitis is seen, severity and the length of
esophagitis involved are recorded. While many different grading systems have been proposed, the commonest system now
in use is the LA grading system. In this system, mild esophagitis is classified LA grade A or B—one or more erosions limited
to the mucosal fold(s) and either less than or greater than 5 mm
in longitudinal extent, respectively (Fig. 25-4). More severe
esophagitis is classified LA grade C or D. In grade C, erosions
extend over the mucosal folds but over less than three-quarters
of the esophageal circumference; in grade D, confluent erosions extend across more than three quarters of the esophageal
circumference. (See Schwartz 11th ed., p. 1018.)
A
FIG. 25-4. Complications of reflux disease as seen on endoscopy. A. Linear erosions of LA grade B esophagitis. B. Uncomplicated Barrett
mucosa. C. High-grade dysplasia in Barrett mucosa. D. Early adenocarcinoma arising in Barrett mucosa. (Continued)
B
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CHAPTER 25
The Esophagus and Diaphragmatic Hernia
C
FIG. 25-4. (Continued)
19. The most direct method of measuring gastric juice exposure in the esophagus is:
A. Esophageal motility study.
B. High resolution manometry.
C. 24-hour ambulatory pH monitoring.
D. Esophageal impedance.
E. Esophageal transit scintigraphy.
D
Answer: C
The most direct method of measuring increased esophageal
exposure to gastric juice is by an indwelling pH electrode,
or, more recently, via a radiotelemetric pH monitoring capsule that can be clipped to the esophageal mucosa. The latter consists of an antimony pH electrode fitted inside a small,
capsule-shaped device accompanied by a battery and electronics that allow 48-hour monitoring and transmission of
the pH data via transcutaneous radio telemetry to a waistmounted data logger. The device can be introduced either
transorally or transnasally, and it can be clipped to the
esophageal mucosa using endoscopic fastening techniques. It
passes spontaneously within 1 to 2 weeks. Prolonged monitoring of esophageal pH is performed by placing the pH
probe or telemetry capsule 5 cm above the manometrically
measured upper border of the distal sphincter for 24 hours.
It measures the actual time the esophageal mucosa is exposed
to gastric juice, measures the ability of the esophagus to clear
refluxed acid, and correlates esophageal acid exposure with
the patient’s symptoms. A 24- to 48-hour period is necessary
so that measurements can be made over one or two complete
circadian cycles. This allows measuring the effect of physiologic activity, such as eating or sleeping, on the reflux of gastric juice into the esophagus (Fig. 25-5). (See Scwartz 11th ed.,
p. 1029–1030.)
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pH
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CHAPTER 25
The Esophagus and Diaphragmatic Hernia
FIG. 25-5. Strip chart display of a 24-hour
esophageal pH monitoring study in a patient
with increased esophageal acid exposure.
mp = meal period; sp = supine period.
(Reproduced with permission from Zuidema
GD, Orringer MB. Shackelford’s Surgery of the
Alimentary Tract, 3rd ed. Vol 1. Philadelphia, PA:
Elsevier/ Saunders; 1991.)
pH
pH
8
6
4
2
sp
8
6
4
2
8
6
4
2
mp
mp mp
22:0016:0014:00 18:00 20:00
06:0000:0022:00 02:00 04:00
14:0008:0006:00 10:00 12:00
20. What is the correct order in the stepwise approach in
treatment for gastroesophageal reflux disease (GERD)?
A. PPI->endoscopy->24-hour pH study->surgery
B. Endoscopy->PPI->24-hour pH study->surgery
C. PPI->24-hour pH study->endoscopy->surgery
D. 24-hour pH study->endoscopy->PPI->surgery
21. An antireflux surgery should ideally do all of the following EXCEPT:
A. Create a flap valve to prevent regurgitation into the
esophagus.
B. Double the resting gastric pressure.
C. Reconstruct the valve to a length <3 cm.
D. Create a loose wrap.
E. Maintain the position of the gastric fundus close to
the distal esophagus.
Answer: A
Traditionally, a stepwise approach is used for the treatment
of GERD. First-line therapy entails antisecretory medication,
usually proton pump inhibitors (PPIs), in most patients. Failure of medication to adequately control GERD symptoms suggests either that the patient may have relatively severe disease
or a non-GERD cause for his or her symptoms. Endoscopic
examination at this stage of the patient’s evaluation is recommended and will provide the opportunity to assess the degree
of mucosal injury and presence of Barrett esophagus (BE).
Treatment options for these patients entail either long-term
PPI use versus antireflux surgery. Laparoscopic antireflux
surgery in these patients achieves long-term control of symptoms in 85% to 90%. The measurement of esophageal acid
exposure via 24-hour pH should be undertaken when patients
are considered for surgery. The status of the lower esophageal
sphincter (LES) and esophageal body function with esophageal manometry should also be performed at this stage. These
studies will serve to establish the diagnosis and assess esophageal body dysfunction. (See Schwartz 11th ed., p. 1037.)
Answer: C
The primary goal of antireflux surgery is to safely create a
new antireflux valve at the gastroesophageal junction, while
preserving the patient’s ability to swallow normally and to
belch to relieve gaseous distention. Regardless of the choice
of the procedure, this goal can be achieved if attention is
paid to some basic principles when reconstructing the antireflux mechanism. First, the operation should create a flap
valve which prevents regurgitation of gastric contents into
the esophagus. This will result in an increase in the pressure
of the distal esophageal sphincter region. Following a Nissen
fundoplication the expected increase is to a level twice the
resting gastric pressure (ie, 12 mm Hg for a gastric pressure
of 6 mm Hg). The extent of the pressure rise is often less fol-
∆
BelseyHill
Nissen
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lowing a partial fundoplication, although with all types of
fundoplication the length of the reconstructed valve should
be at least 3 cm. This not only augments sphincter characteristics in patients in whom they are reduced before surgery
but also prevents unfolding of a normal sphincter in response
to gastric distention (Fig. 25-6). Preoperative and postoperative esophageal manometry measurements have shown
that the resting sphincter pressure and the overall sphincter
length can be surgically augmented over preoperative values,
and that the change in the former is a function of the degree
of gastric wrap around the esophagus (Fig. 25-7). However,
the aim of any fundoplication is to create a loose wrap and to
maintain the position of the gastric fundus close to the distal
intra-abdominal esophagus, in a flap valve arrangement. The
efficacy of this relies on the close relationship between the
fundus and the esophagus, not the “tightness” of the wrap.
(See Schwartz 11th ed., p. 1039.)
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CHAPTER 25
The Esophagus and Diaphragmatic Hernia
Distention
FIG. 25-6. 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.
N=15
20
15
P mm Hg
10
5
0
FIG. 25-7. The relationship between the augmentation of
sphincter pressure over preoperative pressure (ΔP) and the degree
of gastric fundic wrap in three different antireflux procedures.
(Reproduced with permission from O’Sullivan GC, DeMeester
TR, Joelsson BE, et al. Interaction of lower esophageal sphincter
pressure and length of sphincter in the abdomen as determinants of
gastroesophageal competence, Am J Surg. 1982;143(1):40–47.)
Degree of wrap
N=15
Y = 4.63 + .023 (x)
P < .01
240
N=15
360
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