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x Preface
The editors are indebted to the invaluable assistance of Jocelynn Albert. This
project would not have been possible without her dedication and organizational skills.
George Y. Wu,
MD, PhD
Khalid Aziz, MBBS
Giles F. Whalen, MD
CONTENTS
Foreword ...................................................................................................................... vii
Preface .......................................................................................................................... ix
Contributors ............................................................................................................... xiii
PART I. ESOPHAGEAL SURGERY
1 Esophagectomy and Reconstruction .................................................................. 3
Michael Kent, Jeffrey Port, and Nasser Altorki
2 Zenker's Diverticulum .......................................................................................17
Anders Holm and Denis C. Lafreniere
3 Esophagectomy for Achalasia:
Laparoscopic Heller Myotomy and Dor Fundoplication ............................ 23
Joshua M. Braveman, Lev Khitin, and David M. Brams
4 Surgery for Gastroesophageal Reflux Disease ................................................ 33
Lev Khitin and David M. Brams
5 Hiatal Hernia Repair .........................................................................................47
Lev Khitin and David M. Brams
6 Esophageal Stents ..............................................................................................57
Gaspar Nazareno, Nii Lamptey-Mills, and Jay Benson
7 Endoscopic Therapy for Esophageal Varices .................................................. 65
Jaroslaw Cymorek and Khalid Aziz
PART II. GASTRIC SURGERY
8 Surgical Treatment of Peptic Ulcer Disease .................................................... 75
Brent W. Miedema and Nitin Rangnekar
9 Surgical Management of Gastric Tumors ....................................................... 87
Robert C. G. Martin and Martin S. Karpeh, Jr.
10 Reconstruction After Distal Gastrectomy ........................................................ 99
Nitin Rangnekar and Brent W. Miedema
11 Surgery for Obesity ..........................................................................................115
Carlos Barba and Manuel Lorenzo
12 Percutaneous Enterostomy Tubes .................................................................. 123
Gaspar Nazareno and George Y. Wu
PART III. SMALL BOWEL SURGERY
13 Small Bowel Resections ................................................................................... 141
Eric M. Knauer and Robert A. Kozol
14 Urinary Diversion Surgery .............................................................................. 151
Scott Rutchick and Peter Albertsen
xi
xii Contents
PART IV. LARGE BOWEL SURGERY
15 Colonic Resection............................................................................................. 163
Robert A. Kozol
16 Surgery of the Rectum and Anus .................................................................... 175
Mark Maddox and David Walters
PART V. H EPATIC AND BILIARY SURGERY
17 Hepatic Resection............................................................................................. 195
John Taggert and Giles F. Whalen
18 Bypass and Reconstruction of Bile Ducts ......................................................207
John Taggert and Giles F. Whalen
19 Cholecystectomy ...............................................................................................215
John Taggert and Giles F. Whalen
PART VI. PANCREATIC SURGERY
20 Pancreatic Surgery...........................................................................................227
Janette U. Gaw and Dana K. Andersen
21 Endoscopic Management of Pancreatic Pseudocysts ................................... 249
Gaspar Nazareno and Khalid Aziz
PART VII. SURGERY ON AORTA AND ITS BRANCHES
22 Surgery of the Abdominal Aorta and Branches ............................................261
Stephanie Saltzberg, Justin A. Maykel, and Cameron M. Akbari
23 Endovascular Repair of Abdominal Aortic Aneurysm ................................. 271
Grant J. Price
PART VIII. SURGERY ON PORTAL VEIN
24 Portasystemic Venous Shunt Surgery for Portal Hypertension ................... 283
David K. W. Chew and Michael S. Conte
25 Transjuglar Intrahepatic Portosystemic Shunt .............................................297
Grant J. Price
PART IX. ABDOMINAL HERNIA SURGERY
26 Hernia Surgery ................................................................................................. 311
Christine Bartus and David Giles
PART X. PERITONEAL SURGERY
27 Peritoneal Shunts ............................................................................................. 323
Eric M. Knauer and David Giles
Index .......................................................................................................................... 331
CONTRIBUTORS
AMERON M. AKBARI, MD • Assistant Professor of Surgery, Georgetown University School
C
of Medicine, Attending Vascular Surgeon and Director, Vascular Diagnostic Laboratory,
Washington Hospital Center, Washington, DC
P
ETER ALBERTSEN, MD • Professor of Surgery, Chief, Division of Urology,
Department of Surgery, University of Connecticut, Farmington, CT
NASSER ALTORKI, MD • Professor of Thoracic Surgery, Department of Cardiothoracic Surgery,
The New York Presbyterian Hospital, Weill-Cornell Medical Center, New York, NY
DANA K. ANDERSEN, MD • Professor of Surgery, Department of Surgery, University of
Massachusetts Memorial Medical Center, Worcester, MA
KHALID AZIZ, MBBS, MRCP (UK), MRCP (IRE), FACG • Assistant Professor of Medicine,
Division of Gastroenterology-Hepatology, University of Connecticut Health Center,
Farmington, CT
CARLOS BARBA, MD • Chief of Bariatric Surgery, Chief of Trauma, Associate Director
of Surgical Critical Care, St. Francis Hospital and Medical Center, Hartford, CT
CHRISTINE BARTUS, MD • Surgical Resident, Department of Surgery, University of Connecticut
Health Center, Farmington, CT
JAY BENSON, MD • Associate Professor of Medicine, Division of Gastroenterology-
Hepatology, University of Connecticut Health Center, Farmington, CT,
and Attending Physician, St. Francis Hospital and Medical Center, Hartford, CT
DAVID M. BRAMS, MD • Staff Surgeon, Department of General Surgery, Lahey Clinic Medical
Center, Burlington, MA
JOSHUA M. BRAVEMAN, MD • Chief Surgical Resident, Department of General Surgery,
Lahey Clinic Medical Center, Burlington, MA
DAVID K. W. CHEW, MD • Instructor in Surgery, Division of Vascular Surgery,
Brigham and Women's Hospital, Boston, MA
MICHAEL S. CONTE, MD • Associate Professor of Surgery, Division of Vascular Surgery,
Brigham and Women's Hospital, Boston, MA
JAROSLAW CYMOREK, MD • Senior GI Fellow, Division of Gastroenterology-Hepatology,
University of Connecticut Health Center, Farmington, CT
LILY H. FIDUCCIA • Freelance Illustrator
JANETTE U. GAW, MD • Surgical Resident, Department of Surgery, Yale New Haven Hospital,
Yale University School of Medicine, New Haven, CT
DAVID GILES, MD • Assistant Professor, Department of Surgery, University of Connecticut
Health Center, Farmington, CT
ANDERS HOLM, MD • Chief Surgical Resident, Department of Otolaryngology,
University of Connecticut Health Center, Farmington, CT
MARTIN S. KARPEH, JR., MD • Chief of Surgical Oncology, Department of Surgery,
State University of New York at Stony Brook, Stony Brook, NY
MICHAEL KENT, MD • Assistant Professor of Surgery, Department of Cardiothoracic Surgery,
The New York Presbyterian Hospital, Weill-Cornell Medical Center, New York, NY
xiii
xiv Contributors
LEV KHITIN, MD • Resident Surgeon, Department of General Surgery, Lahey Clinic Medical
Center, Burlington, MA
ERIC M. KNAUER, MD • Chief Surgical Resident, Department of Surgery,
University of Connecticut School of Medicine, Farmington, CT
R
OBERT A. KOZOL, MD, MHA, FACS • Professor of Surgery, Chief Division of Surgery,
University of Connecticut Health Center, Farmington, CT
D
ENIS
C. L
AFRENIERE, MD, FACS
• Associate Professor of Surgery, Department of Otolaryngology,
University of Connecticut Health Center, Farmington, CT
NII LAMPTEY-MILLS, MD • GI Fellow, Department of Medicine, Division of Gastroenterology-
Hepatology, University of Connecticut Health Center, Farmington, CT
ANUEL LORENZO, MD • Associate Director of Surgical Critical Care and Trauma,
M
and Director Medical Clinics, St. Francis Hospital and Medical Center, Hartford, CT
M
ARK MADDOX, MD • Fellow, Colon and Rectal Surgery, St. Francis Hospital and Medical
Center, Hartford, CT
ROBERT C. G. MARTIN, MD • Chief Surgical Fellow, Department of Surgery, Cornell Medical
College, Memorial Sloan Kettering Cancer Center, New York, NY
JUSTIN A. MAYKEL, MD • Surgical Resident, Department of Surgery, Beth Israel Deaconess
Medical Center, Harvard Medical School, Boston, MA
BRENT W. MIEDEMA, MD • Associate Professor, Department of Surgery, University of Missouri
Medical Center and Harry S. Truman Veterans Administration Hospital, Columbia, MO
GASPAR NAZARENO, MD • GI Fellow, Department of Medicine, Division of Gastroenterology-
Hepatology, University of Connecticut Health Center, Farmington, CT
JEFFREY PORT, MD • Assistant Professor of Surgery, Department of Cardiothoracic Surgery,
The New York Presbyterian Hospital, Weill-Cornell Medical Center, New York, NY
GRANT J. PRICE, MD, MSCVIR, MACR • Chairman of Radiology, Somerset Medical Center,
Somerville, NJ
NITIN RANGNEKAR, MD • Assistant Professor, Department of Surgery, University of Missouri
Medical Center and Harry S. Truman Veterans Administration Hospital, Columbia, MO
SCOTT RUTCHICK, MD • Assistant Professor, Department of Surgery, Section of Urology,
University of Connecticut, Farmington, CT
STEPHANIE SALTZBERG, MD • Chief Resident, Department of Surgery, Beth Israel Deaconess
Medical Center, Harvard Medical School, Boston, MA
JOHN TAGGERT, MD • Surgical Resident, Department of Surgery, University of Connecticut
School of Medicine, Farmington, CT
DAVID WALTERS, MD • Assistant Professor of Colorectal Surgery, University of Connecticut
Health Center, Farmington, CT
GILES F. WHALEN, MD, FACS • Professor of Surgery, Department of Surgery,
University of Connecticut Health Center, Farmington, CT
GEORGE Y. WU, MD, PhD • Professor of Medicine, Chief, Division of Gastroenterology-
Hepatology, Herman Lopata Chair in Hepatitis Research, University of Connecticut
Health Center, Farmington, CT
Chapter 1 / Esophagectomy and Reconstruction 1
I
ESOPHAGEAL SURGERY
2 Kent, Port, and Altorki
Chapter 1 / Esophagectomy and Reconstruction 3
1
Esophagectomy and Reconstruction
Michael Kent, MD, Jeffrey Port, MD,
and Nasser Altorki,
CONTENTS
INTRODUCTION
EPIDEMIOLOGY OF ESOPHAGEAL CANCER
PREOPERATIVE EVALUATION
TREATMENT
OPTIONS FOR ESOPHAGEAL RECONSTRUCTION
MANAGEMENT OF COMPLICATIONS
COST OF SURGERY AND FUNCTIONAL OUTCOME
SUMMARY
REFERENCES
MD
INTRODUCTION
Esophagectomy is one of the most formidable operations performed by the gas-
trointestinal (GI) surgeon. Esophageal resection carries a complication rate of more than
40%, and should only be performed in centers experienced with the management of these
patients. Indeed, the mortality of esophagectomy has been shown to be significantly
lower in larger volume centers (1).
Esophageal resection is most frequently performed for carcinoma of the esophagus.
Although less common, several other benign conditions may necessitate esophagectomy.
For example, severe caustic burns to the esophagus often require esophageal resection
and reconstruction. Esophageal perforation, primary motility disorders such as achalasia
and scleroderma, and unsuccessful antireflux operations are additional indications for
esophagectomy. Usually, these diseases may be managed with esophageal-sparing surgery, such as fundoplication or myotomy. Esophagectomy often represents the final
treatment of patients with a variety of benign conditions who have failed more conservative surgical management.
From: Clinical Gastroenterology: An Internist's Illustrated Guide to Gastrointestinal Surgery
Edited by: George Y. Wu, Khalid Aziz, and Giles F. Whalen © Humana Press Inc., Totowa, NJ
3
4 Kent, Port, and Altorki
EPIDEMIOLOGY OF ESOPHAGEAL CANCER
Although the prevalence of esophageal cancer reaches nearly epidemic levels in
certain parts of Central and Southeast Asia, it remains a relatively uncommon disease in
the United States. The American Cancer Society estimates that 13,000 patients have
been diagnosed with esophageal cancer in 2001. Unfortunately, the majority of these
patients will present with advanced disease not amenable to curative treatment.
Despite the advent of novel chemotherapeutic agents and refinements in surgical technique, the overall 5-yr survival of patients with carcinoma of the esophagus remains in
the range of 5–10%.
Esophageal cancer may develop as either a squamous cell or an adenocarcinoma.
Although the clinical presentation is similar, the epidemiology and risk factors of these
two histological subtypes differ markedly. Worldwide, squamous cell carcinoma is the
more common. However, the incidence of squamous cell cancer exhibits a remarkable
variability, with a “cancer belt” extending from northern Iran, through Central Asia, and
into Northern China. Indeed, the disease accounts for almost 25% of all cancer deaths
within the People’s Republic of China (2). Outside these endemic areas, squamous cell
carcinoma is far less common. However, clusters of high incidence have been identified
in Northern France and Italy, as well as major metropolitan centers within the United
States, such as New York, Los Angeles, and Washington, D.C. (3).
Several environmental factors have been clearly implicated in the development of
squamous cell cancer of the esophagus. In the Western Hemisphere, alcohol and tobacco
consumption are significant risk factors. The risk of both tobacco and alcohol use are
strongly dose-related (4,5). The consumption of both seems to exert a synergistic rather
than an additive effect. In part, this may owe to the ability of alcohol to improve the
diffusion of tobacco-related carcinogens through the esophageal wall (6). Interestingly,
in those locations where squamous cell cancer has its highest incidence, neither tobacco
nor alcohol use seem to be significant risk factors. Instead, dietary components such as
fermented fish or pickled corn that are rich in secondary amines have been implicated
(7). The ingestion of hot beverages such as tea that are potentially caustic to the esophagus has also been postulated to predispose to squamous cell carcinoma (8). Finally, the
observation that malignant cells may contain papillomavirus particles has suggested a
possible infectious etiology (9).
Although squamous cell carcinoma had been the most common type of esophageal
cancer in the United States 20 yr ago, adenocarcinoma is now the more prevalent. This
change reflects an increase in the incidence of adenocarcinoma of almost 10% per year
every year during the 1980s. This surge surpasses the increase in incidence of lung
cancer, melanoma, and non-Hodgkin’s lymphoma during the same period (10). Although
the reason for this change is not known, it likely parallels the rise of cases of Barrett’s
esophagus, known to be a precursor to adenocarcinoma (11). It has been estimated that
Barrett’s esophagus increases the lifetime risk of developing adenocarcinoma of the
esophagus 30- to 40-fold. At least 50% of resected specimens of adenocarcinoma retain
residual Barrett’s metaplasia (12). Given the likelihood that in other cases the metaplastic mucosa may have been completely overgrown with tumor, it appears that the majority
of cases of adenocarcinoma are associated with Barrett’s esophagus. The association
between Barrett’s esophagus and chronic gastroesophageal reflux has led to an intensive
search for the responsible carcinogens. It appears that gastric and biliary reflux in com-
Chapter 1 / Esophagectomy and Reconstruction 5
bination rather than either alone, which contributes to malignant transformation of the
esophageal mucosa (13). It has been suggested that the increasing use of H
blockers has
2
also contributed to the rise of Barrett’s esophagus and adenocarcinoma. However, this
hypothesis is solely observational and a causative relationship has been difficult to
establish.
In addition to Barrett’s esophagus, several less common conditions have been asso-
ciated with the development of esophageal cancer. For instance, the risk of esophageal
cancer has been estimated to be 30-fold higher in patients with achalasia compared with
the general population (14). Typically, these patients develop large, squamous cell tumors
located in the middle-third of the esophagus. Unfortunately, the majority of patients
present with advanced, unresectable disease. This is in part owing to the fact that the
symptoms of carcinoma are difficult to distinguish from those of achalasia itself. Other
conditions, such as tylosis, Plummer-Vinson syndrome, and caustic strictures are also
known to predispose to esophageal cancer.
PREOPERATIVE EVALUATION
All patients considered for esophagectomy must undergo a thorough preoperative
evaluation. The length of the procedure and high incidence of complications necessitate
that elective surgery be performed only when comorbidities have been optimally managed. The majority of patients undergoing esophagectomy have coexisting pulmonary
and cardiac disease and for this reason pulmonary function tests and cardiac stress
studies are routinely obtained. Indeed, the FEV
of postoperative mortality (15). Often, the incidence of postoperative complications can
be greatly diminished by simple measures such as smoking cessation and a trial of
antibiotics and inhaled bronchodilators.
In addition to a medical evaluation, patients with esophageal cancer must undergo
preoperative staging prior to esophagectomy. Unfortunately, more than 50% of these
patients will have unresectable disease at the time of their initial presentation. As in all
fields of oncology, the main goal of staging is to ascertain which patients harbor locally
advanced or metastatic disease, which would preclude curative surgery.
Several studies are routinely performed to stage esophageal cancer. A barium swallow
is the initial study obtained in any patient who presents with dysphagia. This is customarily followed by esophagoscopy, which can provide vital information to the surgeon and
oncologist. Most importantly, biopsy obtained during endoscopy will provide a tissue
diagnosis. In addition, the length of esophagus involved by tumor, the presence of a hiatal
hernia, and underlying Barrett’s mucosa can all be determined at the time of endoscopy
(Fig. 1). For tumors involving the upper- and middle-third of the esophagus, bronchoscopy is also necessary to exclude invasion of the trachea by tumor, which would imply
unresectability. Computed tomography (CT) scanning is also routinely obtained in all
patients with esophageal cancer. Although CT is not able to accurately determine nodal
status and the depth of mural invasion, it is very sensitive in detecting the presence of
distant disease, such as pulmonary or hepatic metastases.
Many other modalities to stage esophageal cancer have been reported and gained
some degree of acceptance. Endoscopic ultrasound (EUS) is one modality that has
become widely used in the past decade (16). EUS can accurately assess both the depth
of invasion of the esophageal wall by tumor, as well as the presence of local lymphad-
is one of the most accurate predictors
1
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