DISEASES OF THE ESOPHAGUS

Chapter 71 / Thoracic Surgery 641

What nerve runs with the

Vagus nerve

esophagus?

ZENKER’S DIVERTICULUM

What is it?

Pharyngoesophageal diverticulum; a

false diverticulum containing mucosa

and submucosa at the UES at the

pharyngoesophageal junction through

Killian’s triangle

Chapter 71 / Thoracic Surgery 643

What is the differential

Angina pectoris

diagnosis?

Psychoneurosis

Nutcracker esophagus

What are the associated

Esophageal manometry: Motility

diagnostic tests?

studies reveal repetitive, high-

amplitude contractions with normal

sphincter response

Upper GI may be normal, but 50% show

segmented spasms or corkscrew

esophagus

Endoscopy

What is the classic finding

“Corkscrew esophagus”

on esophageal contrast study

(UGI)?

What is the treatment?

Medical (antireflux measures, calcium

channel blockers, nitrates)

Long esophagomyotomy in refractory cases

NUTCRACKER ESOPHAGUS

What is it also known as?

Hypertensive peristalsis

What is it?

Very strong peristaltic waves

What are the symptoms?

Spontaneous chest pain that radiates to

the back, ears, neck, jaw, or arms

What is the differential

Angina pectoris

diagnosis?

Psychoneurosis

Diffuse esophageal spasm

What are the associated

1. Esophageal manometry: motility studies

diagnostic tests?

reveal repetitive, high-amplitude

contractions with normal sphincter

response

2. Results of UGI may be normal (rule

out mass)

3. Endoscopy

What is the treatment?

Medical (antireflux measures, calcium

channel blockers, nitrates)

Long esophagomyotomy in refractory cases

What is it?

Reflux of gastric contents into the lower

esophagus resulting from the decreased

function of the LES

What are the causes?

1. Decreased LES tone

2.

Decreased esophageal motility

3.

Hiatal hernia

4.

Gastric outlet obstruction

5.

NGT

Name four associated

1.

Sliding hiatal hernia

conditions/factors.

2. Tobacco and alcohol

3.

Scleroderma

4.

Decreased endogenous gastrin

production

What are the symptoms?

Substernal pain, heartburn, regurgitation;

symptoms are worse when patient is

supine and after meals

How is the diagnosis made?

1. pH probe in the lower esophagus

reveals acid reflux

2.

EGD shows esophagitis

3.

Manometry reveals decreased LES

pressure

4.

Barium swallow

What is the initial treatment?

Medical: H2-blockers, antacids,

metoclopramide, omeprazole

Elevation of the head of the bed; small,

multiple meals

Which four complications

1. Failure of medical therapy

require surgery?

2.

Esophageal strictures

3.

Progressive pulmonary insufficiency

secondary to documented nocturnal

aspiration

4.

Barrett’s esophagus

Describe each of the

following types of surgery:

Nissen

360 fundoplication: wrap fundus of

stomach all the way around the esophagus

Chapter 71 / Thoracic Surgery 645

Belsey Mark IV

270 fundoplication: wrap fundus of

stomach, but not all the way around

Hill

Tighten arcuate ligament around

esophagus and tack stomach to diaphragm

Lap Nissen

Nissen via laparoscope

Lap Toupet

Lap fundoplication posteriorly with less

than 220 to 250 wrap used with decreased

esophageal motility; disadvantage is more

postoperative reflux

What is Barrett’s esophagus?

Replacement of the lower esophageal

squamous epithelium with columnar

epithelium secondary to reflux

Why is it significant?

This lesion is premalignant

What is the treatment?

People with significant reflux should be

followed with regular EGDs with

biopsies, H2-blockers, and antireflux

precautions; many experts believe that

patients with severe dysplasia should

undergo esophagectomy

CAUSTIC ESOPHAGEAL STRICTURES

Which agents may cause

Lye, oven cleaners, drain cleaners, batteries,

strictures if ingested?

sodium hydroxide tablets (Clinitest)

How is the diagnosis made?

History; EGD is clearly indicated early

on to assess the extent of damage

( 24 hrs); scope to level of severe injury

(deep ulcer) only, water soluble contrast

study for deep ulcers to rule out perforation

What is the initial

1. NPO/IVF/H2-blocker

treatment?

2. Do not induce emesis

3. Corticosteroids (controversial—

probably best for shallow/moderate

ulcers), antibiotics (penicillin/

gentamicin) for moderate ulcers

4. Antibiotic for deep ulcers

5. Upper GI at 10 to 14 days

646 Section III / Subspecialty Surgery

What is the treatment if a

Dilation with Maloney dilator/balloon

stricture develops?

catheter

In severe refractory cases, esophagectomy

with colon interposition or gastric

pull-up

What is the long-term

Because of increased risk of esophageal

follow-up?

squamous cancer (especially with

ulceration), patients endoscopies every

other year

What is a Maloney dilator?

Mercury-filled rubber dilator

ESOPHAGEAL CARCINOMA

What are the two main

1.

Adenocarcinoma at the GE junction

types?

2.

Squamous cell carcinoma in most of

the esophagus

What is the most common

Worldwide: squamous cell carcinoma

histology?

(95%!)

USA: adenocarcinoma

What is the age and gender

Most common in the sixth decade of life;

distribution?

men predominate, especially black men

What are the etiologic

1.

Tobacco

factors (5)?

2.

Alcohol

3.

GE reflux

4.

Barrett’s esophagus

5.

Radiation

What are the symptoms?

Dysphagia, weight loss

Other symptoms include chest pain,

back pain, hoarseness, symptoms of

metastasis

What comprises the

1.

UGI

workup?

2.

EGD

3.

Transesophageal ultrasound (TEU)

4.

CT scan of chest/abdomen

What is the differential

Leiomyoma, metastatic tumor, lymphomas,

diagnosis?

benign stricture, achalasia, diffuse

esophageal spasm, GERD