Esophageal Surgery
Richard I. Whyte MD, MBA1
Jeffrey A. Norton MD1
Vivek Kulkarni MD2
1SURGEONS
2ANESTHESIOLOGIST
ESOPHAGOSTOMY
SURGICAL CONSIDERATIONSDescription: Esophagostomy is performed to divert oral secretions away from the esophagus to a stoma in certain types of esophageal perforation. To perform an esophagostomy, the esophagus is approached through a left cervical incision. The sternocleidomastoid muscle and carotid sheath are retracted laterally and the thyroid medially, exposing the cervical esophagus (Fig. 7.1-1). The esophagus is mobilized with care being taken not to injure the left recurrent laryngeal nerve, which typically lies in the tracheoesophageal groove. The esophagus is brought to the skin surface as a loop or end stoma and sutured to the skin with absorbable sutures.
Variant procedure or approaches: The procedure is usually performed via a left cervical approach; the right side is an alternative.
Usual preop diagnosis: Esophageal perforation; distal esophageal obstruction
▪ SUMMARY OF PROCEDURE
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▪ PATIENT POPULATION CHARACTERISTICS
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ANESTHETIC CONSIDERATIONSSee Anesthetic Considerations for Esophageal Surgery following Esophagectomy, p. 494.
 Figure 7.1-1. Surgical anatomy for cervical esophagostomy. (Reproduced with permission from Nora PF, ed: Operative Surgery Principles and Techniques. WB Saunders, Philadelphia: 1990.) |
Suggested Readings
1. Carrott PW Jr, Low DE: Advances in the management of esophageal perforation. Thorac Surg Clin 2011; 21(4):541-55.
2. Wu JT, Mattox KL, Wall MJ Jr: Esophageal perforations: new perspectives and treatment paradigms. J Trauma 2007; 63:1173-84.
ESOPHAGEAL DIVERTICULECTOMY
SURGICAL CONSIDERATIONSDescription: Esophageal diverticula are divided into three anatomic types: pharyngoesophageal (Zenker’s), midesophageal, and epiphrenic. Structurally, they are either “true” diverticula—meaning they consist of all three layers of the esophageal wall (mucosa, submucosa, and muscularis)—or “false” diverticula consisting of only mucosa (or mucosa and submucosa). Pharyngoesophageal diverticula account for 60-65% of all cases. These are false diverticula that originate in Killian’s triangle, a weak point in the posterior esophagus, just proximal to the transverse fibers of the cricopharyngeal muscle (Fig. 7.1-2A). They are associated with incomplete, or discoordinate, upper esophageal sphincter relaxation and the resultant increased hypopharyngeal pressure produces a
narrow-mouthed posterior diverticulum. These diverticula frequently present in the seventh decade and are 2-3 times more common in men. Symptoms depend on the stage of the disease. Early on, patients may complain of vague pharyngeal sensations, dysphagia, cough, and excess salivation. Later, more severe symptoms—such as severe (or frequent) dysphagia, regurgitation of food, halitosis, voice changes, aspiration, and odynophagia (painful swallowing)—may occur.
narrow-mouthed posterior diverticulum. These diverticula frequently present in the seventh decade and are 2-3 times more common in men. Symptoms depend on the stage of the disease. Early on, patients may complain of vague pharyngeal sensations, dysphagia, cough, and excess salivation. Later, more severe symptoms—such as severe (or frequent) dysphagia, regurgitation of food, halitosis, voice changes, aspiration, and odynophagia (painful swallowing)—may occur.
 Figure 7.1-2. Formation of Zenker’s diverticulum. A: Herniation of the pharyngeal mucosa and submucosa occurs at the point of potential weakness (Killian’s triangle [arrow]) between the oblique fibers of the thyropharyngeus muscle and the more horizontal fibers of the cricopharyngeus muscle. B: As the diverticulum enlarges, it drapes over the cricopharyngeus sphincter and descends into the superior mediastinum in the prevertebral space. (Reproduced with permission from Greenfield LJ, Mulholland, MW, Oldham KT, et al, eds: Surgery: Scientific Principles and Practice, 3rd edition. Lippincott Williams & Wilkins, Philadelphia: 2001. After Orringer MB: Diverticula and miscellaneous conditions of the esophagus. In: Sabiston DC Jr, ed. Textbook of Surgery, 13th edition. WB Saunders, Philadelphia: 1986.) |
Surgery is the only effective therapy for Zenker’s diverticulum. Respiratory complications (aspiration) or nutritional deficiencies (weight loss) may be directly attributable to the diverticulum and should not be contraindications to surgery. Multiple different operative approaches are advocated: diverticulectomy alone, cricopharyngeal myotomy, diverticulectomy with myotomy, and myotomy with suspension of the diverticulum. Myotomy alone, which corrects the underlying physiologic abnormality, is up to 78% effective and may be considered for patients with small (< 2 cm) diverticula. Diverticulectomy or suspension should be added if the diverticulum itself is large or dependent. Both procedures are performed via a left cervical incision (Fig. 7.1-3: inset) and are associated with a low rate of recurrence and complications. The upper esophagus is exposed by retracting the sternocleidomastoid muscle and carotid sheath laterally and the thyroid gland medially. The diverticulum is located in the prevertebral space. Care is taken not to injure the recurrent laryngeal nerve. Following excision of the diverticulum, a cricopharyngeal myotomy may be performed, starting on the upper esophagus and extending across the cricopharyngeal muscle near the neck of the diverticulum, and on to the inferior pharyngeal constrictor muscle.
Recent emphasis has been placed on endoscopic treatment of Zenker’s diverticulum (Dohlman procedure). In this procedure, a modified laryngoscope and endoscopic stapler are used to divide the common wall between diverticulum and true esophageal lumen. This is advantageous because it does not require an incision, and it does not injure the recurrent laryngeal nerve. It has similar results to open procedures.
 Figure 7.1-3. Zenker’s diverticulum approached through a left cervical incision (inset). A: The diverticulum is grasped, and a cricopharyngeal myotomy is extended onto the upper esophagus. B: The base of the diverticulum is stapled, and the diverticulum is resected. (Reproduced with permission from Shields TW, LoCicero J III, Ponn RB: General Thoracic Surgery, 5th edition. Lippincott Williams & Wilkins, Philadelphia: 2000.) |
Midesophageal diverticula, by definition, occur in the middle 3rd of the esophagus. These “true” diverticula typically arise in the setting of mediastinal granulomatous disease whereby a fibrotic reaction around inflamed mediastinal lymph nodes results in traction on the muscular wall of the esophagus. Diverticula usually arise within 4-5 cm of the carina and comprise an estimated 10-17% of all esophageal diverticula. Most midesophageal diverticula are asymptomatic and do not require surgical intervention. In cases that require intervention because of either regurgitation or development of an esophagobronchial fistula, the approach is through a right thoracotomy with excision of the inflammatory mass. Primary closure of the fistula and the interposition of viable tissue, such as muscle, should be performed.
Epiphrenic diverticula arise in the distal 10 cm of the esophagus and are thought to be related to an underlying esophageal motility disorder. These false diverticula are most commonly present in the 6th decade. The clinical presentation is variable; most patients have symptoms related to their underlying dysmotility syndrome: dysphagia, chest pain, or regurgitation. Most patients with epiphrenic diverticula are asymptomatic, and there appears to be no relation between size of the diverticulum and symptoms. Surgery for epiphrenic diverticula typically consists of diverticulectomy with myotomy either through a left thoracotomy (Fig. 7.1-4) or via laparoscopy. With the transthoracic approach, a low, left thoracotomy is used, the esophagus is mobilized and encircled, and the diverticulum is mobilized and excised. A myotomy should be performed opposite the diverticulectomy and should extend proximally above the diverticulum and distally onto the stomach. Because there is, by definition, an underlying motility disorder, the myotomy should be carried onto the stomach, and a nonobstructing fundoplication may be added to prevent significant postoperative reflux.
Variant procedure or approaches: Laparoscopic diverticulectomy and myotomy has gained increasing acceptance, and reported outcomes are similar to those obtained with the open procedure. The surgical approach is similar to that used during laparoscopic fundoplication (see p. 585). Dissection of the diverticula may be facilitated by the passage of a bougie or video endoscope. After the diverticulum is amputated using an endoscopic stapler, a myotomy is performed opposite the diverticula, and a partial fundoplication is fashioned.
Usual preop diagnosis: Esophageal diverticulum
 Figure 7.1-4. Epiphrenic diverticulum. Through a left thoracotomy, the diverticulum is mobilized and resected. A contralateral myotomy is then created and extended distally to the stomach to eliminate any functional obstruction secondary to the preexistent dysmotility. (Reproduced with permission from Shields TW, LoCicero J III, Ponn RB: General Thoracic Surgery, 5th edition. Lippincott Williams & Wilkins, Philadelphia: 2000.) |
▪ SUMMARY OF PROCEDURES
|
▪ PATIENT POPULATION CHARACTERISTICS
|
ANESTHETIC CONSIDERATIONSSee Anesthetic Considerations for Esophageal Surgery following Esophagectomy, p. 494.
Suggested Readings
1. Bock JM, Van Daele DJ, Gupta N, et al: Management of Zenker’s diverticulum in the endoscopic age: current practice patterns. Ann Otol Rhinol Laryngol 2001; 120:796.
2. Dzeletovic I, Ekborn DC, Baron TH: Flexible endoscopic and surgical management of Zenkar’s diverticulum. Expert Rev Gastroenterol Hepatol 2012; 6(4):449-65.
3. Ferreira LE, Simmons DT, Bain TH: Zenker’s diverticula: pathophysiology, clinical presentation, and flexible endoscopic management. Dis Esophagus 2008; 21:1-8.
MANAGEMENT OF ESOPHAGEAL PERFORATION
SURGICAL CONSIDERATIONSDescription: Esophageal perforation may be spontaneous, instrumental (iatrogenic), traumatic, or 2° intrinsic esophageal disease. Spontaneous (or emetogenic) perforation most commonly occurs in the lower 3rd of the esophagus. Instrumental perforations may occur at any level, but are most common just above the cardia and in the cervical esophagus. The level of traumatic perforation depends on the location of the penetrating wound. Symptoms of esophageal perforation at the cricopharyngeal sphincter include neck pain, fever, and crepitations in the substernal and neck areas. Perforation in the mediastinum may result in hydropneumothorax, mediastinitis, fever, and substernal pain. Cervical perforations are managed with antibiotics and drainage in the cervical area. Therapy for intrathoracic perforation generally requires emergent operation. Surgical options include primary repair, drainage and diversion, placement of temporary covered stents, and esophageal resection. The optimal choice depends on the nature and duration of the perforation as well as the clinical condition of the patient. Spontaneous perforations are often amenable to primary repair—either through the abdomen or the left chest. Patients suffering from iatrogenic perforation incurred during dilation of a malignant, or nondilatable, stricture may require urgent esophagectomy.
Patients with delayed recognition of a perforation may be hemodynamically unstable and may only tolerate drainage and diversion (generally through a cervical esophagostomy).
Patients with delayed recognition of a perforation may be hemodynamically unstable and may only tolerate drainage and diversion (generally through a cervical esophagostomy).
Variant procedure or approaches: Cervical or right thoracic drainage is indicated when the perforation occurs in the neck or high in the mediastinum.
Usual preop diagnosis: Esophageal perforation
▪ SUMMARY OF PROCEDURES
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▪ PATIENT POPULATION CHARACTERISTICS
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