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33 Zenker’s Diverticulum
103
Treatment is surgical via open or endoscopic
approaches. Open approach has longer recovery time,
higher rates of symptom improvement, and lower recurrence rates. Endoscopic approaches offer shorter recovery time but possible increased recurrence rates. Patient
selection is key to successful endoscopic procedures, specically related to neck hyperextension ability and diverticulum size.
Bibliography
Mulholland MW, Albo D, Dalman R, Hawn M, Hughes S, Sabel
M.Cricopharyngeal diverticulum: open repair. In: Operative tech-
niques in surgery. Lippincott Williams & Wilkins; 2014a. p.90–5.
Mulholland MW, Albo D, Dalman R, Hawn M, Hughes S, Sabel
M.Cricopharyngeal diverticulum: endoscopic repair. In: Operative
techniques in surgery. Lippincott Williams & Wilkins; 2014b.
p.96–100.
Townsend CM, Beauchamp RD, Evers BM, Mattox KL.Esophagus.
In: Sabiston textbook of surgery E-book. 21st ed. Elsevier Health
Sciences; 2012. p.1014–55.
Part III
Esophagus
Achalasia
SnehaAlaparthi
34
Achalasia
Way Question May BeAsked?
A 37-year-old woman presents with progressive dysphagia to
solid foods with a sensation that food is getting “stuck” in
her chest. This has progressed over several years. She also
reports signicant belching. What does your initial diagnostic workup include?
How toAnswer?
• Full history and physical with focus of type of dysphagia,
Eckhardt scoring, concomitant symptoms
• EGD, Barium swallow, esophageal manometry (HRM)
• Occasionally, pH monitoring would be necessary to dis-
tinguish between achalasia and GERD
Endoscopy was largely normal; however further testing
shows high resolution manometry with an IRP of 16mmhg.
What are treatment options for this patient?
• Pneumatic dilation: weakens LES by tearing some muscle
bers, multiple usually needed
– Usually most cost effective treatment, less invasive
– Efciency wanes over time however
• Surgical myotomy: weakens LES by cutting muscle bers
(Heller myotomy), typically done laparoscopically
– Frequently causes reux however, will need to do anti-
reux procedure
– 90% of patients get symptomatic relief initially
– Prolonged recovery, complications include GERD,
perforation
S. Alaparthi (*)
Department of Surgery, Thomas Jefferson University Hospital,
Philadelphia, PA, USA
e-mail: Sneha.Alaparthi@jefferson.edu
• POEM: peroral endoscopic myotomy: incision made in
esophageal mucosa and then submucosal tunnel is made
which is extended into cardia, then scalpel used to cut
muscularis propria in and around LES
– Severe GERD can result since no antireux procedure
done
• Botox injection: may be considered in patients who are
not good candidates for other above procedures
– Toxin injected into LES to relax smooth muscle, com-
parable to dilation and myotomy, however more frequent relapses
Considering the patient is otherwise healthy and has no
major concomitant symptoms, how would you counsel?
HRM reveals type I achalasia
• Consider type of achalasia
– Type I (Classic): no signicant change in esophageal
pressure on swallowing, 100% failed peristalsis
– Type II: swallowing results in simultaneous pressur-
ization along esophagus
– Type III: swallowing causes premature or lumen oblit-
erating contractions/spasms, no normal peristalsis
• Considering this patient and low risk for surgery, and type
I achalasia- can be counseled to receive dilation, Heller
myotomy, or POEM all considered effective and
comparable
Surgical Treatment
What are major steps and important considerations in performing a Heller Myotomy?
• Positioning: lithotomy, reverse Trendelenburg
• Typically, 4 operative ports, 1 for liver retractor. 2 operative ports in the upper abdomen to either side of midline,
assistant port in LLQ, scope port in lower midline. Liver
retractor may either be sub-xiphoid or RLQ
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_34
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108
S. Alaparthi
• Divide gastrohepatic ligament, identify right crus and
vagus nerve
• Divide phrenoesophageal membrane, identify vagus
nerve and left crus
• Divide short gastric vessels, exposed GEJ
– Cardioesophageal fat pad and vagus nerves must be
mobilized off
• Perform myotomy:
– At 11o’ clock on the esophagus
– 6cm on the esophagus and 3cm onto stomach
– Should use a platform: bougie dilator, or endoscope
(up to 54Fr)
– Avoid electrocautery
– Divide longitudinal muscles rst, exposes underlying
circular muscles, then divide circular layer
– Make sure to repair any mucosal perforations
• Fundoplication
– May perform Toupet (270), Dor (180)
Intraoperatively you notice mucosal perforation in the
esophagus after performing Myotomy. How do you
proceed?
• Should be repaired with an absorbable suture (4–0 or
5–0monolament), typically in gure of 8 fashion
• May be buttressed with Dor fundoplication
• Bleeding should be handled with pressure and not
electrocautery
Postoperatively, the patient initially recovers well however subsequently develops recurrent dysphagia. What are
diagnostic steps and management options?
• Full history and physical, symptomatic evaluation,
repeated imaging/EGD
• Should consider pneumatic dilation rst, may be per-
formed serially
• Revisional surgery can be considered in patients who fail
this, in which a new myotomy should be made on the
opposite side
In an alternate scenario, the same patient presents with
similar symptoms, however has progressive dysphagia from
solids to liquids. This is coupled with a 15lb. Unintentional
weight loss and anemia. How do you proceed?
• Same workup as above, EGD rst followed by UGI and
manometry depending on results
• If EGD demonstrates cancer- proceed with metastatic
workup
Common Curveballs
• Note there are other types of motility disorders subject to
diagnosis with manometry. Not all will be responsive to
treatment for achalasia. Surgeons need to differentiate
ndings on imaging.
• Megaesophagus seen on workup: need to rule out distal
malignancy.
• Secondary achalasia can be caused by multiple infectious
organisms and connective tissue disorders. Surgeons can
treat underlying cause in these conditions versus medical
management.
Bonus Points
• Type III achalasia is typically offered POEM, as myotomy with this is not possible with others.
• Medical therapy for non-surgical candidates includes
Botox, isosorbide dinitrate, and sublingual nitroglycerin.
• No routine endoscopic surveillance performed in these
patients, as absolute risk of cancer is low (although higher
than in patients without achalasia).
Clean Kills
• Fail to do thorough workup for dysphagia, especially with
alarm symptoms, as cancer needs to be ruled out (UGI,
EGD, Manometry)
• Make sure to describe length of myotomy
• Make sure to describe avoidance of vagus nerve during
case
Words ofWisdom
Exam stems often will purposefully include a mucosal injury
noted during the performance of the myotomy. This does not
reect a failure; simply be prepared for this complication and
know how to address it.
Bibliography
Momodu II, Wallen JM. Achalasia. StatPearls. Last updated 31 July
2023. https://www.ncbi.nlm.nih.gov/books/NBK519515/.
Barrett’s Esophagus
JamesFraser
35
Way Question May BeAsked?
A 53-year-old Caucasian male with a 5-year history of
GERD on PPI therapy presents for evaluation of worsening
reux symptoms. He endorses a 20-pack year smoking history and denies weight loss or dysphagia.
How toAnswer?
• After a full history and physical exam to identify risk
factors and exclude additional worrisome symptoms
such as chest pain, weight loss, or dysphagia, esophagogastroduodenoscopy (EGD) is indicated in this
scenario.
• Screening endoscopy specically for Barrett’s esophagus
is recommended in patients with chronic GERD symptoms and three or more additional risk factors for Barrett’s
esophagus, including:
– Male sex
– Age >50years
– White race
– Tobacco smoking
– Obesity
– Family history of Barrett’s esophagus or esophageal
adenocarcinoma in a rst degree relative
What is critical to identify with EGD when evaluating
potential Barrett’s esophagitis?
• Distance of the Z line, and appearance
• Distance from the gastroesophageal junction (GEJ) to the
proximal extent of circumferential Barrett’s and total
length of any metaplasia
J. Fraser (*)
Department of Surgery, Thomas Jefferson University Hospital,
Philadelphia, PA, USA
e-mail: James.Fraser2@jefferson.edu
• Barrett’s esophagus is considered short segment if the
metaplastic columnar mucosa involves <3cm of the distal
esophagus and long segment if it involves ≥3cm.
• Associated nodularity, ulceration, stricture, potential
malignancy, and irregular mucosal contouring
EGD is performed demonstrating 4cm of salmon colored
mucosa extending proximally from the GEJ.How should you
proceed?
• At least eight endoscopic biopsy samples are recommended for accurate diagnosis, typically four quadrant
biopsies every 1–2cm.
• Any nding of Barrett’s esophagitis is an indication for
maximal medical therapy for GERD management with
high dose PPI+H2 blocker.
Biopsies return with intestinal metaplasia without dyspla-
sia. What is the recommended management?
• With nondysplastic Barrett’s, this patient may undergo
routine surveillance with repeat EGD and four quadrant
biopsies every 2cm at an interval of 3–5years.
• Incidence of progression to esophageal adenocarcinoma
in patients with nondysplastic Barrett’s esophagus is
about 2–3 per 1000 patients per year.
• Ablation or resection of nondysplastic Barrett’s is controversial, and not recommended.
Biopsies return with low grade dysplasia (LGD). What is
the recommended management?
• Management decisions in this scenario include shared
decision making between patient and provider; The
incidence of progression to esophageal adenocarcinoma
in patients with LGD is about 7–8 per 1000 patients per
year.
– Option 1: Continued surveillance with four quadrant
biopsies every 1cm in 6months, 12months, and annu-
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_35
109
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J. Fraser
ally thereafter if there is regression of LGD to nondysplastic Barrett’s.
– Option 2: Endoscopic eradication therapy (EET)
EET is indicated upfront for LGD, and for persistent or worsening LGD if found on surveillance
EGD.
Many options for endoscopic therapies exist including, radiofrequency ablation (RFA), cryoablation,
photodynamic therapy, endoscopic mucosal resection (EMR), and endoscopic submucosal dissection
(ESD).
EET decreases progression to high grade dysplasia
and carcinoma.
The goal of these therapies is complete eradication
of intestinal metaplasia (CEIM).
– Barrett’s esophagus alone is not an indication for sur-
gical intervention with fundoplication, as fundoplication has limited success at reversal of Barrett’s
esophagus. Rather, fundoplication should continue to
be used as a treatment for GERD with appropriate
indications, which may reduce the risk of progression
of Barrett’s esophagus.
Should this patient have surveillance after EET?
• Yes, multiple treatments with an EET modality will likely
be required, and the patient should undergo surveillance
EGD with standard biopsies every 6 months, and then
annually after establishment of CEIM.
Biopsies return with high grade dysplasia (HGD). What is
the recommended management?
• All patients with high grade dysplasia should undergo
EET with ablation and/or resection with EMR or ESD.
• Esophagectomy should be considered for those who fail
endoscopic therapy, with persistent multifocal high-grade
disease, and in those who have long segment Barrett’s
(greater than 8cm).
• The incidence of progression to esophageal adenocarcinoma is about 14–15per 1000 patients per year.
EGD demonstrates nodularity, ulceration, or irregular
mucosal contour—How should this be managed?
• Nodular Barrett’s or lesions associated with Barrett’s are
an indication for resection by EMR or ESD, in addition to
ablative therapies as this is both diagnostic and therapeutic.
• These lesions should be resected separately, in addition to
the standard four quadrant biopsies.
Should this patient have surveillance after EET?
• Yes, this patient should undergo EGD with standard biopsies at 3 months, 6 months, and 12 months following
CEIM.
When should esophagectomy be considered?
• Indications for esophagectomy in the management of
Barrett’s esophagus include nodules with a T1b or greater
adenocarcinoma, persistent Barrett’s esophagus with
HGD despite repeated ablation therapy, complicated
strictures or persistent ulcers refractory to treatment, and
burnt-out esophagus causing functional obstruction.
Common Curveballs
• Barrett’s esophagus is present in a candidate for weight
loss surgery. Most surgeons recommend gastric bypass,
both for stabilization/treatment of reux and for preservation of bypassed stomach as future reconstructive conduit
in the event that future esophagectomy is required.
• The question may be about treatment of GERD, and
Barrett’s esophagus will only be diagnosed if the examinee properly performs endoscopy and biopsy.
• Even after the examinee provides proper treatment of
Barrett’s esophagus, the scenario may evolve into the
development of esophageal adenocarcinoma question.
Clean Kills
• Insufcient number of biopsies during screening or diagnostic EGD, or identifying Barrett’s on EGD without performing biopsies.
• Electing for conservative management, or observation of
high grade or nodular Barrett’s esophagus.
• Inappropriate screening or surveillance intervals for
respective grades of dysplasia.
• Inability to identify features of likely malignancy within
Barrett’s esophagus workup or surveillance.
35 Barrett’s Esophagus
111
EGD identifies Barrett’s
(4 quadrant biopsies every 1-2 cm)
Word ofWisdom
Nondysplastic Barrett’s
Low grade dysplasia (LGD)
High grade dysplasia (HGD)
Nodular Barrett’s
Bibliography
Surveillance EGD every 3-5 years with
4 quadrant biopsies every 1-2cm
Option 1: Surveillance EGD with 4
quadrant biopsies every 1 cm in 6 mo,
12 mo, and then annually if regression
of LGD to nondysplastic Barrett’s
Option 2: Endoscopic eradication
therapy (EET) upfront
Indicated for persistent or worsening
LGD if found on surveillance EGD
EET with ablation and/or resection with
EMR or ESD.
Resection by EMR or ESD and ablative
therapies
Examiners will typically expect examinees to know the basic
diagnosis and treatment of Barrett’s esophagus. It is important to know the recommended surveillance plan and the
indications for more aggressive ablative of surgical
treatment.
Rajendra S. Diagnosis and management of Barrett’s esophagus: an
updated ACG guideline. Am J Gastroenterol. 2022;117(11):1880.
Smithers BM, Thomson I.Ablation for patients with Barrett or dys-
plasia. Shackelford’s surgery of the alimentary tract: 2 volume set.
2019. p.350–61.
Wendling MR, Oelschlager BK.Medical and surgical therapy for gas-
troesophageal reux disease and Barrett esophagus. Shackelford’s
surgery of the alimentary tract: 2 volume set. 2019. p.339–49.
Esophageal Cancer
IsheetaMadeka
36
Way Question May BeAsked?
A 55-year-old man has a history of gastroesophageal reux,
heavy smoking, and alcohol use. He presents with progressive dysphagia and unintentional weight loss. What is the
next step?
How toAnswer?
• Obtain thorough history and physical exam.
• In adults with new-onset dysphagia, one MUST rule out
esophageal malignancy.
– TIP: on physical exam, look out for left supraclavicu-
lar lymph node (Virchow’s) or hepatomegaly
• Obtain laboratory tests, including nutritional parameters.
– TIP: look out for elevated liver function tests seen with
hepatic metastasis, hypoalbuminemia due to malnutrition, or anemia due to chronic gastrointestinal blood
loss
• Appropriate initial diagnostic tests in a patient with dysphagia: Upper GI/barium esophagogram, EGD+biopsy/
cytology.
• If a patient is found to have malignancy on biopsy/cytology, the next step is appropriate staging. The following
tests can be used to determine the extent of locoregional
and metastatic disease: EUS ± FNA (to determine depth
of intraluminal tumor invasion); bronchoscopy (to evaluate for airway invasion); laryngoscopy (to assess for synchronous malignancy of head/neck); Computed
Tomography (CT) of chest, abdomen + PET (for occult
metastases); and diagnostic laparoscopy.
I. Madeka (*)
Department of Surgery, Thomas Jefferson University Hospitals,
Philadelphia, PA, USA
e-mail: Isheeta.Madeka@jefferson.edu
You should familiarize yourself with the eighth edition of
the American Joint Commission on Cancer (AJCC) for
esophageal and esophagogastric cancers.
Treatment Considerations
• Stage IA—can consider endomucosal resection (EMR).
• Stage IA/IB—up-front esophagectomy can be offered in
patients who are not neoadjuvant therapy candidates or
have specic, aggressive pathological features.
• Stage II or more advanced-stage tumors—consider neo-
adjuvant chemoradiation therapy.
• Stage IV—not candidates for esophagectomy; should dis-
cuss systemic chemotherapy ± palliation.
Preoperative Evaluation
• Obtain baseline pulmonary function tests if the patient
has smoking history or pulmonary disease.
• Obtain cardiology evaluation for risk stratication, if
applicable.
• Assess functional status.
• Nutritional optimization.
– AVOID gastrostomy tube; will make esophageal con-
duit creation difcult during esophagectomy.
Contraindications to Surgery
• Stage IV metastatic disease
• Tracheobronchial invasion
• Aortic invasion
Surgical Treatment
• Ivor-Lewis esophagectomy; right chest and abdominal
incision; esophagogastric anastomosis in the mediasti-
num
– Abdominal exploration
– Gastric mobilization, conduit creation; preserve right
gastric and right gastroepiploic vessels
– Kocher maneuver
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_36
113
114
I. Madeka
– Pyloromyotomy
– Jejunostomy tube creation
– Intrathoracic esophagogastric anastomosis
• Transhiatal esophagectomy; left neck and abdominal incision; esophagogastric anastomosis in neck
– Abdominal exploration
– Gastric mobilization, conduit creation; preserve right
gastric and right gastroepiploic vessels
– Kocher maneuver
– Pyloromyotomy
– Jejunostomy tube insertion
– Left cervical incision, cervical esophagus mobilization
– Mediastinal dissection
– Cervical esophagogastric anastomosis
Common Curveballs
• Cervical recurrent laryngeal nerve injury due to
retraction
• Intraoperative pneumothorax during esophageal mobilization→placement of chest tube
• Posterior membranous tracheal tear→advance endotracheal tube down left mainstem bronchus; can consider
right thoracotomy to repair if needed
• Chylothorax
• Anastomotic leaks
– Post-operative mediastinal esophagogastric anastomo-
sis leak
NPO, IV antibiotics, source control via wide drainage, continue nutritional optimization via jejunostomy tube feedings
– Post-operative cervical esophagogastric anastomosis leak
NPO, IV antibiotics, open cervical wound at bedside and pack with wet-to-dry dressings, continue
nutritional optimization via jejunostomy tube feeds
– If patient has signs of sepsis, warrants operative explo-
ration for washout and possible diverting esophagos-
tomy; can consider stent placement or negative
pressure wound therapy placement
• Late anastomotic stricture → bougie dilation usually
effective
Clean Kills
• Missing the diagnosis
• Failure to return patient to the operating room for sepsis/
shock after esophagectomy
• Failure to know which gastric vessels to sacrice and
which to save
Words ofWisdom
Not all surgical residents get extensive exposure to the management of esophageal cancer. If that is the case, examinees
should prepare for this topic by ensuring they thoroughly
understand the preoperative evaluation, treatment options
based on stage, and key technical aspects. It might be useful
to understand alternative reconstruction options in the event
that the gastric conduit is not present or usable (e.g., esophagojejunostomy, colonic interposition graft).
Bibliography
Grenda T, Chang A.Esophageal cancer. In: Dimmick J, Upchurch G,
Sonnenday C, Kao L, editors. Clinical scenarios in surgery: decision
making and operative technique. 2nd ed. Philadelphia, PA: Wolters
Kluwer; 2019. p.443–53.
PDQ® Adult Treatment Editorial Board. PDQ esophageal cancer treat-
ment. Bethesda, MD: National Cancer Institute. https://www.can-
cer.gov/types/esophageal/hp/esophageal- treatment- pdq. [PMID:
26389338]. Accessed March 1, 2024. Updated August 9, 2024.
Score. https://www.surgicalcore.org/modulecontent.aspx?id=1000534.
Esophageal Perforation
MicaelaLangilleCollins andOlugbengaT.Okusanya
37
Way Question May BeAsked?
A 50-year-old man with a history of hypertension and GERD
presents to the emergency department 6hours after upper
endoscopy with new onset dysphagia and non-specic chest
pain. He has stable vital signs and is on room air with normal oxygen saturation.
How toAnswer?
• Start with a full history and physical exam.
• In a patient with chest pain, dysphagia, and a recent history of upper endoscopy, a diagnosis of esophageal perforation should be at the top of the differential.
• In the case of iatrogenic injury, the following must be
taken into account:
– The most common area of perforation is at the crico-
pharyngeus muscle
– If the upper endoscopy was performed for dilation, the
most common site of perforation is at the site of
stricture
• In cases of blunt thoracic trauma, shear forces from rapid
acceleration or deceleration can cause perforation (example: high speed motor vehicle collision).
• Forceful emesis can cause tears in the distal esophagus
(Boerhaave syndrome).
• While abdominal and chest radiographs can be used to
assess for pneumothorax, pleural effusion, subcutaneous
emphysema, and abdominal free air, these studies are not
diagnostic.
• An esophagram with water-soluble contrast is the imaging study of choice for diagnosis.
• If the result is equivocal or negative but a high suspicion
for esophageal perforation exists, a barium swallow
should be performed.
• Computed tomography (CT) can be useful for operative
planning and localization of the injury.
Surgical Treatment
Barium swallow reveals a perforation in the cervical esophagus. How do you proceed?
• Start with ensuring adequate resuscitation of the patient.
• Initiate broad spectrum antibiotics.
• Cervical injuries are best approached via the left neck, via
an incision on the medial border of the sternocleidomastoid, or a mid-cervical collar incision.
• Platysmal aps can be used to aid visualization, and the
omohyoid should be divided. The carotid sheath is
retracted laterally and the middle thyroid vein and inferior
thyroid artery should be divided.
Alternative Scenarios
Injury to the upper/middle esophagus (example: perforation
of stricture during dilation)
• Right-sided approach, division of the inferior pulmonary
ligament to retract the lung anteriorly. The mediastinal
pleura should be opened and the esophagus mobilized.
An esophagram with water-soluble contrast is obtained
but does not reveal a perforation. What are your next steps?
M. L. Collins (*) · O. T. Okusanya
Department of Surgery, Thomas Jefferson University Hospital,
Philadelphia, PA, USA
e-mail: micaela.collins@jeffereson.edu;
olugbenga.okusanya@jefferson.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_37
Injury to the distal esophagus (ex: forceful emesis)
• Left-sided approach, division of the inferior pulmonary
ligament to retract the lung anteriorly. The mediastinal
pleura should be opened and the esophagus mobilized.
115