MOD6-SURG2-T1-Surgical Disorders of the Esophagus.pdf

SURG2 SURGERY 2 Surgical Disorders of the Esophagus TRANS 1...

SURG2 SURGERY 2 Surgical Disorders of the Esophagus TRANS 1 MODULE 6 Dr. Mary Therese Celine B. Bautista September 11, 2024 I LECTURE OUTLINE Upper Gastrointestinal Bleed 🧠 Must Know 📖 Book 📝 Previous Trans A. Esophageal Causes B. Clinical Presentation 📝I. UPPER GASTROINTESTINAL BLEED C. Pathophysiology of Esophageal Varices A. ESOPHAGEAL CAUSES 1. Portal Circulation 2. Hypertension D. Management II Achalasia A. Diagnosis B. Treatment 1. Heller Cardiomyotomy C. Complications III Gastroesophageal Reflux Disease (GERD) A. Complications 1. Esophagitis 2. Esophageal Stricture 3. Barrett’s Esophagitis 4. Other Complications B. Risk Factors C. Treatment 1. Lifestyle Modification 2. GERD Medications Figure 1. Esophageal varices (upper right), mallory-weiss tear (upper left), 3. Surgery dieulafoy’s lesion (lower left), and esophageal tumors (lower right) IV Hiatal Hernia Batch 2025 Trans on Surgical Disorders of the Esophagus A. Types of Hiatal Hernia B. Diagnosis NOTE: The right bottom image shows the normal mucosa of C. Management esophagus, compared to first picture, these are your varices/dilated veins that are raised in esophageal mucosa. V Trauma: Esophageal Perforation A. Complications B. Imaging 1 Esophageal Dilated submucosal distal esophageal 1. Esophagogram varices veins. 2. CT Scan 2 Mallory-weiss Commonly a result of forceful belching or C. Management tear vomiting. 1. Stabilization of the Patient 2. Non-operative Management 3 Dieulafoy's In AV malformation, vessel is protruding 3. Primary Closure with Fundoplication lesion outside the mucosa. 4. Other Procedures 4 Most commonly referred surgical case D. Prognosis Endoscopic maneuvers help control VI Trauma: Caustic Ingestion bleeding; hence, surgical intervention is A. Alkali seldomly performed Esophageal B. Acids It causes a non-massive and slow bleeding tumors C. Severity and Extent of Injury condition and is recognized on an D. Management outpatient basis. Early detection keeps it 1. Exploratory Laparotomy from being an emergency case compared 2. Initial Surgery to the above mentioned conditions. 3. Reconstruction Surgery E. Complications after Caustic Ingestion 1. Strictures B. CLINICAL PRESENTATION 2. Esophageal Cancer If massive, hematemesis (red or coffee -ground emesis) 3. Bleeding Melena (black tarry stools) 4. Fistula Formation Hematochezia (bright red stools) Shock VII Benign Esophageal Tumors Tachycardia A. Leiomyoma Signs of hypervolemia 1. Clinical Features 2. Diagnostics C. PATHOPHYSIOLOGY OF ESOPHAGEAL VARICES 3. Surgical Management 1. PORTAL CIRCULATION LECTURE OBJECTIVES Splenic vein, inferior mesenteric, and superior mesenteric → 1. Correctly diagnose common esophageal diseases. converge into portal vein → liver (filtration) → hepatic vein 2. Refer to appropriate specialty for definitive management. (systemic circulation) 3. Create proper surgical plan. Group 6B | Surgical Disorders of the Esophagus 1 of 14  and remains in the parenchyma → blood flow directly goes to the systemic circulation. There is risk for encephalopathy as toxins are not adequately filtered. Definitive surgery ○ Types: Shunt surgeries - Bypassing liver parenchyma - i.e., portosystemic shunt, splenorenal shunt Non-shunt surgeries - Hassab’s procedure - Sugiura and fataura procedure, distal esophagectomy ○ Performed in patients with cardiac problems wherein TIPSS is not recommended or no specialist is available. Figure 2. Portal circulation Batch 2025 Trans on Surgical Disorders of the Esophagus 2. PORTAL HYPERTENSION If with cirrhosis (due to alcoholic liver disease, fatty liver or schistosomiasis), it would cause damage to parenchyma → obstruction in the portal vein → altered systemic blood flow → development of collateral vessels → coronary vein will go to Figure 4. Transjugular intrahepatic portosystemic shunt (TIPSS) Batch 2025 Trans on Surgical Disorders of the Esophagus gastroesophageal varices → presentation of apparent caput medusa and engorged hemorrhoidal tissue (hemorrhoids) ○ Splenomegaly is present during physical examination II. ACHALASIA ○ Other symptoms: ascites, jaundice, encephalopathy An esophageal disorder characterized by impaired motility and incomplete lower esophageal sphincter relaxation. It causes progressive dysphasia, regurgitation of food, and chest 🧠 pains. Gold standard for diagnosis: Esophageal manometry ○ Shows high pressure in the lower esophageal sphincter, incomplete lower esophageal sphincter relaxation, and 📝 decrease in esophageal peristalsis. Other motility disorders: ○ Diffuse Esophageal Spasm (DES) ○ Nutcracker Esophagus ○ Hypertensive Lower Esophageal Sphincter Most of the patients with motility disorder that go for surgery are patients with Achalasia. Achalasia results from the progressive degeneration of ganglion cells in the myenteric plexus in the esophageal wall Leading to failure of relaxation of the lower esophageal sphincter LES) accompanied by loss of peristalsis in the distal esophagus which consequently leads to esophageal dilatation. Patients with achalasia present with dysphagia, regurgitation and sometimes, chest pain Figure 3. Portal hypertension Batch 2025 Trans on Surgical Disorders of the Esophagus D. MANAGEMENT Aggressive fluid resuscitation Blood transfusion Medications (e.g., PPI) ○ Mallory-weiss tear: can heal spontaneously, with medications almost 90% of cases gets resolved (endoscopy for documentation only) Endoscopy ○ Diagnostic to locate source of bleeding ○ Therapeutic can immediately do maneuver to control bleeding like hemoclips, chemical sclerotherapy or coagulation techniques Transjugular intrahepatic portosystemic shunt (TIPSS) ○ For gastroesophageal varices and performed only during active bleeding If uncontrolled with endoscopic maneuvers, it can Figure 5. Achalasia Pace Hospital temporarily do an endoscopic balloon to tamponade the bleeding and to bridge the patient for the definitive (TIPSS) and surgical procedure (shunts). A. DIAGNOSIS ○ Not seen in practice that much Diffuse 🧠🧠🧠 ○ Done by interventional radiology Confirmed by barium swallow appearance ○ Procedure: A small incision is made in the neck to access the ○ “BIRD’S BEAK” appearance internal jugular vein → cannulates and connects hepatic vein Manometry to portal vein by puncturing the liver parenchyma using a Gold standard to confirm that there is hypertension of the LES catheter → serial dilatation of the track → stent is deployed ○ To classify achalasia type Group 6B | Surgical Disorders of the Esophagus 2 of 14  Figure 9. Heller Cardiomyotomy Dr. Bautista’s Video Lecture Figure 6. Bird’s Beak Appearance Batch 2025 Trans on Surgical Disorders of the Esophagus Figure 10. Dor Fundoplication Dr. Bautista’s Video Lecture Doctor’s Notes Done by splitting of the muscles The cut is made proximally on the esophagus for 4-5 cm and distally over the stomach, 1 to 2 cm below the EG junction. In Figure 7. Manometry some books, it is up to 2.5 cm below the EG junction. Dr. Bautista’s Video Lecture C. COMPLICATIONS [BATCH 2025] MANOMETRY Related to tearing of the esophagus 1 Perforation - due to dissection of the mediastinum, there is a risk of perforation of the pleura 2 Pneumothorax 3 Bleeding 4 Vagus nerve injury - if accidentally transected during myotomy 5 Acid Reflux - if fundoplication is not done Figure 8. Achalasia Manometry types Batch 2025 Trans on Surgical Disorders of the Esophagus 6 Respiratory conditions - 📝 (i.e. Aspiration pneumonia) caused by food traveling up your esophagus and into trachea (windpipe) Achalasia type I: classic ○ Pressure over time [BATCH 2025] HELLER CARDIOMYOTOMY ○ When the patient swallows, there is no peristalsis. Achalasia type II Myotomy is indicated if a dilatation procedure didn’t work the first ○ There is pressure build up, but there is actually no peristalsis. time. Achalasia type III Myotomy of the LES can be performed via abdominal or thoracic ○ Spastic achalasia approach. ○ There are abnormal contractions of distal esophagus. Weakening of the LES via surgical myotomy is accomplished by cutting the muscle fibers of the cardia, where the LES is located. B. TREATMENT Focuses on reducing the pressure of lower esophageal sphincters, which can be accomplished by procedures that tear or cut the 📝 sphincter muscle or by medications. Reduction in LES resistance can be accomplished by: ○ Medical: botulinum Injection, oral use of nitrates ○ Endoscopic: pneumatic dilatation, peroral endoscopic myotomy (POEM) ○ Surgical: Heller Cardiomyopathy 1. HELLER CARDIOMYOTOMY Performed when conservative medical management fail to resolve Figure 11. Myotomy symptoms. Batch 2025 Trans on Surgical Disorders of the Esophagus Done to widely open the lower esophageal sphincter by incising it Myotomy is carried across the GEJ and onto the proximal stomach for in order to make it easier for food to fall into the stomach. approximately 2-3 cm If esophageal peristalsis is not able to be restored, resistance to food passage can be reduced surgically. Since LES disruption can cause reflux esophagitis, it is frequently Fundoplication is done after myotomy because the lower combined with an anti-reflux procedure such as a partial esophageal sphincter is wide open after the procedure, the patient fundoplication either Dor fundoplication or a Toupet is at risk for significant reflux. Fundoplication. Dor Fundoplication or partial anterior stomach route is a gentle Almost 95% of people who have surgery get some relief from way to minimize risk of reflux after Heller Cardiomyotomy. symptoms. However, you may develop some complications. Patients with long standing disease whose esophageal function has been destroyed by the disease process or by multiple Group 6B | Surgical Disorders of the Esophagus 3 of 14  previous surgical procedures are best managed by 2. ESOPHAGEAL STRICTURE esophagectomy. Scar tissue develops and narrows the esophagus. DOR FUNDOPLICATION 180° anterior wrap More advantageous than Toupet in cases when you perforate the mucosa and you need to repair the perforation. Dor fundoplication protects or covers the area repaired. Figure 15. Esophageal Stricture Dr. Bautista’s Video Lecture 3. BARRETT’S ESOPHAGITIS Lining of the esophagus resembles a tissue that lines the intestines which can lead to cancer. Figure 12. Dor Fundoplication Batch 2025 Trans on Surgical Disorders of the Esophagus TOUPET FUNDOPLICATION 270° posterior wrap of the fundus around the esophagus. It does not cover the myotomy site. Keeps the longitudinal fibers open. Figure 16. Barrett's Esophagitis Dr. Bautista’s Video Lecture 4. OTHER COMPLICATIONS Repeated airway/respiratory problems like asthma, and aspiration Figure 13. Toupet Fundoplication pneumonia Batch 2025 Trans on Surgical Disorders of the Esophagus Failed maximal medical treatment III. GASTROESOPHAGEAL REFLUX DISEASE (GERD) B. RISK FACTORS Also known as Acid reflux. Obesity A chronic condition in which stomach contents rise and enter the Pregnancy esophagus. Smoking This occurs due to problems with closure of the lower esophageal Certain Medications sphincters. 🧠 Most common symptoms Burning sensation in the best (heartburn) C. TREATMENT 1. LIFESTYLE MODIFICATION 🧠 First line treatment for GERD ○ Regurgitation ○ Acidic taste in the back of the mouth ○ Nausea ○ Frequent burping 1 Losing weight ○ Chest pain 2 Cessation of smoking ○ Sensation of a lump in the throat ○ Wearing away of teeth 3 Eating several small meals a day instead of 3 big meals ○ Bad breath 4 Not lying down after 2-3 hours after eating Can cause recurrent cough, breathing difficulties, chest congestion, and lung inflammation leading to asthma, bronchitis, 5 Raising the head of the bed when lying down and pneumonia. 6 Avoiding stress foods that may exacerbate GERD symptoms (spicy, fatty, or fried foods, garlic, onion, citrus fruits, tomatoes, A. COMPLICATIONS caffeine, fizzy drinks, chocolate, and dairy products) 1. ESOPHAGITIS Inflammation of esophagus Figure 14. Esophagitis Dr. Bautista’s Video Lecture Figure 17. Stress Foods Dr. Bautista’s Video Lecture Group 6B | Surgical Disorders of the Esophagus 4 of 14 2. GERD MEDICATIONS Reduce stomach acid production ○ Proton Pump Inhibitors (PPIs) - to treat symptoms ○ Histamine II (H2 blockers) - to reduce symptoms Alleviate symptoms ○ Prokinetics Cause the stomach to empty more quickly Not common but helpful for some ○ Antacids Neutralize acids in the stomach To treat heartburn Figure 19. Nissen Fundoplication 3. SURGERY Batch 2025 Trans on Surgical Disorders of the Esophagus In cases where some people still have symptoms that interfere with their quality of life despite lifestyle changes and taking PARTIAL FUNDOPLICATION medications and don't want long term medication, surgery can be Used for patients with severe associated motor abnormalities performed to reinforce and strengthen the lower esophageal Developed as an alternative to the Nissen procedure to minimize sphincter. the risk of post-fundoplication side effects related to it (e.g., dysphagia, inability to belge, and flatulence) Two types of partial fundoplication Doctor’s Notes ○ Dor fundoplication Also done for patients who develop complications such as ○ Toupet fundoplication aspiration pneumonia, asthmatic, or other pulmonary conditions Indications for antireflux surgery: ○ Repeated airway/respiratory problems (asthma, aspiration pneumonia ○ Presence of Barrett’s esophagus ○ Failed maximal medical treatment Primary goal is to create a anti-reflux valve FUNDOPLICATION Anti-reflux surgery that is performed in patients with GERD. Fundus of the stomach may be wrapped fully or partially at the distal esophagus. Figure 20. Partial Fundoplication Most people who had a fundoplication enjoy a long lasting relief Dr Bautista’s Synchronous Session from the symptom of reflux. IV. HIATAL HERNIA When one part of the stomach slips through the diaphragm into the 🧠 middle compartment of the chest. GERD is a consequence of this condition. With the advent of clinical radiology, it became evident that a diaphragmatic hernia was a relatively common abnormality but not always detected as it is not commonly accompanied by symptoms. If present, it is also fixed during fundoplication. A. TYPES OF HIATAL HERNIA Type I: Classic Sliding Hiatal Hernia Figure 18. Fundoplication ○ Esophagogastric Junction is above the hiatus Dr. Bautista’s Video Lecture Type II: Paraesophageal or Rolling Hiatal Hernia ○ Esophagogastric Junction is at the level of the hiatus TYPES OF FUNDOPLICATION Type III: Mixed Hiatal Hernia COMPLETE FUNDOPLICATION (TOTAL) - 360° Type IV: Hiatal Hernia with Abdominal content ○ Done to patients with abnormal manometry ○ Worst ○ Contraindicated to patients who have other mobility disorders, ○ Whole stomach is herniated into the thorax or it can be better to to partial accompanied by other organs like transverse colon. PARTIAL FUNDOPLICATION - ○ Dor fundoplication - 180° ○ Toupet fundoplication - 270° If the graft is too tight, post-op patients produce symptoms of dysphagia [BATCH 2025] TYPES OF FUNDOPLICATIONS COMPLETE FUNDOPLICATION Nissen fundoplication: 360° complete fundoplication ○ Most surgeons perform a loose wrap that is about 2-3 cm in length followed by a posterior crural repair ○ The problem with Nissen fundoplication is sometimes, it is too tight so patients may present with dysphagia. In this case, partial fundoplication may be done instead. Figure 21. Types of Hiatal Hernia Dr Bautista’s Synchronous Session Group 6B | Surgical Disorders of the Esophagus 5 of 14 B. DIAGNOSIS Doctor’s Notes Esophagogastroduodenoscopy Repair is done from below, there is a very loose hiatus in which it ○ Will demonstrated widened EGJ area is closed 📝 Contrast studies ○ Esophagogram (Barium swallow) with intake of water-soluble PARAESOPHAGEAL HERNIA REPAIR contrast Paraesophageal hernia can be repaired transabdominally or trans ○ Will show that the stomach has herniated to the diaphragm thoracically, open or laparoscopically CT scan We begin with the dissection of the hiatus and hernial sac. If the ○ For complicated hiatal hernia stomach and other organs are incarcerated, the hernial contents ○ If stomach is within the chest cavity are reduced. The hernial sac must be completely removed from ○ Usually referred to surgery the mediastinum. This is then followed by lengthening the intra abdominal esophagus. If intra abdominal esophageal length cannot be achieved with esophageal mobilization alone, an esophageal lengthening procedure may be required. COLLIS GASTROPLASTY Collis gastroplasty is an esophageal lengthening procedure. This is followed by the closure of the hiatus either with primary repair alone or with a mesh. Figure 22. Diagnostics for Hiatal Hernia Left: EGD, Middle: Esophagogram, RIght: CT Scan Dr. Bautista’s Synchronous Session C. MANAGEMENT Surgical management is indicated when medical management fails to control symptoms such as GERD/Reflux, dysphagia, regurgitation anemia, dyspnea, and intermittent epigastric or abdominal pain. Patients with these symptoms can be repaired as electives. Emergency repair is required when there is a complication such as bleeding, obstruction, gastric volvulus, strangulation, perforation, or with respiratory compromise. The urgency is dependent upon the acuity of the presentation. Surgical repair is associated with improved symptoms and better Figure 24. Collis gastroplasty quality of life. Dr. Bautista’s Synchronous Session Table 1. Elective and Emergency Repairs Doctor’s Notes Usage of a mesh is still controversial due to complications of ELECTIVE REPAIR EMERGENCY REPAIR mesh that can erode to the surrounding tissues (ie: esophagus) Relaxing incisions in the diaphragm are done if the hiatus is too Reflux Bleeding wide to stretch so it can oppose it Dysphagia Obstruction Regurgitation Volvulus CLOSURE OF THE HIATUS The problem with placing a mesh (biologic or synthetic) is it can Anemia Strangulation lead to serious complications that would be needing operations. Dyspnea Perforation Complications include intraluminal mesh erosion, esophageal stenosis, and dense fibrosis. Epigastric Pain Respiratory Compromise Others suggest fundoplication afterwards. Source: Dr. Bautista’s Synchronous Session Figure 25. Closure of the hiatus (with primary repair alone) Dr. Bautista’s Synchronous Session Figure 23. Laparoscopic repair. Top-Left: Type 3 hiatal hernia, Top-Right: Normal hiatus with a stomach below the hiatus, Bottom: Lengthening of the intra abdominal esophagus Dr. Bautista’s Synchronous Session Group 6B | Surgical Disorders of the Esophagus 6 of 14  V. TRAUMA: ESOPHAGEAL PERFORATION Usually caused by injury to the esophagus ○ Injuries from outside or inside the esophagus ○ Sudden injuries from traumatic events Stab wounds, gunshot wounds, blunt chest trauma Foreign bodies ○ Progress slowly (corrosive or caustic substance ingestion) ○ 🧠 Common symptoms include: Chest pain - most striking and most consistent symptom that strongly suggests esophageal rupture. ○ Difficulty in swallowing ○ Shortness of breath ○ Tachycardia ○ Nausea ○ Hematemesis Figure 26. Closure of the hiatus (with synthetic mesh placed over the primary ○ Fever repair) ○ Hypotension Dr. Bautista’s Synchronous Session ○ Symptoms noticed at a later stage include dyspnea, and fever. This is caused by the leakage of saliva, irritation of the GASTROPEXY mediastinum, and tissues around the esophagus. Both complete and partial fundoplication benefit patients with Inflammatory responses, and shock. pre-existing symptomatic gastroesophageal reflux disease by restoring competency to the gastroesophageal sphincter. ○ Anterior Gastropexy may also be done by fixating the stomach to the abdominal wall either by suturing or by placing a gastrostomy tube. These procedures reduce recurrence rates. Figure 29. Severe Subcutaneous Emphysema Dr. Bautista’s Synchronous Session Doctor’s Notes Patient’s face is puffy because the air formed within the esophagus escapes to the subcutaneous tissues Most morbid presentation of perforation is shock due to delayed management SPONTANEOUS PERFORATIONS Boerhaave’s Syndrome ○ Rarely, can occur spontaneously under tremendous stress ○ Usually happens during forceful and repeated vomiting Figure 27. Gastropexy by suturing ○ Accounts for only 15% of esophageal perforation. Dr. Bautista’s Synchronous Session Doctor’s Notes GASTROSTOMY TUBE PLACEMENT Presents with chest pain because the contents of the esophagus May also be done has leaked out Compared to the mallory-weiss tear (upper GI bleed), boerhaave is more on penetration 🧠 IATROGENIC Most common case Majority occur during medical procedures especially during endoscopy. Other procedures that can cause iatrogenic injury to the esophagus: ○ NGT insertion ○ Endotracheal intubation ○ Tracheostomy ○ Spine surgery ○ Etc. Rigid endoscopy usually causes perforation in the proximal esophagus. WHY IS ESOPHAGUS AT RISK FOR PERFORATIONS? Esophagus does not have an outer lining which is the serosa like Figure 28. Gastrostomy Tube most of the other organs, thus, this makes the esophagus more Dr. Bautista’s Synchronous Session vulnerable to rupture. It is especially more susceptible to rupture if the inner lining or the mucosa is inflamed or injured. Group 6B | Surgical Disorders of the Esophagus 7 of 14  Table 2. Factors Affecting Results A. COMPLICATIONS When esophagogastric contents leak through the perforation, they Time interval between the perforation and radiographic can cause the following complications: examination. As mentioned earlier, mediastinal widening and pleural effusion occurs later in the course of condition. 1 Chemical inflammation or pleurisy of the lining of the chest cavity Site of perforation 2 Pleural effusion Integrity of mediastinal pleura. If the pleura is weak, the x-ray 3 Mediastinal emphysema finding that you will see is pneumothorax. If pleural integrity is 4 Necrosis maintained, mediastinal emphysema rather than pneumothorax appears rapidly. 5 Septicemia → Septic shock Source: Batch 2025 Trans on Surgical Disorders of the Esophagus Another complication is subcutaneous emphysema. This happens when there is a presence of air trapped under the skin in the Because of these factors, the diagnosis should not strongly rely subcutaneous tissue. This condition is more commonly seen in on the x-ray findings. airway perforations such as tracheal perforations. The diagnosis is confirmed with the contrast esophagogram which shows extravasation in 90% of patients. The use of water-soluble contrast gastrografin is preferred over barium and is less toxic. 1. ESOPHAGOGRAM If a perforation is expected, an esophagogram is requested to locate the perforation. Perforation is demonstrated by the extravasation of dye through the rupture. Figure 30. Chemical inflammation or pleurisy of the lining of the chest cavity Dr. Bautista’s Video Lecture Figure 33. Esophagogram Dr. Bautista’s Video Lecture Extravasation of dye through the rupture (black arrow) 2. CT SCAN May also be requested This can help find pockets of leaked dye and fluids that would need draining and repair of the surrounding tissues. Figure 31. Mediastinal emphysema Dr. Bautista’s Video Lecture Figure 34. CT scan Source: Dr. Bautista Video Lecture Pockets of leaked dye and fluids (white arrows) C. MANAGEMENT 1. STABILIZATION OF THE PATIENT Figure 32. Necrosis Dr. Bautista’s Video Lecture 🧠 The key to optimum management is early diagnosis. 2. NON-OPERATIVE MANAGEMENT 📝 B. IMAGING Request for diagnostics (i.e. chest x-ray) and look for these classic features: The major principles in the primary and immediate management of an esophageal perforation include prompt diagnosis, ○ Mediastinal emphysema: a strong indicator of perforation seen stabilization of patient, and assessment for operative or in thoracic perforation nonoperative management. ○ Mediastinal widening: occurs secondary to edema which Once the diagnosis is suspected, treatment should start occurs several hours after perforation immediately. The initial management would include: placing the ○ Subcutaneous emphysema: common in cervical perforation patient on NPO, start fluid resuscitation, start IV antibiotics. ○ Pleural effusion which is secondary to inflammation of 1 IV Fluids For aggressive resuscitation mediastinum and occurs late ○ Pneumothorax 2 IV antibiotics with or To treat infections ○ Tracheal deviation without antifungals Group 6B | Surgical Disorders of the Esophagus 8 of 14  3 IV nutritions or tube Since patient will be unable to EXCEPTIONS feedings swallow during recovery Exceptions to performing a primary repair include Not all esophageal perforations require surgery. ○ Cervical perforation that cannot be accessed but can be It depends upon the size and location of the perforation. drained In some cases, an esophageal perforation can be a life-threatening ○ Diffuse mediastinal necrosis condition that requires prompt surgical repair in addition to ○ Large perforation for the esophagus to be approximated intravenous fluid and antibiotics. ○ Esophageal malignancy Antifungal drugs should be considered in selective cases and who ○ Pre-existing end-stage benign esophageal disease like are immunocompromised or receiving antimicrobials long before achalasia their perforation. ○ Unstable patient Contrast esophagogram: no extravasation (for confirmation) ○ As long as patients remain clinically stable, contrast ALTERNATIVES esophagogram may still be requested at 5-7 days which must Drainage reveal no extravasation of contrast. Resumption of oral intake ○ Since primary repair is a relatively long procedure unstable under observation is considered depending on the result. patients are managed through drainage. ○ Sole operative management and is reserved for the 3. PRIMARY CLOSURE WITH FUNDOPLICATION perforations of the cervical esophagus The most favorable outcome is obtained following primary closure ○ When the perforation site cannot be completely visualized of the perforations within 24 hours resulting in 80-90% survival. ○ When there is no distal obstruction When there has been a delay in diagnosis greater than 24 hours, and or substantial extraluminal contamination from the leakage of ENDOLUMINAL STENT fluid and debris has occurred, the integrity of the repair can be May be placed instead of a drainage since the latter alone is enhanced with the use of a vascularized pedicle flap. contraindicated on the management of the thoracic and The most common flap used is the intercostal muscle flap. intra-abdominal perforation because of uncontrolled leakage and contamination of adjacent spaces like pleura and peritoneum. Stents may be appropriate for patients with: ○ Extensive comorbidities ○ Advanced mediastinal sepsis ○ Patients inability to tolerate more extensive surgery However, it will not work if: ○ The perforations are located in the proximal cervical esophagus ○ The perforation traverses the EGJ ○ Perforation that is more than 6 cm in length In some hospitals also, the stents and the specialist may not be available. Figure 35. Primary closure with fundoplication Dr. Bautista’s Synchronous Session Figure 37. Endoluminal Stent Dr. Bautista’s Synchronous Session T-TUBE PLACEMENT May be inserted into the perforation to create a controlled fistula when a patient cannot tolerate a more extensive surgery. Done if patient is very toxic (ie in shock, hypotensive) Figure 36. Intercostal Muscle Flap Dr. Bautista’s Synchronous Session For intra-abdominal esophageal perforations, same principles in primary repair apply as described those in the management of cervical and thoracic perforations, but following a primary repair, a Nissen or Dor Fundoplication is created to buttress the site of repair. Figure 38. Endoluminal Stent Batch 2025 Trans on Surgical Disorders of the Esophagus Doctor’s Notes For perforations at the distal or below the diaphragm, do the primary repair then do fundoplication (cover the perforation with the fundus of the stomach) Group 6B | Surgical Disorders of the Esophagus 9 of 14  DIVERSION REPAIR OF THE PERFORATION EITHER VIA OPEN APPROACH It is a procedure to divert the esophageal contents rather than OR MINIMALLY INVASIVE SURGERY (MIS) perform a primary repair. Done in more stable patients Steps would include the ff: ○ The proximal esophagus is exteriorized by creating a cervical esophagostomy. ○ The remaining esophagus is resected. ○ A gastrostomy tube is placed to create a gastric diversion or decompression ○ A tube jejunostomy is placed for feeding. Figure 42 Open approach or MIS Dr. Bautista’s Video Lecture ESOPHAGECTOMY In extreme cases, when the esophagus cannot be repaired. Figure 39. Diversion Dr. Bautista’s Synchronous Session 4. OTHER PROCEDURES Based on the severity of perforation and clinical findings, a number of procedures can be performed including: Figure 43. Esophagectomy Dr. Bautista’s Video Lecture DRAINAGE OF SPILLED FLUIDS AND FOOD WITH CHEST TUBE Since this is too technical, just remember the importance of prompt diagnosis. Dr. Bautista D. PROGNOSIS Esophageal perforation is survivable but the prognosis depends on how soon the treatment is received. The more time the infections have spread from the perforation through the chest and into the bloodstream, the higher the risk. Those who received treatment within the first 24 hours of perforation are likely to make a full recovery. VI. TRAUMA: CAUSTIC INGESTION Caustic ingestion is mainly accidental in children and rather in small quantities. Figure 40. Chest Tube Dr. Bautista’s Video Lecture On the other hand, in adults or teenagers, the swallowing of caustic liquid is usually deliberate during a suicide attempt and greater quantities are swallowed. ENDOSCOPY AND STENT PLACEMENT It is important to know what type of chemical the patient has Insertion of a hollow tube in the esophagus at the level of injury to ingested because the severity of injury can be predicted from this. occlude the perforation. A. ALKALI Alkalis are more frequently swallowed accidentally than acids because strong acids cause an immediate burning pain in the mouth. Alkalis dissolves tissue by causing liquefactive necrosis where it penetrates tissue more deeply. Alkalis: sodium and potassium hydroxide ○ Drain cleaners ○ Household cleaning products ○ Lye ○ Disc battery B. ACIDS Figure 41. Endoscopy and stent placement Acids cause coagulative necrosis that limits their penetration. Dr. Bautista’s Video Lecture Acids: hydrochloric acid, sulfuric acid, and phosphoric acid ○ Toilet and swimming pool cleaners ○ Anti-rust compounds ○ Battery fluid Group 6B | Surgical Disorders of the Esophagus 10 of 14 C. SEVERITY AND EXTENT OF INJURY ○ CT evidence of transmural necrosis The severity and extent of esophageal and gastric damage ○ Perforation of esophagus and or stomach resulting from caustic ingestion depends upon the following During the exploratory laparotomy, all transmural necrotic tissues factors: should be resected. A second look operation may be required for patients with 1 The nature of the caustic substance suspected ongoing necrosis. Alkali produce more damage than acid When there is extensive gastric involvement, the esophagus is nearly always necrotic or severely burned. Therefore 2 Concentration and amount ingested esophagogastrectomy thru a combined abdominal and The higher the concentration of the substance and the larger cervical incision is always performed the amount of substance ingested, the more likely it will cause an esophageal injury. 1. EXPLORATORY LAPAROTOMY 3 Physical form of the caustic substance The stomach wall has already been perforated and within are Solid caustic material which tends to adhere to the mucosa extensive burns. can produce deep burns of the oral cavity and esophagus Even the esophagus is severely burned. It may not be obvious but are less likely to reach the stomach. outside but within the esophagus, a leathery appearance indicates Liquid preparation can injure larger mucosal surfaces. a severely burned mucosa. 4 Duration of contact with the mucosa Sometimes, if the EGD shows necrosis limited to the stomach, Longer duration of contact produces deeper injuries. only a total gastrectomy is done and the esophagus is preserved. Solids have longer exposure to the tissue → causes necrosis Liquids have faster transit → damage the stomach more Figure 44. Different presentation of caustic injury Dr. Bautista’s Synchronous Session The clinical features of caustic injury vary widely. Some may Figure 46. Example of resected esophagus and stomach with extensive burns present with overt signs and symptoms (left most picture) like pain Dr. Bautista’s Synchronous Session in the mouth because of the oral burns and accompanied by dysphagia and dyspnea while others may only have a mild sign 2. INITIAL SURGERY like in the middle picture. After esophagogastrectomy, esophagostomy or spit fistula is Sometimes, patients may present with no apparent oral injuries created. The duodenal stamp is closed and a feeding tube at all but there may already be excessive burn injuries in the upper jejunostomy is placed. airway or in the esophagus. Therefore, early signs and symptoms It is important not to forget placing a feeding tube jejunostomy as it may not correlate well with the severity and extent of tissue injury. is your access in providing nutrition to your patient. This is why after initial supportive management has been provided, Building up your patient’s nutritional status is crucial in preparation early EGD is advocated to establish the severity of esophageal for his/her eventual reconstruction. and gastric injuries. The GIT reconstruction is not advised to be done on the same operation but delayed at least 6 months later to stabilize the injury. Figure 45. Upper Left: mediastinitis, Upper Right: Peritonitis, Lower Left: EGD Findings, Lower Right: CT Evidence Dr. Bautista’s Synchronous Session D. MANAGEMENT Figure 47. Initial surgery Management Batch 2025 Trans on Surgical Disorders of the Esophagus ○ Respiratory support ○ Fluid resuscitation ○ PPI to avoid further stress from stress ulcers in the stomach ○ Broad spectrum antibiotics ○ Pain medications ○ Diagnostics (X-rays like rupture; EGD is optimal during the first 24 hours) ○ Avoid: use of NGT ○ Avoid: medications to induce retching or vomiting Indications for emergency surgery: ○ Clinical signs of perforations (such as mediastinitis or peritonitis) ○ EGD findings of extensive necrosis Group 6B | Surgical Disorders of the Esophagus 11 of 14 3. RECONSTRUCTION SURGERY 2. ESOPHAGEAL CANCER The colon is usually used as a new conduit. This is called colonic A complication for those with preserved esophagus interposition. Literature suggests endoscopic surveillance every 2-3 years ○ Either the right or left colon can be used as a conduit with beginning 10-20 years after the caustic ingestion comparable results. 3. BLEEDING Another complication of caustic injury 4. FISTULA FORMATION As in tracheobronchial or aortoenteric fistula VII. 📝BENIGN ESOPHAGEAL TUMORS INTRAMURAL TUMORS Either solid tumors or cysts Vast majority are leiomyomas Made up of varying portions of smooth, muscle, and fibrous tissue 1 Leiomyomas 7 Neurofibromas 2 Fibromas 8 Hemangiomas 3 Myomas 9 Osteochondromas Figure 48. Reconstruction surgery Batch 2025 Trans on Surgical Disorders of the Esophagus 4 Lipomyomas 10 Granular cell myoblastoma E. 📝COMPLICATIONS AFTER CAUSTIC INGESTION 5 6 Fibromyomas Lipomas 11 Glomus tumors 1. STRICTURES One of the most common complications after caustic ingestion is INTRALUMINAL TUMORS the formation of strictures especially for those patients who did not Polypoid and pedunculated growth that originates in the undergo surgery and the esophagus was preserved. submucosa Patients will have to undergo endoscopic dilatations. Develop mainly into lumen and covered by normal stratified ○ If however, multiple attempts of dilatations have failed, squamous epithelium reconstructive surgery is considered. Majority of these tumors are composed of fibrous tissue of varying Gastric Pull-Up / Gastric Transposition degrees of compactness with a rich vascular supply ○ In the absence of significant gastric injury, the stomach is preferred as a new conduit. 1 Myxoma Colonic Interposition 2 Myxofibroma ○ If there’s a significant gastric injury or the stomach has already been removed from the initial surgery, colonic interposition is 3 Fibroma performed. 4 Fibrolipoma A. LEIOMYOMAS 1. CLINICAL FEATURES Leiomyomas are the most common intramural tumor Benign It constitutes more than 50% of benign esophageal tumors They are usually solitary, but multiple have been found on occasion They vary greatly in size and shape Dysphagia and pain are the most common complaints. Bleeding is rare Figure 49. Strictures 2. DIAGNOSTICS Batch 2025 Trans on Surgical Disorders of the Esophagus BARIUM SWALLOW TEST You can see the typical configuration of smooth, semilunar crescent shaped defect that moves with swallowing. Figure 50. (Left) Gastric Pull-up; (Right) Colonic Interposition Figure 51. Barium swallow test, with crescent shape (Left), Endoscopic Batch 2025 Trans on Surgical Disorders of the Esophagus ultrasound (Right) Batch 2025 Trans on Surgical Disorders of the Esophagus Group 6B | Surgical Disorders of the Esophagus 12 of 14  When doing EGD, it’s covered with a smooth normal appearing ○ Patients with non-gastrointestinal symptoms (i.e. chronic mucosa. cough, hoarseness, laryngitis) ○ Patients who cannot tolerate or do not wish to continue lifelong medical therapy Surgical repair for paraesophageal hernias is reserved for symptomatic patients and for management of complications (i.e. gastric volvulus, bleeding, obstruction, strangulation, perforation, and respiratory compromise secondary to a paraesophageal hernia) Perforation is a true surgical emergency. Prompt diagnosis and management is critical to minimizing mortality. A primary repair is the gold standard of care and should be utilized for perforations of the thoracic and abdominal esophagus, as well as for visualized perforations of the cervical esophagus. Figure 52. Leiomyoma in the esophagus Caustic ingestion can cause severe injury to the esophagus and Batch 2025 Trans on Surgical Disorders of the Esophagus the stomach. Alkalis and acids produce tissue injury by different mechanisms and depend on several factors. Clinical signs of You can go away with a biopsy, but it’s much better to perform a perforation (mediastinitis or peritonitis) and diagnostic evidence of biopsy. transmural necrosis are indications for emergency surgery. Biopsy will affect the approach of your surgery. ○ Most commonly performed procedure is esophagogastrectomy Since leiomyoma is benign, you can simply inoculate. You don’t ○ Reconstruction is delayed 6 months after the initial surgery. have to take normal margins. If the tumor is GIST (Gastrointestinal Leiomyoma is the most common benign smooth muscle tumor in stromal tumor), you have to take approximately 1 cm normal the esophagus. Surgical removal can be done by simple margin together with the tumor. enucleation and is indicated if the tumor becomes symptomatic, enlarges to >1cm or shows structural changes during surveillance, [BATCH 2024] EGD or malignancy is suspected. It is the most used method to demonstrate a leiomyoma in the esophagus IX. APA REFERENCES Sharply demarcated, covered and surrounded by normal mucosa Bautista, M. T. C. B. (2024). Surgical Disorders of the Esophagus EGD (Upper GI Endoscopy) should be performed to exclude the [Video Lecture]. reported observation of a co-existence with a carcinoma Brunicardi, F. C. (2019). Schwartz’s Principles of Surgery. (11th The freely movable mass, which bulges into the lumen, should ed). USA: McGraw-Hill Education. not be biopsied because of increased chance of mucosal perforation at the time of surgical enucleation X. REVIEW QUESTIONS 3. SURGICAL MANAGEMENT No. QUESTIONS Majority of leiomyomas can be removed by simple enucleation 1 A 30 year old man reports to you retrosternal chest pain After tumor removal, the outer esophageal wall should be associated with sour taste in the mouth. What is the reconstructed by closure of the muscle layer recommended surgical procedure after medical treatment Location of lesion and extent of surgery required will dictate the has failed? approach. A. Peroral endoscopic myotomy ○ Lesions of the proximal and middle esophagus require right B. Fundoplication thoracotomy while distal esophageal lesions require left C. Heller cardiomyotomy thoracotomy. D. Distal esophagectomy 2 A 62 year old man was brought to the ER because of massive hematemesis. Patient was known to be alcoholic during younger years and was recently diagnosed to have cirrhosis. What is the most likely diagnosis? A. Bleeding peptic ulcer B. Dieulafoy lesion C. Esophageal varices D. Esophagogastric junction bleeding tumor 3 A 27-year-old male consults because of pain on perianal area. Your diagnosis is external hemorrhoids. The treatment of choice will be: A. Stapled hemorrhoidectomy B. Excisional hemorrhoidectomy Figure 53. Removal of a leiomyoma C. Rubber band ligation Batch 2025 Trans on Surgical Disorders of the Esophagus D. Lateral internal sphincterotomy VIII. SUMMARY 4 A 28 yo young man was found to have “Bird’s Beak” sign Treatment for achalasia is aimed at disrupting the muscle fibers of on his barium swallow and abnormal LES relaxation on the LES medically by oral nitrates, botulinum toxin injection, manometry. What is the most likely diagnosis?. endoscopically by pneumatic dilation and POEM, and if all else A. Boerhaave’s Syndrome fails surgically by Heller myotomy B. Paraesophageal Hernia Heller Cardiomyotomy is a surgical procedure for achalasia that C. Achalasia entails cutting the muscle fibers or the lower esophageal sphincter. D. Gastroesophageal reflux disease Total or partial fundoplication is the surgical treatment for 5 A 28 yo man with complaints of dysphagia to solid foods gastroesophageal reflux disease (GERD). and sensation of obstruction of food in the chest. What is Esophageal perforation, once diagnosed, requires timely surgical the recommended INITIAL diagnostic test to request? intervention. A. Barium swallow Treatment for achalasia is aimed at disrupting the muscle fibers of B. Chest CT scan the LES medically by oral nitrates, botulinum toxin injection, C. Esophagoscopy endoscopically by pneumatic dilatation and POEM, and if all else D. Chest ultrasound fails, surgically by Heller myotomy. Antireflux procedures offered to patients with: ○ Chronic GERD who do not respond to optimal medical therapy Group 6B | Surgical Disorders of the Esophagus 13 of 14  XI. RATIONALIZATION 4 CORRECT ANSWER: C. Achalasia No. RATIONALIZATION Patients with achalasia present with dysphagia, regurgitation 1 CORRECT ANSWER: B. Fundoplication and sometimes, chest pain. The diagnosis of achalasia shows a Bird’s Beak Appearance (Fig 1) confirmed by barium swallow This is a case of GERD. First line treatment consists of lifestyle appearance. While manometry is able to confirm if there is modification and medications. Surgical management (antireflux hypertensive lower esophageal sphincter (LES) and to classify surgery) is reserved for patients who have persistent symptoms achalasia type. or developed complications despite optimal medical therapy. Fundoplication is the more commonly performed antireflux A is incorrect because Boerhaave’s Syndrome is a type of procedure. The primary goal of antireflux surgery is to safely perforation. It is a spontaneous perforation which is considered create a new antireflux valve at the gastroesophageal junction a fatal condition that is caused by forceful vomiting and (GEJ) while preserving the patient’s ability to swallow normally, accounts for only 15% of esophageal perforation. and to belch to relieve gaseous distention. B is incorrect because Paraesophageal Hernia is a hiatal The new valve created by the wrap should be tight enough to hernia. It is a type II known as Paraesophageal or Rolling Hiatal prevent regurgitation of gastric contents into the esophagus but Hernia. The esophagogastric Junction is at the level of the loose enough to relax on deglutition and respond to the hiatus. changes in intra-abdominal pressure. D is incorrect because Gastroesophageal reflux disease is an Ratio Batch 2025 inflammatory disease that develops due to reflux of gastric contents. While achalasia is a motility disorder characterized by 2 CORRECT ANSWER: C. Esophageal varices esophageal aperistalsis and nonrelaxation of the LES Esophageal varices are dilated collateral veins resulting from Ratio Batch 2025 increased blood flow due to portal hypertension, often caused by cirrhosis. Screening is usually done with EGD and is 5 CORRECT ANSWER: A. Barium Swallow recommended at the time of cirrhosis diagnosis. The patient presents with achalasia, the most common There are two (2) types of varices: 1) non-bleeding, which are esophageal motility disorder of the lower esophagus. This typically asymptomatic, and 2) bleeding varices which are condition is associated with dysphagia, regurgitation and composed by sudden onset of severe symptoms of GI bleeding sometimes, chest pain. The non-relaxing lower esophageal (such as: hematemesis, hematochezia, and melena). sphincter that results from this condition causes a functional retention of ingested materials in the esophagus which leads to In the case of the patient, he was diagnosed to have cirrhosis a sensation of obstruction of food in the chest. and had an episode of massive hematemesis which led to an ER consult. With these pertinent findings, esophageal varices is Achalasia is confirmed by a barium swallow which shows a the most plausible diagnosis. “Bird’s beak” appearance or a “Rat Tail” sign. Ratio Batch 2025 B is incorrect because a Chest CT Scan has little role in the initial assessment of achalasia. However, it can be used in 3 CORRECT ANSWER: B. Excisional hemorrhoidectomy complicated cases or in detecting the subtypes of achalasia. Excision of a thrombosed external hemorrhoid is done by C is incorrect because Esophagoscopy is not done as an initial injection of anesthetic, excision of the external component, and diagnostic test for achalasia. closure with two or three interrupted absorbable sutures. D is incorrect because Chest ultrasound is also not done as a Based on the given choices, it appears that excisional diagnostic test for achalasia. Instead, it can be performed when hemorrhoidectomy is the only one that addresses external an underlying malignancy is suspected. hemorrhoids. Ratio Batch 2025 A is incorrect because stapled hemorrhoidectomy is indicated for grade II or III internal hemorrhoids. C is incorrect because rubber band ligation indicated for grade II and some grade III internal hemorrhoids. D is incorrect because lateral internal sphincterotomy is indicated for chronic anal fissures. Ratio Batch 2025 Group 6B | Surgical Disorders of the Esophagus 14 of 14