Surgery

Surgical Diseases of the Esophagus

Zote Francisco C. Chabon, MD
September 7, 2020

OUTLINE - The abdominal portion of the esophagus receives its blood supply
from the ascending branch of the left gastric artery and from
ANATOMY ....................................................................................................1 inferior phrenic arteries.
Blood Supply ..........................................................................................................................1
Innervation .............................................................................................................................1
Lymphatics .............................................................................................................................1
Innervation
ASSESSMENT OF ESOPHAGEAL FUNCTION .............................................1 - The parasympathetic innervation of the pharynx and esophagus is
Barium Swallow .....................................................................................................................1
Endoscopic Evaluation .........................................................................................................2 provided mainly by the vagus nerves. The cricopharyngeal
sphincter and the cervical portion of the esophagus receive
SURGICAL DISEASES OF THE ESOPHAGUS ..............................................3
Gastroesophageal Reflux Disease (GERD) ........................................................................3 branches from both recurrent laryngeal nerves, which originate
Barrett’s Esophagus (BE) .....................................................................................................4 from the vagus nerves.
Achalasia ................................................................................................................................4
o Damage to these nerves interferes not only with the function
Benign Esophageal Tumors .................................................................................................5
Malignant Esophageal Tumors ............................................................................................5 of the vocal cords but also with the function of the
Esophageal Perforation ........................................................................................................6 cricopharyngeal sphincter and the motility of the cervical
APPENDIX ....................................................................................................8 esophagus, predisposing the individual to pulmonary
aspiration on swallowing.

ANATOMY Lymphatics
- The esophagus is a muscular tube that starts as the continuation of - The lymphatics located in the submucosa of the esophagus are so
the pharynx and ends as the cardia of the stomach. dense and interconnected that they constitute a single plexus.
- Three normal areas of esophageal narrowing are evident on the There are more lymph vessels than blood capillaries in the
barium esophagogram or during esophagoscopy. submucosa.
o Uppermost narrowing: located at the entrance into the - As a consequence of this nonsegmental lymph drainage, a primary
esophagus and is caused by the cricopharyngeal muscle. It is tumor can extend for a considerable length superiorly or inferiorly
the narrowest point of the esophagus in the submucosal plexus.
o Middle narrowing: indentation of the anterior and left lateral
esophageal wall caused by the crossing of the left main stem ASSESSMENT OF ESOPHAGEAL FUNCTION
bronchus and aortic arch - Tests to detect structural abnormalities
o Lowermost narrowing: is at the hiatus of the diaphragm and o Radiographic evaluation
is caused by the gastroesophageal sphincter mechanism. o Barium swallow
- The cervical portion of the esophagus is approximately 5 cm long.
- The thoracic portion of the esophagus is approximately 20 cm long.
A thorough understanding of the patient’s underlying anatomic and
- The abdominal portion of the esophagus is approximately 2 cm
functional deficits before making therapeutic decisions is fundamental to
long.
the successful treatment of esophageal disease.

- The diagnostic tests, as presently used, may be divided into four

broad groups:
o tests to detect structural abnormalities of the esophagus
o tests to detect functional abnormalities of the esophagus
o tests to detect increased esophageal exposure to gastric juice
o tests of duodenogastric function as they relate to esophageal
disease

Barium Swallow
- Barium swallow evaluation is undertaken selectively to assess
anatomy and motility.
- To detect lower esophageal narrowing, such as rings and
strictures, fully distended views of the esophagogastric region are
crucial.
- The density of the barium used to study the esophagus can
Figure 1. Anatomy of the esophagus (left image) and esophagogram (right side). potentially affect the accuracy of the examination.
o Esophageal disorders shown clearly by a full-column technique
Blood Supply include circumferential carcinomas, peptic strictures,
- The cervical portion of the esophagus receives its main blood large esophageal ulcers, and hiatal hernias.
supply from the inferior thyroid artery. - The radiographic assessment of the esophagus is not complete
- The thoracic portion receives its blood supply from the bronchial unless the entire stomach and duodenum have been examined.
arteries, with 75% of individuals having one right-sided and two - A gastric or duodenal ulcer, partially obstructing gastric neoplasm, or
left-sided branches. Two esophageal branches arise directly from scarred duodenum and pylorus may contribute significantly to
the aorta. symptoms otherwise attributable to an esophageal abnormality.

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 Surgery | Surgical Diseases of the Esophagus
- When a patient’s complaints include dysphagia and no obstructing
lesion is seen on the barium swallow, it is useful to have the patient
swallow a barium-impregnated marshmallow, a barium-soaked
piece of bread, or a hamburger mixed with barium. This test may
bring out a functional disturbance in esophageal transport that can
be missed when liquid barium is used.
Figure 2. Barium swallow.
Endoscopic Evaluation
- Flexible fiberoptic endoscopy
- Esophagitis
o Grade I- small, circular, non-confluent erosions
o Grade II- linear erosions, granulation tissue, bleeds easily
o Grade III- circumferential loss of epithelium “cobblestone”
esophagus
o Grade IV- presence of a stricture
- The first diagnostic test in patients with suspected esophageal
disease is usually upper gastrointestinal endoscopy.
o This allows assessment and biopsy of the mucosa of the
stomach and the esophagus, as well as the diagnosis and
assessment of obstructing lesions in the upper gastrointestinal
tract.
Figure 3. Endoscopy of esophagus .
In any patient complaining of dysphagia, esophagoscopy is indicated,
even in the face of a normal radiographic study. Example is esophagitis
and Barret’s esophagus as they are complications of gastroesophageal
reflux disease or GERD.
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Initial Endoscopic Assessment
- The flexible fiberoptic esophagoscope is the instrument of choice
because of its technical ease, patient acceptance, and the ability to
simultaneously assess the stomach and duodenum.
- Rigid endoscopy is now only rarely required, mainly for the
disimpaction of difficult foreign bodies impacted in the esophagus,
and few individuals now have the skill set and experience to use this
equipment.
Figure 4. Endoscopic Evaluation. a. Endoscope; b. Process of Endoscopy; and c.
Esophagus endoscopy.
Esophagitis LA grading system
Figure 5. Complications of reflux disease as seen on endoscopy. A. Linear
erosions of LA grade B esophagitis. B. Uncomplicated Barrett’s mucosa. C. High-
grade dysplasia in Barrett’s mucosa. D. Early adenocarcinoma arising in Barrett’s
mucosa.
- When GERD is the suspected diagnosis, particular attention should
be paid to detecting the presence of esophagitis and Barrett’s
columnar-lined esophagus (CLE).
- The commonest system now in use is the Los Angeles (LA) grading
system.
o Mild esophagitis is classified LA grade A or B—one or more
erosions limited to the mucosal fold(s) and either less than or
greater than 5 mm in longitudinal extent respectively.
o More severe esophagitis is classified LA grade C or D
▪ Grade C, erosions extend over the mucosal folds but
over less than threequarters of the esophageal
circumference
▪ Grade D, confluent erosions extend across more than
three-quarters of the esophageal circumference.
- In addition to these grades, more severe damage can lead to the
formation of a stricture.
- A stricture’s severity can be assessed by the ease of passing a
standard endoscope.
o When a stricture is observed, the severity of the esophagitis
above it should be recorded. The absence of esophagitis
 Surgery | Surgical Diseases of the Esophagus
above a stricture suggests the possibility of a chemical- o Failure of medication to adequately control GERD symptoms
induced injury or a neoplasm as a cause. suggests either that the patient may have relatively severe
o The latter should always be considered and is ruled out only by disease or a non-GERD cause for his or her symptoms.
evaluation of a tissue biopsy of adequate size. - Endoscopic examination at this stage of the patient’s evaluation is
- It should be remembered that gastroesophageal reflux is not always recommended and will provide the opportunity to assess the degree
associated with visible mucosal abnormalities, and patients can of mucosal injury and presence of BE.
experience significant reflux symptoms, despite an apparently - High-dosage regimens of hydrogen potassium PPIs, such as
normal endoscopy examination. omeprazole (up to 40 mg/d), can reduce gastric acidity by as much
as 80% to 90%.
SURGICAL DISEASES OF THE ESOPHAGUS - Unfortunately, within 6 months of discontinuation of any form of
Gastroesophageal Reflux Disease (GERD) medical therapy for GERD, 80% of patients have a recurrence of
symptoms, and 40% of individuals with daily GERD eventually
- Common problem
develop symptoms that “breakthrough” adequately dosed PPIs.
o Heartburn
- Once initiated, most patients with GERD will require lifelong treatment
o Dysphagia
with PPIs, both to relieve symptoms and to control any coexistent
o Chest pain
esophagitis or stricture.
o Food regurgitation
- Chronic disease
Surgical:
- Lifelong treatment
- Surgical – anti-reflux procedures
- Pathophysiology: defective LES
o Key indications for anti-reflux surgeries:
- Complications
▪ Objectively proven GERD
o Esophagitis
▪ Typical symptoms of GERD (e.g. heartburn,
o Stricture
regurgitation) despite adequate medical management
o BE
▪ Younger patient and willing to take lifelong medication
o Respiratory problems
- In addition, structurally defective LES can predict which patients are
- GERD has grown to be a very common problem and now accounts
more likely to fail with medical therapy
for a majority of esophageal pathology.
- Primary Goal – safely create a new anti-reflux valve at the GE
o It is recognized as a chronic disease, and when medical
junction while preserving the patient’s ability to swallow normally
therapy is required, it is often lifelong treatment.
and to belch to relieve gaseous distention
- It is believed that GERD has its origins within the stomach.
- Primary Anti-Reflux Repairs: Nissen fundoplication
o Distention of the fundus occurs because of overeating and
o Most common
delayed gastric emptying secondary to a high fat diet.
o Rudolf Nissen described this procedure as a 360°
o The resultant distention causes “unrolling” of the sphincter by
fundoplication around the lower esophagus for a distance of
the expanding fundus, and this subsequently exposes the
4-5 cm without division of the short gastric blood vessels
squamous epithelium in the region of the distal LES to gastric
o Although this provided good control of the reflux, it was
juice.
associated with a number of side effects that have encouraged
- Repeated exposure results in inflammation and the development of
modifications of the procedure as originally described
columnar epithelium at the cardia.
o The essential elements necessary for the performance of a
- This is the initial step of the development of carditis and explains why
transabdominal fundoplication are common to both the
in early disease esophagitis is mild and commonly limited to the very
laparoscopic and open procedures and include the following:
distal aspect of the esophagus.
▪ Hiatal dissection and preservation of both vagus nerves
o The development of carditis explains the complaint of
along the entire length
epigastric pain often experienced by patients with early reflux
▪ Circumferential mobilization
disease.
▪ Hiatal closure, usually posterior to the esophagus
- Additionally, this process can lead to a fibrotic mucosal ring located
▪ Creation of a short and floppy fundoplication over an
at the squamocolumnar junction, which is termed a “Schatzki ring”
esophageal dilator
and which may result in dysphagia.
- This inflammatory process may extend into muscularis propria and
thus result in a progressive loss in the length and pressure of the
LES.
- This explanation for the pathophysiology of GERD is supported by the
observation that severe esophagitis is almost always associated with
a defective LES.

Treatment
- Medical
o Acid suppression
o Long term PPI therapy
- Surgical
o Antireflux procedures

Figure 6. Laparoscopic Nissen fundoplication

Medical:
o The outcome of the fundoplication is that it relieved typical
- Once the diagnosis is established, treatment may be initiated with
reflux symptoms like heartburn, regurgitation and dysphagia
either PPI therapy or antireflux surgery.
in >90% of patients at follow-up intervals averaging 2-3 years
- First-line therapy entails antisecretory medication, usually PPIs, in
and 80-90% of patients 5 years or more following surgery
most patients.
- Other procedures:
o Posterior partial fundoplication
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o Anterior partial fundoplication
o Collis Gastroplasty
▪ An esophageal lengthening procedure before
fundoplication to reduce the tension on the
gastroesophageal junction
▪ Entails the division of the cardia and upper stomach,
parallel to the lesser curvature of the stomach, thereby
creating a gastric tube in continuity with the esophagus,
and effectively lengthening the esophagus by several
centimeters
Figure 8. Normal esophagus

Figure 9. Barrett's esophagus

Figure 7. Laparoscopic techniques for Collis gastroplasty

Barrett’s Esophagus (BE)

- A condition in which the tubular esophagus is lined with columnar
epithelium (normal: squamous epithelium)
- Histologically, it appears as intestinal metaplasia
- It is suspected at endoscopy when there is difficulty in visualizing the
squamocolumnar junction at its normal location, and by the
appearance of a redder, salmon-colored mucosa in the lower
esophagus, with a clearly visible line of demarcation at the top of the
Barrett’s esophagus segment
- Confirmed by biopsy
- Multiple biopsy specimens should be taken in a cephalad direction to
confirm the presence of intestinal metaplasia
- Susceptible to ulceration, bleeding, stricture formation and most
importantly, malignant degeneration
o The early sign of the latter is high grade dysplasia or
intramucosal adenocarcinoma
- Most, if not all, of the adenocarcinoma of esophagus arise in Barrett’s
epithelium, and one-third of patients with BE present with
malignancy
- Treatment is either long-term PPI therapy or anti-reflux surgery
based on the severity of the disease
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Figure 10. Barrett's esophagus on microscope
Achalasia
- The best known and understood primary motility disorder of the
esophagus
- The pathogenesis is presumed to be a neurogenic degeneration
which is either idiopathic or due to infection
- In patients with the disease, degenerative changes have been shown
in the vagus nerve and in the ganglia in the myenteric plexus of the
esophagus itself. This degeneration results in hypertension of the
lower esophageal sphincter (LES), a failure of the sphincter to relax
on swallowing, elevation of intraluminal esophageal pressure,
esophageal dilatation, and a subsequent loss of progressive
peristalsis in the body of the esophagus
- Manometric characteristics:
o Incomplete LES relaxation (<75% relaxation)
o Aperistalsis in the esophageal body
o Elevated LES pressure ≤ 26 mmHg
o Increased intraesophageal baseline pressures relative to
gastric baseline
- With time, the functional disorder results in anatomic alterations seen
on radiographic studies, such as a dilated esophagus with a tapering
“bird’s beak”-like narrowing of the distal end
- There is usually an air-fluid level in the esophagus from the retained
food and saliva. The height of which reflects the degree of resistance
imposed by the non-relaxing sphincter
 Surgery | Surgical Diseases of the Esophagus
- As the disease progresses, the esophagus becomes massively o Most common complaints
dilated and tortuous - Barium swallow
o Most useful method to demonstrate a leiomyoma of the
esophagus
- Esophagoscopy
o Should be performed to exclude a reported observation of a
coexistence with carcinoma
- Endoscopic ultrasound
o Useful adjunct in the workup of leiomyoma
o Provides detail related to the anatomic extent and relationship
to surrounding structures
- The majority can be removed by simple enucleation, excision or
resection

Figure 11. Barium esophagogram showing a markedly dilated esophagus and

characteristic "bird's beak" in achalasia

Treatment:
- In performing a surgical myotomy of the LES in achalasia there are 4
important principles:
o Complete division of all circular and collar sling muscle fibers
o Adequate distal myotomy to reduce outflow resistance
o Undermining of the muscularis to allow wide separation of the
esophageal muscle
o Prevention of the post-operative reflux
- Heller Myotomy (Myotomy of LES)
o To relieve the functional outflow obstruction secondary to the
loss of relaxation and compliance of the LES
o Treatment of choice for achalasia

Figure 13. Leiomyomas

Malignant Esophageal Tumors

Figure 12. Heller myotomy

- Other treatments:
o Hydrostatic balloon dilatation
▪ Ruptures the sphincter muscle
o Botulinum toxin injection
▪ Longer duration of action that may be measured in
weeks or months rather than years
▪ May best be used as a diagnostic tool when it is not clear
whether a hypertensive LES is the primary cause of Figure 14. AJCC Staging for Esophageal Cancer.
dysphagia
▪ Both achieve similar results - Squamous Cell Carcinoma
o Most common malignant esophageal cancer
- Adenocarcinoma
Benign Esophageal Tumors
o Once an unusual malignancy is diagnosed with increasing
Leiomyomas frequency and now accounts for more than 50% of
- Most common type; >50% of benign esophageal tumors esophageal cancer in most western countries.
- Appears as a smooth, semilunar or crescent-shaped filling defect that o Cause progressive dysphagia and weight loss (anorexia
moves with swallowing, is sharply demarcated, and is covered and leading to malnutrition)
o Common in middle and distal third portion of the esophagus
surrounded by a normal mucosa
o Treatment depends on the stage of the disease
- Average age at presentation: 38 years old
- Risk Factors:
o In sharp contrast to that seen with esophageal carcinoma o Barrett’s esophagus/ metaplastic columnar line
- Males in 3rd-4th decade ▪ most important etiologic factor in the development of
o Twice as common in males primary adenocarcinoma, occurs in 10-25% of patients
- Located in distal 2/3 of the esophagus with GERD)
o 90% located here because they originate in smooth muscles o Heavy alcohol use (25x in high percentage of alcohol, 10X in
- Usually solitary but multiple tumors have been found on occasion beer)
- Dysphagia and pain o Tobacco smoking

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o Betel nut chewing - Pain
o Food preservatives o A striking and consistent symptom that suggest that an
o Chronic gastritis from GERD esophageal rupture has occurred.
o Long standing achalasia - High mortality rate
o HPV o Due to delay in recognition and treatment.
- Tumors that arise within the middle third of the esophagus are
squamous carcinoma most frequently associated with lymph node
metastasis which are usually in the thorax but may be in the neck Diagnosis
or abdomen and may skip areas in between. - Chest X-ray
- Tumors of the lower esophagus and cardia are usually o Mediastinal emphysema – a strong indicator of perforation
adenocarcinomas. takes at least 1 hour to be demonstrated and is present in only
40% of patients.
Main Treatment Modalities: - 3 factors:
1) Surgery (Mainstay) o Time interval between the perforation and the radiographic
- Dependent upon: examination
o location of the cancer o Site of perforation
o depth of invasion o Integrity of the mediastinal pleura
o lymph node metastasis
o fitness of the patient for the operation
o culture and the belief of the individuals
o Institution in which the treatment is performed.
- Currently the use of radiotherapy is restricted to patients who are not
candidates for surgery and is usually combined with
chemotherapy.

2) Chemotherapy
- Used as either adjuvant or neo-adjuvant setting concurrent with
radiation therapy depending on the stage of the patient.

3) Radiation Therapy
- Radiation alone is used for palliation of dysphagia but the benefit is
short lived, lasting only 2-3 months. Radiation is effective against
patients with hemorrhage from the primary tumor

Figure 16. Chest radiogram showing air in the deep muscles of cervical
emphysema of the neck following perforation of the esophagus.

- Cervical Emphysema
- Often the earliest sign of perforation and can be present without
evidence of air in the mediastinum.
- The integrity of mediastinal pleura influences the radiographic
abnormality in that rupture of the pleura results in pneumothorax.
- Seen in 77% of patients
- Perforation is on the left side in 2/3 of patients

Figure 15. Global algorithm for the management of carcinoma of the esophagus.

- A good clinical evaluation must be considered. A pre-op diagnostic is

essential in arriving the stage of the disease.
- A biopsy is required through endoscopy or bronchoscopy.
- Further work-up include chest and abdominal CT scan, endoscopic
ultrasound, MRI and chest X-ray.

Esophageal Perforation
- Emergency
- Most commonly occurs following diagnostic or therapeutic
procedures
- Spontaneous perforation accounts only for 15% of all esophageal Figure 17. Water soluble contrast esophagogram or barium swallow.
perforation, foreign bodies for 14 % and trauma for 10%
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- Water soluble contrast esophagogram or barium swallow - Usually follows an injury occurring during dilation of esophageal
o Confirmatory strictures or pneumatic dilations of achalasia.
o Extravasation in 90% of patients - Conservative management should not be used in patients with
o Right lateral decubitus position perforations into the pleural space
o The contrast material fills the entire length of the esophagus - Cameron criteria:
allowing the actual site of perforation and its interconnecting a) Perforation contained within the mediastinum drain back into
cavities to be visualized in almost all patients. the esophagus
b) Mild symptoms
Management c) Minimal Sepsis
- Treatment:
- Key: early diagnosis and intervention
- Most favorable outcome is obtained following primary closure of - Hyperaliamentation
the perforation within 24 hours (to 80% to 90% survival) - Antibiotics
- Mortality rate associated with immediate closure: 8% - 20% - Cimetidine (decrease acid secretion and diminish pepsin activity)
- Primary closure, resection, drainage
Oral intake resumed in 7-14 days dependent on subsequent
After 24 hours, survival decreases to less than 50% and is not influenced radiographic examinations
by the type of operative therapy meaning, drainage alone or drainage
plus closure of the perforation.
If the time delay for closing the perforation approaches 24 hours, and
the tissues are inflamed, division of the cardia and resection of diseased
portion of the esophagus are recommended.
Patient will have an end cervical esophagostomy with a feeding
jejunostomy tube.

Non-Operative Management:

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APPENDIX

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