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A
B
FIGURE 1.26. (A) Gross appearance of squamous cell carcinoma in the mid-esophagus, (B) manifest
microscopically as poorly differentiated carcinoma invading the submucosa. (Courtesy of Linda D.
Ferrell, MD.)
TABLE 1.10. Modified WNM Staging of Cancer of the
Esophagus and Cardia and Survival
Stage Classification 5-Year Survival Rate
0W
IW
II W1N1M
III W2N1M
IV Any W, any N, M 0
Source: Reprinted with permission from Ellis FH Jr, Heatley GJ, Krasna MJ,
et al. Esophagogastrectomy for carcinoma of the esophagus and cardia: a
comparison of findings and results after standard resection in three consecutive eight-year intervals with improved staging criteria. J Thorac Cardiovasc Surg 1997;113:836–846.
0N0M0
0N1M0
0
0
88%
50%
22%
10%
C linical D isorders.............................................................................................................................. 29
A
B
FIGURE 1.27. (A) In adenocarcinoma of the esophagus, the barium swallow test can be used to indi-
cate the extent of the lesion, the extent of any luminal narrowing, and any angulation of the axis of
the esophagus. The tumor in this patient is polypoid (arrow). (B) The surgical specimen is shown.
(Courtesy of Linda D. Ferrell, MD, and Henry I. Goldberg, MD.)
30 .......................................................................................................................................... Esophagus
C linical D isorders.............................................................................................................................. 31
TABLE 1.11. Essentials: Carcinoma of the Esophagus
Incidence
䊏
20 : 100,000 population in North America and Europe
䊏
8 times more common in China
Type of cancer
䊏
Squamous cell cancer: 95% worldwide
䊏
Adenocarcinoma: >50% in North America
Risk factors
䊏
Squamous: Tobacco, alcohol, tylosis, achalasia
䊏
Adenocarcinoma: Barrett’s esophagus and high-fat diet
Clinical presentation: Dysphagia, weight loss, weakness, anemia
Diagnosis: Endoscopy and biopsy
Staging
䊏
Endoscopic ultrasound
䊏
Barium swallow (axis)
䊏
CT scan or MRI of chest and abdomen
䊏
Bronchoscopy
䊏
Thoracoscopy
Treatment
䊏
Surgical: Stages I, II, following preoperative radiation of
stage III
䊏
Chemoradiotherapy: 5-FU, cisplatin and mitomycin-C in
combination with 2500–3000 cGy external radiation
Choice of operation
䊏
Distal one third: Transhiatal esophagectomy or Ivor Lewis
procedure
䊏
Middle one third: Ivor-Lewis procedure, transhiatal
䊏
Upper one third: Total esophagectomy (three-cavity) with
esophagogastrostomy in the neck
Outcome
䊏
Stage I: 35% 5-year survival
䊏
Stage II: 20% 5-year survival
Abbreviations: CT, computerized tomography; 5-FU, 5-fluorouracil; MRI,
magnetic resonance imaging.
B
RONCHOSCOPY
An important preoperative investigation in cancer of the upper and middle esophagus,
bronchoscopy can determine whether or not the tracheopulmonary tree has been invaded.
Tr e at m e n t
THERAPEUTIC OPTIONS Basic information regarding
esophageal carcinoma is summarized in Table 1.11. The
four therapeutic options for carcinoma of the esophagus
are surgery, radiotherapy, chemotherapy, or a combination
of methods. In patients who are good candidates for
surgery and in whom no distant organ metastasis has been
identified (stages I and II), surgical resection provides the
best chance for cure and the best palliation when cure is
not possible. Preoperative radiation is useful in stage III
squamous cell carcinoma and may convert an unresectable
lesion into a resectable one. Combined chemoradiotherapy
has produced, in some studies, complete remission in 20%
to 30% of patients.
9
Typically, fluorouracil, cisplatin, and
mitomycin-C or vincristine are given in combination with
2500 to 3000cGy external radiation directed at the lesion.
This therapy may be given as the sole treatment or preoperatively. There is debate whether patients with complete
endoscopic disappearance of the tumor after chemoradiotherapy should be subjected to resection. Adenocarcinoma
is generally less responsive to radiotherapy, and surgical
resection is the preferred method.
S
URGICAL T
HERAPY
Preoperative staging determines
whether a patient is operable. Surgery is usually of little
benefit in cases that involve distant organ metastasis (e.g.,
lung, liver), or invasion of the trachea or aorta. Esophagectomy can be accomplished with or without thoracotomy.
Ivor-Lewis Procedure A common procedure for resection of tumors in the distal half of the esophagus is the
Ivor-Lewis operation (Figure 1.28). Through an abdominal
approach, the stomach is completely mobilized, preserving
the right gastric and right gastroepiploic vessels, and a
pyloroplasty or pyloromyotomy is performed. The hiatus
is opened and the distal esophagus mobilized within the
mediastinum. A jejunostomy for eating is also performed.
Right thoracotomy is then performed through the bed of
the sixth rib, and the thoracic esophagus is mobilized. The
stomach is then pulled up into the right chest for resection.
At least 10cm of proximal margin on the esophagus is
needed. The resection line is distal to the gastroesophageal
junction, and the portion of the stomach to be resected
depends on tumor location within the esophagus.
Gastroesophageal anastomosis is performed at or above
the azygous vein.
The entire esophagus must be resected in the presence
of more proximal thoracic lesions or extensive Barrett’s
metaplasia. In this case, the operation may be modified to
include a left cervical dissection of the esophagus with
esophagogastric anastomosis in the neck.
Transhiatal Esophagectomy Alternatively, resection can
be accomplished without thoracotomy. The procedure of
choice is transhiatal esophagectomy, requiring abdominal
and left cervical incisions. This procedure is best suited for
carcinoma of the distal esophagus and is often the preferred
procedure when associated Barrett’s esophagus is extensive.
The thoracic esophagus is mobilized with blunt transhiatal
dissection. Esophagogastric anastomosis is performed in
the neck (Figure 1.29) and has two advantages. First, thoracotomy and its attending disabilities are avoided. Second,
the performance of the anastomosis in the neck is safer
because anastomotic leak in the neck is less morbid and
easily controlled.
Left Thoracic Esophagogastrectomy Esophagogastrectomy can also be accomplished through a left thoracic incision or a left thoraco-abdominal incision. The popularity
of this approach has declined due to the difficulty of consistently achieving a proximal clear margin of resection.
A
B
FIGURE 1.28. The Ivor-Lewis procedure is commonly performed for resection of tumors in the distal
half of the esophagus. (A) Through a vertical upper abdominal incision, the stomach and duodenum
are mobilized, all gastric vessels are divided (but sparing the right gastric and right gastroepiploic
vessels), and (B) pyloromyotomy and feeding jejunostomy are performed. (C) Esophagogastric resection to the extent shown is accomplished in the chest through a right thoracotomy incision, and (D)
esophagogastric anastomosis is performed at the level of the azygous vein. (Adapted from Jamieson
GG, Debas HT, eds. Rob & Smith’s Operative Surgery: Surgery of the Upper Gastrointestinal Tract.
London: Chapman & Hall Medical, 1994; and Orringer MB, Sloan H. Substernal gastric bypass of the
excluded thoracic esophagus for palliation of esophageal carcinoma. J Thorac Cardiovasc Surg
1975;70:836.)
32 .......................................................................................................................................... Esophagus
C
D
FIGURE 1.28. Continued
C linical D isorders.............................................................................................................................. 33
A
D
C
FIGURE 1.29. Transhiatal esophagectomy is the procedure of choice in carcinoma of the distal esopha-
gus. It is preferred in all cases when extensive Barrett’s esophagus accompanies the cancer. (A) A vertical upper abdominal incision and a left cervical incision are employed. (The mobilization and vascular
division of the stomach is the same as for the Ivor-Lewis procedure shown in Figure 1.28. (B) The
stomach is divided 6–10 cm beyond the gastro-esophageal junction in such a way that the gastric
remnant forms a tube that can reach the neck. (C) The gastric tube is passed to the neck through the
posterior mediastinum and (D) esophagogastric anastomosis performed in the left neck. (Adapted
from Jamieson GG, Debas HT, eds. Rob & Smith’s Operative Surgery: Surgery of the Upper Gastrointestinal Tract. London: Chapman & Hall Medical, 1994; and Orringer MB, Sloan H. Esophagectomy
without thoracotomy. J Thorac Cardiovasc Surg 1978;76:643.)
B
34 .......................................................................................................................................... Esophagus
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SELECTED READINGS
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Castell DO, ed. The Esophagus. 1st ed. Boston: Little, Brown, 1992.
Castell DO, Richter JE, Dalton CB. Esophageal Motility Testing.New
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DeMeester TR, Wang CI, Wernly JA, et al. Technique, indications,
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Duranceau A, Liebermann-Meffert C. Embryology, anatomy
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Shackelford’s Surgery of the Alimentary Tract. 3rd ed. Philadelphia: WB Saunders, 1991.
Emde C, Armstrong D, Castiglione F, et al. Reproducibility of
long-term ambulatory esophageal combined pH/manometry.
Gastroenterology 1991;100:1630–1637.
Gray SW, Rowe JS Jr, Skandalakis JE. Surgical anatomy of the
gastroesophageal junction. Am Surg 1979;45:575–587.
Helm JF, Dodds WJ, Riedel DR, et al. Determinants of esophageal
acid clearance in normal subjects. Gastroenterology 1983;
85:607–612.
Joelsson BE, DeMeester TR, Skinner DB, et al. The role of the
esophageal body in the antireflux mechanism. Surgery
1982;92:417–424.
Kahrilas PJ, Dodds WJ, Hogan WJ. Effect of peristaltic dysfunction
on esophageal volume clearance. Gastroenterology 1988;94:
73–80.
Siewert JR, Blum AL. The oesophagus. Part I: Surgery at the upper
oesophageal sphincter, tubular oesophagus and lower
oesophageal sphincter. Clin Gastroenterol 1979;8:271–291.
Stein HJ, DeMeester TR. Outpatient physiologic testing and surgi-
cal management of foregut motility disorders. Curr Probl Surg
1992;29:413–555.
Motility Disorders
Birgisson S, Richter JE. Achalasia: what’s new in diagnosis and
treatment? Dig Dis 1997;15(Suppl 1):1–27.
Bonavina L, Khan NA, DeMeester TR. Pharyngoesophageal
dysfunctions. The role of cricopharyngeal myotomy. Arch Surg
1985;120:541–549.
Browning TH. Diagnosis of chest pain of esophageal origin. A guide-
line of the Patient Care Committee of the American Gastroenterological Association. Dig Dis Sci 1990;35:289–293.
Csendes A, Braghetto I, Henriquez A, et al. Late results of a prospec-
tive randomised study comparing forceful dilatation and
oesophagomyotomy in patients with achalasia. Gut
1989;30:299–304.
Felix VN, Cecconello I, Zilberstein B, et al. Achalasia: a prospective
study comparing the results of dilatation and myotomy. Hepato-
gastroenterology 1998;45:97–108.
Goldenberg SP, Burrell M, Fette GG, et al. Classic and vigorous acha-
lasia: a comparison of manometric, radiographic, and clinical
findings. Gastroenterology 1991;101:743–748.
Pellegrini CA, Leichter R, Patti M, et al. Thoracoscopic esophageal
myotomy in the treatment of achalasia. Ann Thorac Surg 1993;
56:680–682.
Shimi SM, Nathanson LK, Cuschieri A. Thoracoscopic long oeso-
phageal myotomy for nutcracker oesophagus: initial experience
of a new surgical approach. Br J Surg 1992;79:533–536.
Waters PF, DeMeester TR. Foregut motor disorders and their surgi-
cal management. Med Clin North Am 1981;65:1235–1268.
Watson TJ, DeMeester TR, Kauer WK, et al. Esophageal replacement
for end-stage benign esophageal disease. J Thorac Cardiovasc
Surg 1998;115:1241–1249.
Esophageal Diverticula
Bonafede JP, Lavertu P, Wood BG, et al. Surgical outcome in 87
patients with Zenker’s diverticulum. Laryngoscope 1997;107:
720–725.
Cook IJ, Gabb M, Panagopoulos V, et al. Pharyngeal (Zenker’s)
diverticulum is a disorder of upper esophageal sphincter
opening. Gastroenterology 1992;103:1229–1235.
Debas HT, Payne WS, Cameron AJ, et al. Physiopathology of lower
esophageal diverticulum and its implications for treatment. Surg
Gynecol Obstet 1980;151:593–600.
Peracchia A, Bonavina L, Narne S, et al. Minimally invasive surgery
for Zenker diverticulum: analysis of results in 95 consecutive
patients. Arch Surg 1998;133:695–700.
Gastroesophageal Reflux Disease
Allison PR. Reflux esophagitis sliding hiatal hernia and the anatomy
of repair. Surg Gynecol Obstet 1951;92:419.
Champault G. Gastroesophageal reflux. Treatment by laparoscopy.
940 cases—French experience. Ann Chir 1994;48:159–164.
Duranceau A, Ferraro P, Jamieson GG. The staging of severity in
gastroesophageal reflux disease. Chest Surg Clin N Am 2001;11:
507–515.
S elected R eadings............................................................................................................................... 35
Heitmiller RF, Redmond M, Hamilton SR. Barrett’s esophagus with
high-grade dysplasia. An indication for prophylactic esophagectomy. Ann Surg 1996;224:66–71.
Hill LD. An effective operation for hiatal hernia: an eight year
appraisal. Ann Surg 1967;166:681–692.
Hinder RA, Filipi CJ, Wetscher G, et al. Laparoscopic Nissen fundo-
plication is an effective treatment for gastroesophageal reflux
disease. Ann Surg 1994;220:472–483.
Kochhar R, Makharia GK. Usefulness of intralesional triamcinolone
in treatment of benign esophageal strictures. Gastrointest Endosc
2002;56:829–834.
Lerut T, Coosemans W, Christiaens R, et al. The Belsey Mark IV
antireflux procedure: indications and long-term results. Acta
Gastroenterol Belg 1990;53:585–590.
Orlando RC. The pathogenesis of gastroesophageal reflux disease:
the relationship between epithelial defense, dysmotility, and acid
exposure. Am J Gastroenterol 1997;92(4 Suppl):3S–7S.
Peters JH. The surgical management of Barrett’s esophagus. Gas-
troenterol Clin North Am 1997;26:647–668.
Pisegna JR. GERD and its complications. The pathogenic relation-
ship between symptoms and disease progression. Postgrad Med
2001;19–23.
Sampliner RE. Updated guidelines for the diagnosis, surveillance,
and therapy of Barrett’s esophagus. Am J Gastroenterol 2002;97:
1888–1895.
Carcinoma of the Esophagus
Akiyama H. Surgery for carcinoma of the esophagus. Curr Probl Surg
1980;17:53–120.
Akiyama H, Hiyama M, Miyazono H. Total esophageal reconstruc-
tion after extraction of the esophagus. Ann Surg 1975;182:
547–552.
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ations in the rising incidence of esophageal adenocarcinoma in
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DeMeester TR. Esophageal carcinoma: current controversies. Semin
Surg Oncol 1997;13:217–233.
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esophagectomy for cancer. Surg Endosc 1996;10:147–151.
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1998;113(1 Suppl):107S–111S.
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Surg 2001;35:271–295.
Lewis I. The surgical treatment of carcinoma of esophagus with
special reference to new operation for growths of the middle
third. Br J Surg 1946;34:18–31.
Orringer MB. Transhiatal esophagectomy without thoracotomy for
carcinoma of the thoracic esophagus. Ann Surg 1984;200:
282–288.
Stark SP, Romberg MS, Pierce GE, et al. Transhiatal versus transtho-
racic esophagectomy for adenocarcinoma of the distal esophagus and cardia. Am J Surg 1996;172:478–482.
Swisher SG, Wynn P, Putnam JB, et al. Salvage esophagectomy for
recurrent tumors after definitive chemotherapy and radiotherapy. J Thorac Cardiovasc Surg 2002;123:175–183.
van Sandick JW, van Lanschot JJ, ten Kate FJ, et al. Indicators of
prognosis after transhiatal esophageal resection without thoracotomy for cancer. J Am Coll Surg 2002;194:28–36.
Vigneswaran WT, Trastek VF, Pairolero PC, et al. Extended
esophagectomy in the management of carcinoma of the upper
thoracic esophagus. J Thorac Cardiovasc Surg 1994;107:901–
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modal therapy and surgery for esophageal adenocarcinoma. N
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36 .......................................................................................................................................... Esophagus
........................................................................................................................................................... 37
SURGICAL ANATOMY
Parts of the Stomach
Like the esophagus, the stomach is closed at each end with
a sphincter, the LES proximally and the pyloric sphincter
distally. Also like the esophagus, the musculature of the
stomach consists of an inner circular muscle and an
outer longitudinal smooth muscle. Unlike the esophagus,
however, the stomach has a well-developed serosal layer.
Just distal to the esophagogastric junction, the circular
fibers are more robust and are arranged obliquely around
the proximal stomach; they are often referred to as the
“sling fibers.” These oblique fibers may extend distally to
form a third muscular layer. For ease of description, the
stomach consists of four parts: the cardia, the fundus, the
body, and the antrum (Figure 2.1).
Anatomic Relationships
The left lobe of the liver lies anterior to the proximal
stomach. Thus, to obtain easy access to the proximal
stomach and the hiatus, the left lobe of the liver is usually
displaced to the right after division of the left triangular
ligament (Figure 2.2). To the left, the stomach is closely
related to the spleen, and several short gastric vessels
attach the stomach to the splenic vessels at the splenic
hilum. The rate of incidental splenectomy in gastric
surgery can be high, particularly in reoperations if the
adhesions and short gastric vessels are not carefully
divided early in the operation. The inferior relationship of
the stomach is to the transverse colon and the gastrocolic
2
Stomach and Duodenum
ANATOMY
ligament. Due to proximity of the transverse colon and the
potential of its being invaded by gastric malignancy, the
prudent practice has evolved of preoperative bowel preparation when gastric resection for cancer is contemplated.
Behind the stomach is the lesser sac. Within it lies the
pancreas, which extends transversely from the c-loop of
the duodenum on the right to the hilum of the spleen on
the left. Ligamentous bands of connective tissue attach the
posterior of the stomach to the anterior of the pancreas.
These bands, remnants of the mesogastrium in the
embryo, must be divided to mobilize the stomach off the
pancreas.
A key relationship is that of the pylorus to the distal
common bile duct (CBD). In severe duodenal ulcer
disease, in which the first portion of the duodenum is
scarred and foreshortened, the antropyloric region is
brought even closer to the CBD. Care must be taken not
to injure the CBD during surgery for complex chronic
duodenal ulcer disease and during suture control of bleeding duodenal ulcer.
Blood Supply
The blood supply of the stomach is pictured in Figure 2.3.
The celiac axis provides the arterial supply in the following manner. The left gastric artery, a branch of the celiac
itself, supplies the lesser curvature aspect of the body and
cardia; the right gastric artery, a branch of the common
hepatic, supplies the lesser curvature aspect of the antrum.
The greater curvature of the stomach is supplied by the
right gastroepiploic, a branch of the gastroduodenal, and
the left gastroepiploic, a branch of the splenic artery.
It is customary to consider the duodenum with the stomach because its most common affliction is peptic ulcer disease. This chapter first reviews the anatomy and physiology of the
stomach. This information then forms the basis for discussion of the pathophysiology and
management of secretory, motor, and neoplastic disorders of the stomach and duodenum.
FIGURE 2.1. Anatomy of the stomach. The fundus and body of
the stomach contain the parietal cell mass. The mucosa of the
cardia is composed primarily of mucous and chief cells; the
antral mucosa is the site of the gastrin-secreting cells and contains no parietal cells. A transitional zone exists between the
body and antrum, where gastric ulcers tend to occur.
FIGURE 2.2. Anatomic relationships of the stomach. The esophagus emerges through the hiatus, where the abdominal esophagus and cardia are covered anteriorly by the left lobe of the
liver. The spleen is intimately related to the gastric fundus
through the short gastric vessels. The transverse colon is below
the stomach and is draped with the greater omentum. The
immediate space between the two organs is covered with the
gastrocolic ligament, the division of which provides access to the
lesser sac. Distally, near the junction of the stomach and duodenum, important relationships exist with the gall bladder and the
common bile duct. Posterior to the stomach is the lesser sac, in
which lies the pancreas with the splenic vessels.
FIGURE 2.3. Arterial blood supply to the stomach. The stomach is supplied through branches of the
celiac axis (CA). The left gastric artery (LGA) supplies the distal esophagus and the lesser curvature
aspect of the cardia and body. The right gastric artery (RGA) and the gastroduodenal artery (GDA) are
branches of the common hepatic artery (CHA). The right gastric artery supplies the lesser curvature
aspect of the antrum and anastomoses with branches of the LGA. The GDA travels behind the pyloroduodenal area, where it is often eroded by a duodenal ulcer. Inferior to the pylorus, it leads to the
right gastroepiploic (RGE) and the pancreaticoduodenal arteries. The RGE travels about 0.5 cm inferiorly to the greater curvature and supplies the greater curvature aspect of the antrum and body of the
stomach. The left gastroepiploic artery (LGE), a branch of the splenic artery, courses 0.5 to 1.0cm to
the left of the stomach at the greater curvature and anastomoses with the RGE. Finally, the fundus of
the stomach is supplied through several short gastric arteries (SGA), which originate from the splenic
artery (SPA) as it branches in the splenic hilum.
38 ..................................................................................................................... Stomach and Duodenum
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