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Surgery_Schwartz. to the prevertebral fascia of the tho-racic vertebra, a myotomy is begun at the neck of the diverticu-lum and extended across the LES. If the diverticulum is excised by dividing the neck, the muscle is closed over the excision site, and a myotomy is performed on the opposite esophageal wall, starting just above the level of the diverticulum or at the proximal extent of the spastic segment of the esophagus if high resolution motility is used. If complete, the myotomy will cross the LES, reducing distal esophageal peak pressure, and it will increase the likelihood that dysphagia will be replaced with GERD symp-toms. Increasingly, partial fundoplication (anterior or posterior) is performed after LES myotomy to decrease the frequency of disabling GERD developing after myotomy and diverticulec-tomy. When a large diverticulum is associated with a hiatal her-nia, then hiatal hernia repair is added. All these procedures may be performed with traditional or minimally invasive


Surgery_Schwartz

Surgery_Schwartz. and diverticulec-tomy. When a large diverticulum is associated with a hiatal her-nia, then hiatal hernia repair is added. All these procedures may be performed with traditional or minimally invasive techniques.Midesophageal or traction diverticula were first described in the 19th century (Fig. 25-57). At that time, they were fre-quently noted in patients who had mediastinal LN involve-ment with tuberculosis. It was theorized that adhesions formed between the inflamed mediastinal nodes and the esophagus. By contraction, the adhesions exerted traction on the esophageal wall and led to a localized diverticulum (Fig. 25-58). This theory was based on the findings of early dissections, where adhesions between diverticula and LNs were commonly found. Other con-ditions associated with mediastinal lymphadenopathy, such as pulmonary fungal infections (e.g., aspergillosis), lymphoma, or sarcoid, may create traction esophageal diverticula after success-ful treatment. Rarely, when no underlying


Surgery_Schwartz

Surgery_Schwartz. lymphadenopathy, such as pulmonary fungal infections (e.g., aspergillosis), lymphoma, or sarcoid, may create traction esophageal diverticula after success-ful treatment. Rarely, when no underlying inflammatory pathol-ogy is identified, a motility disorder may be identified.Most midesophageal diverticula are asymptomatic and incidentally discovered during investigation for nonesophageal complaints. In such patients, the radiologic abnormality may Brunicardi_Ch25_p1009-p1098.indd 105901/03/19 6:04 PM 1060SPECIFIC CONSIDERATIONSPART II100%80%60%40%20%Normal volunteersPat, no dysphagiaPat, dysphagia0%Figure 25-59. Prevalence of effective contractions (i.e., peristaltic contractions with an amplitude >30 mmHg) during meal periods in individual normal volunteers, patients (Pat) without dysphagia, and patients with nonobstructive dysphagia.100%% Symptomatic10 cm5 cm0 cm80%60%40%20%0%Pre Rx17NEso. diameter% Retention0–24mo1725–48mo1649–72mo1473–120mo12Figure 25-60. Esophageal (Eso.)


Surgery_Schwartz

Surgery_Schwartz. dysphagia, and patients with nonobstructive dysphagia.100%% Symptomatic10 cm5 cm0 cm80%60%40%20%0%Pre Rx17NEso. diameter% Retention0–24mo1725–48mo1649–72mo1473–120mo12Figure 25-60. Esophageal (Eso.) diameter, dysphagia, and esoph-ageal retention in patients with achalasia treated with myotomy and Nissen fundoplication, 10 years after treatment (Rx). (Data from Topart P, Deschamps C, Taillefer R, et al: Long-term effect of total fundoplication on the myotomized esophagus, Ann Thorac Surg. 1992 Dec;54(6):1046-1051.)be ignored. Patients with symptoms of dysphagia, regurgita-tion, chest pain, or aspiration, in whom a diverticulum is dis-covered, should be thoroughly investigated for an esophageal motor abnormality. Occasionally, a patient will present with a bronchoesophageal fistula manifested by a chronic cough on ingestion of meals. The diverticulum in such patients is most likely to have an inflammatory etiology.The indication for surgical intervention is dictated by the degree of


Surgery_Schwartz

Surgery_Schwartz. by a chronic cough on ingestion of meals. The diverticulum in such patients is most likely to have an inflammatory etiology.The indication for surgical intervention is dictated by the degree of symptomatic disability. Usually, midesophageal diverticula can be suspended due to their proximity to the spine. If a motor abnormality is documented, a myotomy should be performed as described for an epiphrenic diverticulum.OPERATIONS FOR ESOPHAGEAL MOTOR DISORDERS AND DIVERTICULALong Esophageal Myotomy for Motor Disorders of the Esophageal BodyA long esophageal myotomy is indicated for dysphagia caused by any motor disorder characterized by segmental or general-ized simultaneous waveforms in a patient whose symptoms are not relieved by medical therapy. Such disorders include diffuse and segmental esophageal spasm, vigorous or type 3 achalasia, and nonspecific motility disorders associated with a midor epiphrenic esophageal diverticulum. However, the decision to operate must be made by a


Surgery_Schwartz

Surgery_Schwartz. esophageal spasm, vigorous or type 3 achalasia, and nonspecific motility disorders associated with a midor epiphrenic esophageal diverticulum. However, the decision to operate must be made by a balanced evaluation of the patient’s symptoms, diet, lifestyle adjustments, and nutritional status, with the most important factor being the possibility of improv-ing the patient’s swallowing disability. The symptom of chest pain alone is not an indication for a surgical procedure.The identification of patients with symptoms of dyspha-gia and chest pain who might benefit from a surgical myotomy is difficult. Ambulatory motility studies have shown that when the prevalence of “effective contractions” (i.e., peristaltic waveforms consisting of contractions with an amplitude above 30 mmHg) drops below 50% during meals, the patient is likely to experience dysphagia (Fig. 25-59). This would suggest that relief from the symptom can be expected with an improvement of esophageal contraction amplitude


Surgery_Schwartz

Surgery_Schwartz. 50% during meals, the patient is likely to experience dysphagia (Fig. 25-59). This would suggest that relief from the symptom can be expected with an improvement of esophageal contraction amplitude or amelioration of non-peristaltic waveforms. Prokinetic agents may increase esopha-geal contraction amplitude, but they do not alter the prevalence of simultaneous waveforms. Patients in whom the efficacy of esophageal propulsion is severely compromised because of a high prevalence of simultaneous waveforms usually receive little benefit from medical therapy. In these patients, a surgi-cal myotomy of the esophageal body can improve the patients’ dysphagia, provided the loss of contraction amplitude in the remaining peristaltic waveforms, caused by the myotomy, has less effect on swallowing function than the presence of the excessive simultaneous contractions. This situation is reached when the prevalence of effective waveforms during meals drops below 30% (i.e., 70% of esophageal waveforms


Surgery_Schwartz

Surgery_Schwartz. than the presence of the excessive simultaneous contractions. This situation is reached when the prevalence of effective waveforms during meals drops below 30% (i.e., 70% of esophageal waveforms are ineffective).In patients selected for surgery, preoperative high-resolution manometry is essential to determine the proximal extent of the esophageal myotomy. Most surgeons extend the myotomy distally across the LES to reduce outflow resistance. Consequently, some form of antireflux protection is needed to avoid gastroesophageal reflux if there has been extensive dissection of the cardia. In this situation, most authors prefer a partial, rather than a full, fundoplication, in order not to add back-resistance that will further interfere with the ability of the myotomized esophagus to empty (Fig. 25-60). If the symptoms of reflux are present preoperatively, 24-hour pH monitoring is required to confirm its presence.The procedure may be performed either open or via thoracoscopy. The open


Surgery_Schwartz

Surgery_Schwartz. (Fig. 25-60). If the symptoms of reflux are present preoperatively, 24-hour pH monitoring is required to confirm its presence.The procedure may be performed either open or via thoracoscopy. The open technique is performed through a left thoracotomy in the sixth intercostal space (Fig. 25-61). An incision is made in the posterior mediastinal pleura over the esophagus, and the left lateral wall of the esophagus is exposed. The esophagus is not circumferentially dissected unless necessary. A 2-cm incision is made into the abdomen through the parietal peritoneum at the midportion of the left crus. A tongue of gastric fundus is pulled into the chest. This exposes the GEJ and its associated fat pad. The latter is excised to give a clear view of the junction. A myotomy is performed through all muscle layers, extending distally over the stomach 1 to 2 cm below the GEJ, and proximally on the esophagus over the distance of the manometric abnormality. The muscle layer is dissected from the


Surgery_Schwartz

Surgery_Schwartz. all muscle layers, extending distally over the stomach 1 to 2 cm below the GEJ, and proximally on the esophagus over the distance of the manometric abnormality. The muscle layer is dissected from the mucosa laterally for a distance of 1 cm. Care is taken to divide all minute muscle bands, particularly in the area of the GEJ. The gastric fundic tongue is sutured to the margins of the myotomy over a distance of 3 to 4 cm and replaced into the abdomen. This maintains separation of the muscle and acts as a partial fundoplication to prevent reflux.Brunicardi_Ch25_p1009-p1098.indd 106001/03/19 6:04 PM 1061ESOPHAGUS AND DIAPHRAGMATIC HERNIACHAPTER 25Figure 25-61. Technique of long myotomy: A. Exposure of the lower esophagus through the left sixth intercostal space and incision of the mediastinal pleura in preparation for surgical myotomy. B. Location of a 2-cm incision made through the phrenoesophageal mem-brane into the abdomen along the midlateral border of the left crus. C. Retraction


Surgery_Schwartz

Surgery_Schwartz. pleura in preparation for surgical myotomy. B. Location of a 2-cm incision made through the phrenoesophageal mem-brane into the abdomen along the midlateral border of the left crus. C. Retraction of tongue of gastric fundus into the chest through the previously made incision. D. Removal of the gastroesophageal fat pad to expose the gastroesophageal junction. E. A myotomy down to the mucosa is started on the esophageal body. F. Completed myotomy extending over the stomach for 1 cm. G. Reconstruction of the cardia after a myotomy, illustrating the position of the sutures used to stitch the gastric fundic flap to the margins of the myotomy. H. Reconstruction of the cardia after a myotomy, illustrating the intra-abdominal position of the gastric tongue covering the distal 4 cm of the myotomy.Brunicardi_Ch25_p1009-p1098.indd 106101/03/19 6:04 PM 1062SPECIFIC CONSIDERATIONSPART IIIf an epiphrenic diverticulum is present, it is excised by dividing the neck with a stapler sized for the


Surgery_Schwartz

Surgery_Schwartz. 106101/03/19 6:04 PM 1062SPECIFIC CONSIDERATIONSPART IIIf an epiphrenic diverticulum is present, it is excised by dividing the neck with a stapler sized for the thickness of the diverticulum (2.0to 4.8-mm staple leg length) followed by a closure of the muscle over the staple line, when possible. The myotomy is then performed on the opposite esophageal wall. If a midesophageal diverticulum is present, the myotomy is made so that it includes the muscle around the neck, and the diver-ticulum is suspended by attaching it to the paravertebral fascia of the thoracic vertebra above the level of the diverticular neck. Before performing any operation for an esophageal diverticu-lum, it is wise to endoscope the patient to wash all food and other debris from the diverticulum.The results of myotomy for motor disorders of the esopha-geal body have improved in parallel with the improved preop-erative diagnosis afforded by manometry. Previous published series report between 40% and 92%


Surgery_Schwartz

Surgery_Schwartz. of myotomy for motor disorders of the esopha-geal body have improved in parallel with the improved preop-erative diagnosis afforded by manometry. Previous published series report between 40% and 92% improvement of symptoms, but interpretation is difficult due to the small number of patients involved and the varying criteria for diagnosis of the primary motor abnormality. When myotomy is accurately done, 93% of the patients have effective palliation of dysphagia after a mean follow-up of 5 years, and 89% would have the procedure again, if it was necessary. Most patients gain or maintain rather than lose weight after the operation. Postoperative motility studies show that the myotomy reduces the amplitude of esophageal contractions to near zero and eliminates simultaneous peristaltic waves. If the benefit of obliterating the simultaneous waves exceeds the adverse effect on bolus propulsion caused by the loss of peristaltic waveforms, the patient’s dysphagia is likely to be improved by


Surgery_Schwartz

Surgery_Schwartz. If the benefit of obliterating the simultaneous waves exceeds the adverse effect on bolus propulsion caused by the loss of peristaltic waveforms, the patient’s dysphagia is likely to be improved by the procedure. If not, the patient is likely to continue to complain of dysphagia and to have little improvement as a result of the operation.The thoracoscopic technique may be performed through the left or right chest. There has been little experience gained with doing adequate operations (as described previously with the open exposure) through left thoracoscopy, so most surgeons will combine a right thoracoscopic long myotomy with an abdominal approach for Heller myotomy and partial fundopli-cation. These two procedures may be done at the same setting, by double positioning the patient, or they may be done at two operations. If this is the case, it is best to do the abdominal com-ponent first, as the esophageal outflow obstruction is the source of most of the symptoms. Performing


Surgery_Schwartz

Surgery_Schwartz. or they may be done at two operations. If this is the case, it is best to do the abdominal com-ponent first, as the esophageal outflow obstruction is the source of most of the symptoms. Performing abdominal myotomy (and diverticulectomy, if present) may be all that is required.Figure 25-61. (Continued )A new procedure, peroral endoscopic myotomy (POEM) allows a long myotomy to be performed from the lumen of the esophagus with an endoscope. This procedure is attractive for, at a minimum, those with type 3 achalasia (vigorous achalasia), where it is necessary to divide esopha-gogastric circular muscle on both sides of the diaphragm to the extent that might not be possible with laparoscopy or thoracoscopy alone. The POEM procedure is started by open-ing the esophageal mucosa several centimeters above the spastic segment with a needle–knife electrosurgery device passed through an endoscope. A long submucosal plane is developed with the endoscope, down to and below the LES. The circular


Surgery_Schwartz

Surgery_Schwartz. above the spastic segment with a needle–knife electrosurgery device passed through an endoscope. A long submucosal plane is developed with the endoscope, down to and below the LES. The circular muscle of the LES and the esophagus is divided with endoscopic electrosurgery all the way back until normal (nonspastic) esophagus is reached. The submucosal entry site in the esophagus is then closed with endoscopic clips. While the results of POEM are still accumulating, the procedure is attractive because it is extremely minimally invasive and can be done on an outpatient basis.Epiphrenic diverticula cannot be treated with POEM and are most frequently addressed with laparoscopic access, in combination with a laparoscopic division of the LES (Heller myotomy) (Fig. 25-62). If the diverticulum can be completely mobilized through the hiatus, it may be safely excised from below. The neck of the diverticulum is transected with a GIA stapler after passage of a 48F dilator. Not infrequently, the


Surgery_Schwartz

Surgery_Schwartz. be completely mobilized through the hiatus, it may be safely excised from below. The neck of the diverticulum is transected with a GIA stapler after passage of a 48F dilator. Not infrequently, the diverticulum is sufficiently large that access to the neck of the diverticulum across the hiatus is quite difficult. Addi-tionally, the inflammatory reaction to the diverticulum may further make the transhiatal dissection difficult. Under these circumstances, it is safer to perform the diverticulectomy through a right thoracoscopic approach either at the time of the initial procedure or at a later date, depending upon the frailty of the patient. Following diverticulectomy, it is critical that the esophageal staple line be treated with a great deal of care. Closure of the muscle over the staple line is preferable. Additionally, the patient is kept NPO or on clear liquids for 5 to 7 days, and a contrast study is obtained before advancing to a full liquid or “mushy food” diet. Solid foods are


Surgery_Schwartz

Surgery_Schwartz. is preferable. Additionally, the patient is kept NPO or on clear liquids for 5 to 7 days, and a contrast study is obtained before advancing to a full liquid or “mushy food” diet. Solid foods are withheld for 2 weeks to decrease the likelihood of staple line leak. But-tressing or sealing the staple line with fibrin glue is also an attractive option.Brunicardi_Ch25_p1009-p1098.indd 106201/03/19 6:04 PM 1063ESOPHAGUS AND DIAPHRAGMATIC HERNIACHAPTER 25Figure 25-62. A. Epiphrenic diverticula are situated above the lower esophageal sphincter on right side of esophagus. B. Stapler amputates neck of diverticulum. C. Muscle reapproximated over staple line, and Heller myotomy is performed.Myotomy of the Lower Esophageal Sphincter (Heller Myotomy)Second only to reflux disease, achalasia is the most common functional disorder of the esophagus to require surgical intervention. The goal of treatment is to relieve the functional outflow obstruction secondary to the loss of relaxation and


Surgery_Schwartz

Surgery_Schwartz. the most common functional disorder of the esophagus to require surgical intervention. The goal of treatment is to relieve the functional outflow obstruction secondary to the loss of relaxation and compliance of the LES. This requires disrupting the LES muscle. When performed adequately (i.e., reducing sphincter pressure to <10 mmHg), and done early in the course of disease, LES myotomy results in symptomatic improvement with the occasional return of esophageal peristalsis. Reduction in LES resistance can be accomplished intraluminally by hydrostatic balloon dilation, which ruptures the sphincter muscle, by botulinum toxin injection, or by a surgical myotomy that cuts the sphincter. The difference between these three methods appears to be the greater likelihood of reducing sphincter pressure to <10 mmHg by surgical myotomy compared with hydrostatic balloon dilation. However, patients whose sphincter pressure has been reduced by hydrostatic balloon dilation to <10 mmHg have an outcome


Surgery_Schwartz

Surgery_Schwartz. to <10 mmHg by surgical myotomy compared with hydrostatic balloon dilation. However, patients whose sphincter pressure has been reduced by hydrostatic balloon dilation to <10 mmHg have an outcome similar to those after surgical myotomy (Fig. 25-63). Botulinum toxin injection may achieve similar results, but it has a longer duration of action that may be measured in weeks or months, rather than years. Botulinum toxin injection may best be used as a diagnostic tool, when it is not clear whether a hypertensive LES is the primary cause of dysphagia. Responsiveness to botulinum toxin injection may predict a good response to Heller myotomy.The therapeutic decisions regarding the treatment of patients with achalasia center on four issues. The first issue is the question of whether newly diagnosed patients should be treated with pneumatic dilation or a surgical myotomy. Long-term follow-up studies have shown that pneumatic dilation Brunicardi_Ch25_p1009-p1098.indd 106301/03/19 6:05 PM


Surgery_Schwartz

Surgery_Schwartz. patients should be treated with pneumatic dilation or a surgical myotomy. Long-term follow-up studies have shown that pneumatic dilation Brunicardi_Ch25_p1009-p1098.indd 106301/03/19 6:05 PM 1064SPECIFIC CONSIDERATIONSPART II10.80.60.40.200122426LES < 10 mmHg0.530.23LES > 10 mmHg48Months% in remission60728496Figure 25-63. Prevalence of clinical remission in 122 patients stratified according to postdilatation lower esophageal sphincter (LES) pressures greater than or <10 mmHg. (Reproduced with per-mission from Ponce J, Garrigues V, Pertejo V, et al: Individual pre-diction of response to pneumatic dilation in patients with achalasia, Dig Dis Sci. 1996 Nov;41(11):2135-2141.)achieves adequate relief of dysphagia and pharyngeal regurgi-tation in 50% to 60% of patients (Fig. 25-64). Close follow-up is required, and if dilation fails, myotomy is indicated. For those patients who have a dilated and tortuous esophagus or an associ-ated hiatal hernia, balloon dilation is dangerous and


Surgery_Schwartz

Surgery_Schwartz. follow-up is required, and if dilation fails, myotomy is indicated. For those patients who have a dilated and tortuous esophagus or an associ-ated hiatal hernia, balloon dilation is dangerous and surgery is the better option. The outcome of the one controlled random-ized study (38 patients) comparing the two modes of therapy suggests that surgical myotomy as a primary treatment gives better long-term results. Several randomized trials comparing laparoscopic cardiomyotomy with balloon dilation or botuli-num toxin injection have favored the surgical approach as well. 100908070605040%302010001234567Years89101112131415Pneumatic dilatation n = 122Pneumatic dilatation n = 54Myotomy + antireflux n = 22Myotomy n = 65Myotomy n = 81Figure 25-64. Summary of long-term studies reporting the proportion of patients with complete relief or minimal dysphagia (Stage 0–1) stratified according to type of treatment. (Data from: Ellis FH, Jr. Oesophagomyotomy for achalasia: a 22-year experience. Br J Surg.


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Surgery_Schwartz. of patients with complete relief or minimal dysphagia (Stage 0–1) stratified according to type of treatment. (Data from: Ellis FH, Jr. Oesophagomyotomy for achalasia: a 22-year experience. Br J Surg. 1993;80:882; Goulbourne IA, Walbaum PR. Long-term results of Heller’s operation for achalasia. J Royal Coll Surg. 1985;30:101; Malthaner RA, Todd TR, Miller L, et al. Long-term results in surgically managed esophageal achalasia. Ann Thorac Surg. 1994;58:1343; Ponce J, Garrigues V, Pertejo V, et al. Individual prediction of response to pneumatic dilation in patients with achalasia. Dig Dis Sci. 1996;41:2135; Eckardt V, Aignherr C, Bernhard G. Predictors of outcome in patients with achalasia treated by pneumatic dilation. Gastroenterology. 1992;103:1732.)Although it has been reported that a myotomy after previous balloon dilation is more difficult, this has not been the experi-ence of these authors unless the cardia has been ruptured in a sawtooth manner. In this situation, operative


Surgery_Schwartz

Surgery_Schwartz. a myotomy after previous balloon dilation is more difficult, this has not been the experi-ence of these authors unless the cardia has been ruptured in a sawtooth manner. In this situation, operative intervention, either immediately or after healing has occurred, can be difficult. Sim-ilarly, myotomy after botulinum toxin injection has reported to be more difficult, but this is largely a function of the submucosal inflammatory response, which may be a bit unpredictable, and is most intense in the first 6 to 12 weeks after injection. It is impor-tant to wait at least 3 months after botulinum toxin injection to perform cardiomyotomy to minimize the risk of encountering dense inflammation.The second issue is the question of whether a surgical myotomy should be performed through the abdomen or the chest. Myotomy of the LES can be accomplished via either an abdominal or thoracic approach. In the absence of a previous upper abdominal surgery, most surgeons prefer the abdominal approach to


Surgery_Schwartz

Surgery_Schwartz. or the chest. Myotomy of the LES can be accomplished via either an abdominal or thoracic approach. In the absence of a previous upper abdominal surgery, most surgeons prefer the abdominal approach to LES myotomy as laparoscopy results in less pain and a shorter length of stay than thoracoscopy. In addition, it is a bit easier to ensure a long gastric myotomy when the approach is transabdominal.The third issue—and one that has been long debated—is the question of whether an antireflux procedure should be added to a surgical myotomy. Excellent results have been reported fol-lowing meticulously performed myotomy without an antireflux component. Retrospective studies, with long-term follow-up of large cohorts of patients undergoing Heller myotomy demon-strated that, after 10 years, more than 50% of patients had reflux symptoms without a fundoplication. In a recent randomized clin-ical trial, 7% of patients undergoing Dor fundoplication follow-ing LES myotomy had abnormal 24-hour pH


Surgery_Schwartz

Surgery_Schwartz. than 50% of patients had reflux symptoms without a fundoplication. In a recent randomized clin-ical trial, 7% of patients undergoing Dor fundoplication follow-ing LES myotomy had abnormal 24-hour pH probes, and 42% of patients with a myotomy only had abnormal reflux profiles. If an antireflux procedure is used as an adjunct to esophageal myotomy, a complete 360° fundoplication should be avoided. Rather, a 270° Belsey fundoplication, a Toupet posterior 180° fundoplication, or a Dor anterior 180° fundoplication should be used to avoid the long-term esophageal dysfunction secondary to the outflow obstruction afforded by the fundoplication itself.The fourth issue centers on whether or not a cure of this disease is achievable. Long-term follow-up studies after surgical myotomy have shown that late deterioration in results occurs after this procedure, regardless of whether an antireflux pro-cedure is done, and also after balloon dilation, even when the sphincter pressure is reduced to below


Surgery_Schwartz

Surgery_Schwartz. deterioration in results occurs after this procedure, regardless of whether an antireflux pro-cedure is done, and also after balloon dilation, even when the sphincter pressure is reduced to below 10 mmHg. It may be that, even though a myotomy or balloon rupture of the LES muscle reduces the outflow obstruction at the cardia, the underlying motor disorder in the body of the esophagus persists and dete-riorates further with the passage of time, leading to increased impairment of esophageal emptying. The earlier an effective reduction in outflow resistance can be accomplished, the better the outcome will be, and the more likely some esophageal body function can be restored.In performing a surgical myotomy of the LES, there are four important principles: (a) complete division of all circular and collar-sling muscle fibers, (b) adequate distal myotomy to reduce outflow resistance, (c) “undermining” of the muscularis to allow wide separation of the esophageal muscle, and (d) pre-vention of


Surgery_Schwartz

Surgery_Schwartz. and collar-sling muscle fibers, (b) adequate distal myotomy to reduce outflow resistance, (c) “undermining” of the muscularis to allow wide separation of the esophageal muscle, and (d) pre-vention of postoperative reflux. In the past, the drawback of a surgical myotomy was the need for an open procedure, which often deterred patients from choosing the best treatment option for achalasia. With the advent of minimally invasive surgi-cal techniques two decades ago, laparoscopic cardiomyotomy Brunicardi_Ch25_p1009-p1098.indd 106401/03/19 6:05 PM 1065ESOPHAGUS AND DIAPHRAGMATIC HERNIACHAPTER 25(Heller myotomy) has become the treatment of choice for most patients with achalasia.Open Esophageal MyotomyOpen techniques of distal esophageal myotomy are rarely used outside reoperations. In fact, primary procedures can almost always be successfully completed via laparoscopy. A modified Heller myotomy can be performed through a left thoracotomy incision in the sixth intercostal space along the


Surgery_Schwartz

Surgery_Schwartz. primary procedures can almost always be successfully completed via laparoscopy. A modified Heller myotomy can be performed through a left thoracotomy incision in the sixth intercostal space along the upper border of the seventh rib. The esophagus and a tongue of gastric fun-dus are exposed as described for a long myotomy. A myotomy through all muscle layers is performed, extending distally over the stomach to 1 to 2 cm below the junction, and proximally on the esophagus for 4 to 5 cm. The cardia is reconstructed by suturing the tongue of gastric fundus to the margins of the myotomy to prevent rehealing of the myotomy site and to pro-vide reflux protection in the area of the divided sphincter. If an extensive dissection of the cardia has been done, a more for-mal Belsey repair is performed. The tongue of gastric fundus is allowed to retract into the abdomen. Traditionally, nasogastric drainage is maintained for 6 days to prevent distention of the stomach during healing. An oral diet is


Surgery_Schwartz

Surgery_Schwartz. The tongue of gastric fundus is allowed to retract into the abdomen. Traditionally, nasogastric drainage is maintained for 6 days to prevent distention of the stomach during healing. An oral diet is resumed on the seventh day, after a barium swallow study shows unobstructed passage of the bolus into the stomach without extravasation.In a randomized, long-term follow-up by Csendes and colleagues of 81 patients treated for achalasia, either by forceful dilation or by surgical myotomy, myotomy was associated with a significant increase in the diameter at the GEJ and a decrease in the diameter at the middle third of the esophagus on follow-up radiographic studies. There was a greater reduction in sphincter pressure and improvement in the amplitude of esophageal contractions after myotomy. After dilation, 13% of patients regained some peristalsis, compared with 28% after surgery. These findings were shown to persist over a 5-year follow-up period, at which time 95% of those treated with


Surgery_Schwartz

Surgery_Schwartz. dilation, 13% of patients regained some peristalsis, compared with 28% after surgery. These findings were shown to persist over a 5-year follow-up period, at which time 95% of those treated with surgical myotomy were doing well. Of those who were treated with dilation, only 54% were doing well, while 16% required redilation, and 22% eventually required surgical myotomy to obtain relief.If simultaneous esophageal contractions are associated with the sphincter abnormality, the so-called vigorous achala-sia, then the myotomy should extend over the distance of the abnormal motility as mapped by the preoperative motility study. Failure to do this will result in continuing dysphagia and a dis-satisfied patient. The best objective evaluation of improvement in the patient following either balloon dilation or myotomy is a scintigraphic measurement of esophageal emptying time. A good therapeutic response improves esophageal emptying toward normal. However, some degree of dysphagia may per-sist


Surgery_Schwartz

Surgery_Schwartz. dilation or myotomy is a scintigraphic measurement of esophageal emptying time. A good therapeutic response improves esophageal emptying toward normal. However, some degree of dysphagia may per-sist despite improved esophageal emptying, due to disturbances in esophageal body function. When an antireflux procedure is added to the myotomy, it should be a partial fundoplication. A 360° fundoplication is associated with progressive retention of swallowed food, regurgitation, and aspiration to a degree that exceeds the patient’s preoperative symptoms.Laparoscopic CardiomyotomyMore commonly known as a laparoscopic Heller myotomy, after Ernst Heller, a German surgeon who described a “dou-ble myotomy” in 1913, the laparoscopic approach is similar to the Nissen fundoplication in terms of the trocar placement and exposure and dissection of the esophageal hiatus (Fig. 25-65). The procedure begins by division of the short gastric vessels in preparation for fundoplication. Exposure of the GEJ via


Surgery_Schwartz

Surgery_Schwartz. placement and exposure and dissection of the esophageal hiatus (Fig. 25-65). The procedure begins by division of the short gastric vessels in preparation for fundoplication. Exposure of the GEJ via removal of the gastroesophageal fat pad follows. The anterior vagus nerve is swept right laterally along with the fat pad. Once completed, the GEJ and distal 4 to 5 cm of esophagus should be bared of any overlying tissue, and generally follows dissection of the GEJ. A distal esophageal myotomy is performed. It is generally easiest to begin the myotomy 1 to 2 cm above the GEJ, in an area above that of previous botulinum toxin injections or balloon dilation. Either scissors or a hook-type electrocautery can be used to initiate the incision in the longitudinal and circu-lar muscle. Distally, the myotomy is carried across the GEJ and onto the proximal stomach for approximately 2 to 3 cm. After completion, the muscle edges are separated bluntly from the esophageal mucosa for approximately 50% of


Surgery_Schwartz

Surgery_Schwartz. is carried across the GEJ and onto the proximal stomach for approximately 2 to 3 cm. After completion, the muscle edges are separated bluntly from the esophageal mucosa for approximately 50% of the esophageal circumference. An antireflux procedure follows completion of the myotomy. Either an anterior hemifundoplication augment-ing the angle of His (Dor) or posterior partial fundoplication (Toupet) can be performed. The Dor type fundoplication is slightly easier to perform, and it does not require disruption of the normal posterior gastroesophageal attachments (a theoretical advantage in preventing postoperative reflux).Per Oral Endoscopic Myotomy (POEM)The POEM procedure was developed in Japan. It is the ultimate minimally invasive myotomy as it requires no incisions through the skin. With the POEM procedure, a very effective myotomy is performed entirely from the lumen of the esophagus. The POEM procedure is started by opening the esophageal mucosa 10 cm above the lower esophageal


Surgery_Schwartz

Surgery_Schwartz. the POEM procedure, a very effective myotomy is performed entirely from the lumen of the esophagus. The POEM procedure is started by opening the esophageal mucosa 10 cm above the lower esophageal sphincter with a needle–knife electrosurgery device passed through an endoscope. A long submucosal plane is developed with the endoscope, down to and below the LES. The circular muscle of the LES, above and below the gastroesophageal junction, is divided with endoscopic electrosurgery. The submucosal entry site in the esophagus is then closed with endoscopic clips. While the results of POEM are still accumulating, the procedure is attractive because it is extremely minimally invasive, and can be done on an outpatient basis. The major downside of POEM is that an effective antire-flux valve cannot be created, exposing the patient to a 40% to 50% risk of GERD post procedure.Outcome Assessment of the Therapy for AchalasiaCritical analysis of the results of therapy for motor disor-ders of the


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Surgery_Schwartz. be created, exposing the patient to a 40% to 50% risk of GERD post procedure.Outcome Assessment of the Therapy for AchalasiaCritical analysis of the results of therapy for motor disor-ders of the esophagus requires objective measurement. The use of symptoms alone as an endpoint to evaluate therapy for achalasia may be misleading. The propensity for patients to unconsciously modify their diet to avoid difficulty swallowing is underestimated, making an assessment of results based on symptoms unreliable. Insufficient reduction in outflow resis-tance may allow progressive esophageal dilation to develop slowly, giving the impression of improvement because the volume of food able to be ingested with comfort increases. A variety of objective measurements may be used to assess success, including LES pressure, esophageal baseline pressure, and scintigraphic assessment of esophageal emptying time. Esophageal baseline pressure is usually negative compared to gastric pressure. Given that the


Surgery_Schwartz

Surgery_Schwartz. LES pressure, esophageal baseline pressure, and scintigraphic assessment of esophageal emptying time. Esophageal baseline pressure is usually negative compared to gastric pressure. Given that the goal of therapy is to eliminate the outflow resistance of a nonrelaxing sphincter, measure-ments of improvements in esophageal baseline pressure and scintigraphic transit time may be better indicators of success, but these are rarely reported.Brunicardi_Ch25_p1009-p1098.indd 106501/03/19 6:05 PM 1066SPECIFIC CONSIDERATIONSPART IIFigure 25-65. A. Longitudinal muscle is divided. B. Mechanical disruption of lower esophageal sphincter muscle fibers. C. Myotomy must be carried across gastroesophageal junction. D. Gastric extension should equal 2 to 3 cm. E. Anterior (Dor) fundoplication is sutured to the diaphragmatic arch. F. Posterior (Toupet) fundoplication is sutured to cut edges of myotomy. EG jct = esophagogastric junction.Eckardt and associates investigated whether the outcome of


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Surgery_Schwartz. to the diaphragmatic arch. F. Posterior (Toupet) fundoplication is sutured to cut edges of myotomy. EG jct = esophagogastric junction.Eckardt and associates investigated whether the outcome of pneumatic dilation in patients with achalasia could be pre-dicted on the basis of objective measurements. Postdilation LES pressure was the most valuable measurement for predict-ing long-term clinical response. A postdilatation sphincter pres-sure <10 mmHg predicted a good response. Approximately 50% of the patients studied had postdilatation sphincter pressures between 10 and 20 mmHg, with a 2-year remission rate of 71%. More important, 16 of 46 patients were left with a postdilatation sphincter pressure of >20 mmHg and had an unacceptable out-come. Overall, only 30% of patients dilated remained in symp-tomatic remission at 5 years.Bonavina and colleagues reported good to excellent results with transabdominal myotomy and Dor fundoplication in 94% of patients after a mean follow-up of 5.4 years.


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Surgery_Schwartz. symp-tomatic remission at 5 years.Bonavina and colleagues reported good to excellent results with transabdominal myotomy and Dor fundoplication in 94% of patients after a mean follow-up of 5.4 years. No operative mortality occurred in either of these series, attesting to the safety of the procedure. Malthaner and Pearson reported the long-term clinical results in 35 patients with achalasia, having a minimum follow-up of 10 years (Table 25-10). Twenty-two of these patients underwent primary esophageal myotomy and Belsey hemifundoplication at the Toronto General Hospital. Excellent to good results were noted in 95% of patients at 1 year, declining to 68%, 69%, and 67% at 10, 15, and 20 years, respectively. Two patients underwent early reoperation for an incomplete myotomy, and three underwent an esophagectomy for progressive disease. They concluded that there was a deterioration of the initially good results after surgical myotomy and hiatal repair for achalasia, which is due to late


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Surgery_Schwartz. an esophagectomy for progressive disease. They concluded that there was a deterioration of the initially good results after surgical myotomy and hiatal repair for achalasia, which is due to late complications of gastroesophageal reflux.Ellis reported his lifetime experience with transthoracic short esophageal myotomy without an antireflux procedure. One hundred seventy-nine patients were analyzed at a mean follow-up of 9 years, ranging from 6 months to 20 years. Overall, 89% of patients were improved at the 9-year mark. He also observed that the level of improvement deteriorated with time, with excel-lent results (patients continuing to be symptom free) decreasing from 54% at 10 years to 32% at 20 years. He concluded that a short transthoracic myotomy without an antireflux procedure provides excellent long-term relief of dysphagia, and, contrary to Malthaner and Pearson’s experience, does not result in com-plications of gastroesophageal reflux. Both studies document nearly identical


Surgery_Schwartz

Surgery_Schwartz. excellent long-term relief of dysphagia, and, contrary to Malthaner and Pearson’s experience, does not result in com-plications of gastroesophageal reflux. Both studies document nearly identical results 10 to 15 years following the procedure, and both report deterioration over time, probably due to progres-sion of the underlying disease. The addition of an antireflux procedure if the operation is performed transthoracically has no significant effect on the outcome.Brunicardi_Ch25_p1009-p1098.indd 106601/03/19 6:05 PM 1067ESOPHAGUS AND DIAPHRAGMATIC HERNIACHAPTER 25Figure 25-65. (Continued )Table 25-10Reasons for failure of esophageal myotomyREASONAUTHOR, PROCEDURE (N)ELLIS, MYOTOMY ONLY (N = 81)GOULBOURNE, MYOTOMY ONLY (N = 65)MALTHANER, MYOTOMY + ANTIREFLUX (N = 22)Reflux4%5%18%Inadequate myotomy2%—9%Megaesophagus2%——Poor emptying4%3%—Persistent chest pain1%——Data from Malthaner RA, et al. Long-term results in surgically managed esophageal achalasia. Ann Thorac Surg.


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Surgery_Schwartz. myotomy2%—9%Megaesophagus2%——Poor emptying4%3%—Persistent chest pain1%——Data from Malthaner RA, et al. Long-term results in surgically managed esophageal achalasia. Ann Thorac Surg. 1994;58:1343; Ellis FH, Jr. Oesophagomyotomy for achalasia: a 22-year experience. Br J Surg. 1993;80:882; and Goulbourne IA, et al. Long-term results of Heller’s operation for achalasia. J R Coll Surg Edinb. 1985;30:101.Brunicardi_Ch25_p1009-p1098.indd 106701/03/19 6:05 PM 1068SPECIFIC CONSIDERATIONSPART IIThe outcome of laparoscopic myotomy and hemifun-doplication has been well documented. Two reports of over 100 patients have documented relief of dysphagia in 93% of patients. Richter and coworkers reviewed published reports to date, including 254 patients with an average success rate of 93% at 2.5 years. Conversion to an open procedure occurs in 0% to 5% of patients. Complications are uncommon, occurring in <5% of patients. Intraoperative complications consist largely of mucosal perforation, and have


Surgery_Schwartz

Surgery_Schwartz. Conversion to an open procedure occurs in 0% to 5% of patients. Complications are uncommon, occurring in <5% of patients. Intraoperative complications consist largely of mucosal perforation, and have been more likely to occur after botulinum toxin injection. The incidence of objective reflux dis-ease as evidenced by abnormal acid exposure is <10%.A number of randomized clinical trials in the past decade have compared the outcomes of laparoscopic Heller myotomy to pneumatic dilation and to botulinum toxin injection. In each of these trials, laparoscopic Heller myotomy and partial fun-doplication was superior to the alternative treatment. Lastly, a randomized clinical trial examining the need for fundoplica-tion following Heller myotomy demonstrated a great deal more reflux in patients without fundoplication, and no better swallow-ing in the Heller-only group. The best treatment for achalasia is a laparoscopic Heller myotomy and partial fundoplication. The role of POEM in the management


Surgery_Schwartz

Surgery_Schwartz. fundoplication, and no better swallow-ing in the Heller-only group. The best treatment for achalasia is a laparoscopic Heller myotomy and partial fundoplication. The role of POEM in the management of classic (nonspastic) achalasia is yet to be established.Esophageal Resection for End-Stage Motor Disorders of the EsophagusPatients with dysphagia and long-standing benign disease, whose esophageal function has been destroyed by the disease process or multiple previous surgical procedures, are best man-aged by esophagectomy. Fibrosis of the esophagus and cardia can result in weak contractions and failure of the distal esopha-geal sphincter to relax. The loss of esophageal contractions can result in the stasis of food, esophageal dilatation, regurgitation, and aspiration. The presence of these abnormalities signals end-stage motor disease. In these situations, esophageal replace-ment is usually required to establish normal alimentation. Before proceeding with esophageal resection for


Surgery_Schwartz

Surgery_Schwartz. these abnormalities signals end-stage motor disease. In these situations, esophageal replace-ment is usually required to establish normal alimentation. Before proceeding with esophageal resection for patients with end-stage benign disease, the choice of the organ to substitute for the esophagus (i.e., stomach, jejunum, or colon) should be considered. The choice of replacement is affected by a num-ber of factors, as described later in “Techniques of Esophageal Reconstruction.” If minimally invasive esophagectomy is to be performed, thoracoscopic dissection should be combined with abdominal dissection. Attempts at MIS transhiatal esophagec-tomy for the massively dilated esophagus may result in large volume bleeding from mediastinal vessels that become enlarged with esophageal dilation, and such bleeding must be directly controlled for hemostasis to be adequate and the operation to be safe.CARCINOMA OF THE ESOPHAGUSSquamous carcinoma accounts for the majority of esophageal carcinomas


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Surgery_Schwartz. such bleeding must be directly controlled for hemostasis to be adequate and the operation to be safe.CARCINOMA OF THE ESOPHAGUSSquamous carcinoma accounts for the majority of esophageal carcinomas worldwide. Its incidence is highly variable, ranging from approximately 20 per 100,000 in the United States and Britain, to 160 per 100,000 in certain parts of South Africa and the Henan Province of China, and even 540 per 100,000 in the Guriev district of Kazakhstan. The environmental factors responsible for these localized high-incidence areas have not been conclusively identified, though additives to local foodstuffs (nitroso compounds in pickled vegetables and smoked meats) and mineral deficiencies (zinc and molybdenum) have been suggested. In Western societies, smoking and alcohol consumption are strongly linked with squamous carcinoma. Other definite associations link squamous carcinoma with long-standing achalasia, lye strictures, tylosis (an autosomal dominant disorder characterized


Surgery_Schwartz

Surgery_Schwartz. are strongly linked with squamous carcinoma. Other definite associations link squamous carcinoma with long-standing achalasia, lye strictures, tylosis (an autosomal dominant disorder characterized by hyperkeratosis of the palms and soles), and human papillomavirus.Adenocarcinoma of the esophagus, once an unusual malig-nancy, is diagnosed with increasing frequency (Fig. 25-66) and now accounts for more than 50% of esophageal cancer in most Western countries. The shift in the epidemiology of esophageal cancer from predominantly squamous carcinoma seen in associ-ation with smoking and alcohol to adenocarcinoma in the setting of BE is one of the most dramatic changes that has occurred in the history of human neoplasia. Although esophageal carcinoma is a relatively uncommon malignancy, its prevalence is explod-ing, largely secondary to the well-established association among gastroesophageal reflux, BE, and esophageal adenocarcinoma. Although BE was once a nearly uniformly lethal disease,


Surgery_Schwartz

Surgery_Schwartz. is explod-ing, largely secondary to the well-established association among gastroesophageal reflux, BE, and esophageal adenocarcinoma. Although BE was once a nearly uniformly lethal disease, sur-vival has improved slightly because of advances in the under-standing of its molecular biology, screening and surveillance practices, improved staging, minimally invasive surgical tech-niques, and neoadjuvant therapy.Furthermore, the clinical picture of esophageal adenocar-cinoma is changing. It now occurs not only considerably more frequently but also in younger patients, and it is often detected at an earlier stage. These facts support rethinking the traditional approach of assuming palliation is appropriate in all patients. The historical focus on palliation of dysphagia in an elderly patient with comorbidities should change when dealing with a young patient with dependent children and a productive life ahead. The potential for cure becomes of paramount importance.The gross appearance


Surgery_Schwartz

Surgery_Schwartz. with comorbidities should change when dealing with a young patient with dependent children and a productive life ahead. The potential for cure becomes of paramount importance.The gross appearance resembles that of squamous cell car-cinoma. Microscopically, adenocarcinoma almost always origi-nates in Barrett’s mucosa and resembles gastric cancer. Rarely, it arises in the submucosal glands and forms intramural growths that resemble the mucoepidermal and adenoid cystic carcinomas of the salivary glands.The most important etiologic factor in the development of primary adenocarcinoma of the esophagus is a metaplastic columnar-lined or Barrett’s esophagus, which occurs in approxi-mately 10% to 15% of patients with GERD. When studied pro-spectively, the incidence of adenocarcinoma in a patient with BE is one in 100 to 200 patient-years of follow-up (i.e., for every 100 patients with BE followed for 1 year, one will develop adenocarcinoma). Although this risk appears to be small, it is at


Surgery_Schwartz

Surgery_Schwartz. with BE is one in 100 to 200 patient-years of follow-up (i.e., for every 100 patients with BE followed for 1 year, one will develop adenocarcinoma). Although this risk appears to be small, it is at least 40 to 60 times that expected for a similar population without BE. This risk is similar to the risk for developing lung cancer in a person with a 20-pack-per-year history of smoking. Endoscopic surveillance for patients with BE is recommended for two reasons: (a) at present there is no reliable evidence that medical therapy removes the risk of neoplastic transformation, and (b) malignancy in BE is curable if detected at an early stage.Clinical ManifestationsEsophageal cancer generally presents with dysphagia, although increasing numbers of relatively asymptomatic patients are now identified on surveillance endoscopy, or present with nonspecific upper GI symptoms and undergo screening endoscopy. Extension of the primary tumor into the tracheobronchial tree can occur primarily with


Surgery_Schwartz

Surgery_Schwartz. on surveillance endoscopy, or present with nonspecific upper GI symptoms and undergo screening endoscopy. Extension of the primary tumor into the tracheobronchial tree can occur primarily with squamous cell carcinoma and can cause stridor, tracheoesophageal fistula, and resultant coughing, choking, and aspiration 6Brunicardi_Ch25_p1009-p1098.indd 106801/03/19 6:05 PM 1069ESOPHAGUS AND DIAPHRAGMATIC HERNIACHAPTER 25U.S. esophageal cancer incidence19851993199720012005Incidence per 100,00002520151051989NCI esophageal cancer research investment$21.8M$21.7M$21.6M srallod fo snoilliMilliBo snolod fsralFiscal year020032004200520062007252015105054321Esophageal cancer funding Total NCI budget $22.3M$4.8B$4.7B$4.7B$4.6B$4.8B$22.7MU.S. esophageal cancer mortalityMortality per 100,000198519931997200120050252015105White malesOverall rateAfrican American malesWhite femalesAfrican American females1989Figure 25-66. Incidence and mortality rate trends for esophageal cancer. NCI = National Cancer


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Surgery_Schwartz. malesOverall rateAfrican American malesWhite femalesAfrican American females1989Figure 25-66. Incidence and mortality rate trends for esophageal cancer. NCI = National Cancer Institute. (Reproduced with permis-sion from the National Cancer Institute. Last updated September, 2008.)pneumonia. Rarely, severe bleeding from the primary tumor or from erosion into the aorta or pulmonary vessels occurs. Either vocal cord may be invaded, causing paralysis, but most commonly, paralysis is caused by invasion of the left recurrent laryngeal nerve by the primary tumor or LN metastasis. Systemic organ metastases are usually manifested by jaundice or bone pain. The situation is different in high-incidence areas where screening is practiced. In these communities, the most prominent early symptom is pain on swallowing rough or dry food. In patients that present with back pain at the time of esophageal cancer diagnosis, there is usually distant metastasis or celiac encasement.Dysphagia usually presents


Surgery_Schwartz

Surgery_Schwartz. swallowing rough or dry food. In patients that present with back pain at the time of esophageal cancer diagnosis, there is usually distant metastasis or celiac encasement.Dysphagia usually presents late in the natural history of the disease because the lack of a serosal layer on the esopha-gus allows the smooth muscle to dilate with ease. As a result, the dysphagia becomes severe enough for the patient to seek medical advice only when more than 60% of the esophageal circumference is infiltrated with cancer. Consequently, the dis-ease is usually advanced if symptoms herald its presence. Tra-cheoesophageal fistula may be present in some patients on their first visit to the hospital, and more than 40% will have evidence of distant metastases. With tumors of the cardia, anorexia and weight loss usually precede the onset of dysphagia. The physical signs of esophageal tumors are those associated with the pres-ence of distant metastases.General Approach to Esophageal CancerTherapy of


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Surgery_Schwartz. loss usually precede the onset of dysphagia. The physical signs of esophageal tumors are those associated with the pres-ence of distant metastases.General Approach to Esophageal CancerTherapy of esophageal cancer is dictated by the stage of the can-cer at the time of diagnosis. Put simply, one needs to determine if the disease is confined to the esophagus, (T1–T2, N0), locally advanced (T1–3, N1), or disseminated (any T, any N, M1). If cancer is confined to the esophagus, removal of the tumor with adjacent lymph nodes may be curative. Very early tumors con-fined to the mucosa (T in situ, T1a, intramucosal cancer) may be addressed with endoscopic treatment. When the tumor is locally aggressive, modern therapy dictates a multimodality approach in a surgically fit patient. Multimodality therapy is either che-motherapy followed by surgery or radiation and chemotherapy followed by surgery. When given before surgery, these treat-ments are referred to as neoadjuvant or induction therapy. For


Surgery_Schwartz

Surgery_Schwartz. is either che-motherapy followed by surgery or radiation and chemotherapy followed by surgery. When given before surgery, these treat-ments are referred to as neoadjuvant or induction therapy. For disseminated cancer, treatment is aimed at palliation of symp-toms. If the patient has dysphagia, as many do, the most rapid form of palliation is the endoscopic placement of an expandable esophageal stent. For palliation of GEJ cancer, radiation may be the first choice, as stents placed across the GEJ create a great deal of gastroesophageal reflux.Staging of Esophageal CancerChoosing the best therapy for an individual patient requires accurate staging. Staging starts with the history and physical. LN disease remote from the tumor, particularly in the cervi-cal region, may be palpable on neck examination and generally indicates cancer dissemination. This is often referred to as M1a disease, indicating that these patients should not be treated with therapy directed toward locally advanced


Surgery_Schwartz

Surgery_Schwartz. examination and generally indicates cancer dissemination. This is often referred to as M1a disease, indicating that these patients should not be treated with therapy directed toward locally advanced cancer. Other meta-static LNs are rarely palpable but are equally ominous, espe-cially the umbilical LN in GEJ cancer.Computed tomographic (CT) scanning of the chest, abdo-men, and pelvis provides information on local invasion of the primary cancer, LN involvement, or disseminated disease. The most common sites of esophageal cancer metastases are lung, liver, and peritoneal surfaces, including the omentum and small bowel mesentery. If masses are identified that are Brunicardi_Ch25_p1009-p1098.indd 106901/03/19 6:05 PM 1070SPECIFIC CONSIDERATIONSPART IInot characteristic for cancer or are in a location that precludes resection with the cancer specimen, positron emission tomogra-phy (PET) scanning may be able to tell whether the masses are metabolically active (likely to be cancer) or


Surgery_Schwartz

Surgery_Schwartz. in a location that precludes resection with the cancer specimen, positron emission tomogra-phy (PET) scanning may be able to tell whether the masses are metabolically active (likely to be cancer) or not. A PET active focus corresponding to a mass on CT scan outside of the field of esophageal resection should be biopsied before resection is performed.The introduction of endoscopic ultrasound (EUS) has made it possible to identify patients who are potentially curable before surgical therapy. Using an endoscope, the depth of the wall penetration by the tumor and the presence of LN metasta-ses can be determined with 80% accuracy. A curative resection should be encouraged if EUS indicates that the tumor has not invaded adjacent organs (T4b), and/or fewer than six enlarged LNs are imaged. Thoracoscopic and laparoscopic staging of esophageal cancer may add benefit when the nature of enlarged LNs remote from the cancer cannot be determined or when advanced imaging systems (PET and


Surgery_Schwartz

Surgery_Schwartz. Thoracoscopic and laparoscopic staging of esophageal cancer may add benefit when the nature of enlarged LNs remote from the cancer cannot be determined or when advanced imaging systems (PET and high-resolution spiral CT) are not available.Occasionally, diagnostic laparoscopy and jejunostomy tube placement may precede induction chemoradiation in the patient with severe dysphagia and weight loss from a locally advanced cancer. In summary, esophageal cancer is diagnosed with endoscopic biopsy and is staged with CT scanning of the chest and abdomen, EUS, and PET scan for all patients with CT or EUS evidence of advanced disease (T2 or greater, N1-2 or NX). Experience with esophageal resection in patients with early stage disease has identified characteristics of esophageal cancer that are associated with improved survival. A number of studies suggest that only metastasis to LNs and tumor penetration of the esophageal wall have a significant and independent influence on prognosis. Factors


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Surgery_Schwartz. with improved survival. A number of studies suggest that only metastasis to LNs and tumor penetration of the esophageal wall have a significant and independent influence on prognosis. Factors known to be important in the survival of patients with advanced disease, such as cell type, degree of cellular differentiation, or location of tumor in the esophagus, have no effect on survival of patients who have undergone resection for early disease. Studies also showed that patients having five or fewer LN metastases have a better outcome. Using these data, Skinner developed the wall penetration, LN, and distant organ metastases system for staging.The wall penetration, LN, and distant organ metastases system differed somewhat from the previous efforts to develop a satisfactory staging criteria for carcinoma of the esophagus. Most surgeons agreed that the 1983 tumor, nodes, and metastasis system left much to be desired. In the third edition of the manual for Staging of Cancer of the American


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Surgery_Schwartz. carcinoma of the esophagus. Most surgeons agreed that the 1983 tumor, nodes, and metastasis system left much to be desired. In the third edition of the manual for Staging of Cancer of the American Joint Committee on Cancer (AJCC) in 1988, an effort was made to provide a finer discrimination between stages than had been contained in the previous edition in 1983. In 2016, further refinements of the staging system of esophageal cancer were approved by the AJCC, recognizing the difference in survival afforded by resection of limited LN disease adjacent to the tumor, compared to multilevel LN disease and positive LNs remote from the primary. Table 25-11 shows the AJCC definitions for the primary tumor, lymph nodes, distant metastasis, and overall staging schema for both squamous cell carcinoma and adenocarcinoma.Clinical Approach to Carcinoma of the Esophagus and CardiaThe selection of a curative vs. a palliative operation for cancer of the esophagus is based on the location of the tumor,


Surgery_Schwartz

Surgery_Schwartz. and adenocarcinoma.Clinical Approach to Carcinoma of the Esophagus and CardiaThe selection of a curative vs. a palliative operation for cancer of the esophagus is based on the location of the tumor, the patient’s age and health, the extent of the disease, and preoperative stag-ing. Figure 25-67 shows an algorithm of the clinical decisions important in the selection of curative or palliative therapy.Tumor Location. The selection of surgical therapy for patients with carcinoma of the esophagus depends not only on the ana-tomic stage of the disease and an assessment of the swallowing capacity of the patient but also on the location of the primary tumor.It is estimated that 8% of the primary malignant tumors of the esophagus occur in the cervical portion (Fig. 25-68). They are almost always squamous cell cancer, with a rare adenocar-cinoma arising from a congenital inlet patch of columnar lining. These tumors, particularly those in the postcricoid area, repre-sent a separate pathologic


Surgery_Schwartz

Surgery_Schwartz. squamous cell cancer, with a rare adenocar-cinoma arising from a congenital inlet patch of columnar lining. These tumors, particularly those in the postcricoid area, repre-sent a separate pathologic entity for two reasons: (a) they are more common in females and appear to be a unique entity in this regard; and (b) the efferent lymphatics from the cervical esophagus drain completely differently from those of the tho-racic esophagus. The latter drain directly into the paratracheal and deep cervical or internal jugular LNs with minimal flow in a longitudinal direction. Except in advanced disease, it is unusual for intrathoracic LNs to be involved.Cervical esophageal cancer is frequently unresectable because of early invasion of the larynx, great vessels, or trachea. Radical surgery, including esophagolaryngectomy may occa-sionally be performed for these lesions, but the ensuing mor-bidity makes this a less than desirable approach in the face of uncertain cure. Thus, for most patients


Surgery_Schwartz

Surgery_Schwartz. esophagolaryngectomy may occa-sionally be performed for these lesions, but the ensuing mor-bidity makes this a less than desirable approach in the face of uncertain cure. Thus, for most patients with cervical esophageal cancer, stereotactic radiation with concomitant chemotherapy is the most desirable treatment.Tumors that arise within the middle third of the esopha-gus are squamous carcinomas most commonly and are fre-quently associated with LN metastasis, which are usually in the thorax but may be in the neck or abdomen, and may skip areas in between. Although it is generally felt that individu-als with midthoracic cancer and abdominal LN metastases are incurable with surgery, there are some emerging data that suggest that cervical LN metastases, if isolated, can be resected with benefit. Generally, T1 and T2 cancers with-out LN metastases are treated with resection only, but there is more and more data to suggest that LN involvement or transmural cancer (T3) warrants treatment with


Surgery_Schwartz

Surgery_Schwartz. Generally, T1 and T2 cancers with-out LN metastases are treated with resection only, but there is more and more data to suggest that LN involvement or transmural cancer (T3) warrants treatment with neoadjuvant chemoradiation therapy followed by resection. Although some surgeons prefer a transhiatal esophagectomy for all tumor locations, most surgeons believe that resection of mid-esophageal cancer should be performed under direct vision with either thoracoscopy (video-assisted thoracic surgery [VATS]) or with thoracotomy.Tumors of the lower esophagus and cardia are usually adenocarcinomas. Unless preoperative and intraoperative stag-ing clearly demonstrate an incurable lesion, resection in con-tinuity with a LN dissection should be performed. Because of the propensity of GI tumors to spread for long distances sub-mucosally, long lengths of grossly normal GI tract should be resected. The longitudinal lymph flow in the esophagus can result in skip areas, with small foci of tumor above


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Surgery_Schwartz. for long distances sub-mucosally, long lengths of grossly normal GI tract should be resected. The longitudinal lymph flow in the esophagus can result in skip areas, with small foci of tumor above the primary lesion, which underscores the importance of a wide resection of esophageal tumors. Wong has shown that local recurrence at the anastomosis can be prevented by obtaining a 10-cm margin of normal esophagus above the tumor. Anatomic studies have also shown that there is no submucosal lymphatic barrier between the esophagus and the stomach at the cardia, and Wong has Brunicardi_Ch25_p1009-p1098.indd 107001/03/19 6:05 PM 1071ESOPHAGUS AND DIAPHRAGMATIC HERNIACHAPTER 25Table 25-11American Joint Committee on Cancer (AJCC) Staging Schema for Esophageal CancerTXT0TisT1T1aT1bT2T3T4T4aT4bNXN0N1N2N3M0M1Primary tumor cannot be assessed.No evidence of primary tumor.High-grade dysplasia.Tumor invades lamina propria, muscularis mucosae, or submucosa.Tumor invades lamina propria or muscularis


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Surgery_Schwartz. tumor cannot be assessed.No evidence of primary tumor.High-grade dysplasia.Tumor invades lamina propria, muscularis mucosae, or submucosa.Tumor invades lamina propria or muscularis mucosae.Tumor invades submucosa.Tumor invades muscularis propria.Tumor invades adventitia.Tumor invades adjacent structures.Resectable tumor invading pleura, pericardium, or diaphragm.Unresectable tumor invading other adjacent structures, such as aorta, vertebral body, trachea, etc.Regional lymph nodes cannot be assessed.No regional lymph node metastasis.Metastases in 1–2 regional lymph nodes.Metastases in 3–6 regional lymph nodes.Metastases in ≥7 regional lymph nodes.No distant metastasis.Distant metastasis.SQUAMOUS CELL CARCINOMA Pathological (pTNM)When And And And And Then the stagepT is... pN is... M is... G is... location is... group is...Tis N0 M0 N/A Any 0T1a N0 M0 G1 Any IAT1a N0 M0 G2–3 Any IBT1a N0 M0 GX Any IAT1b N0 M0 G1–3 Any IBT1b N0 M0 GX Any IBT2 N0 M0 G1 Any IBT2 N0 M0 G2–3 Any


Surgery_Schwartz

Surgery_Schwartz. is... G is... location is... group is...Tis N0 M0 N/A Any 0T1a N0 M0 G1 Any IAT1a N0 M0 G2–3 Any IBT1a N0 M0 GX Any IAT1b N0 M0 G1–3 Any IBT1b N0 M0 GX Any IBT2 N0 M0 G1 Any IBT2 N0 M0 G2–3 Any IIAT2 N0 M0 GX Any IIAT3 N0 M0 G1–3 Lower IIAT3 N0 M0 G1 Upper/middle IIAT3 N0 M0 G2–3 Upper/middle IIBClinical (cTNM)When And And Then the cT is... cN is... M is... stage group is...Tis N0 M0 0T1 N0–1 M0 IT2 N0–1 M0 IIT3 N0 M0 IIT3 N1 M0 IIIT1–3 N2 M0 IIIT4 N0–2 M0 IVAAny T N3 M0 IVAAny T Any N M1 IVBPostneoadjuvant Therapy (ypTNM)When yp And yp And Then the stageT is... N is... M is... group is...T0–2 N0 M0 IT3 N0 M0 IIT0–2 N1 M0 IIIAT3 N1 M0 IIIBT0–3 N2 M0 IIIBT4a N0 M0 IIIBT4a N1–2 M0 IVAT4a NX M0 IVAT4b N0–2 M0 IVAAny T N3 M0 IVAAny T Any N M1 IVBClinical (cTNM)When And And Then the cT is... cN is... M is... stage group is...Tis N0 M0 0T1 N0 M0 IT1 N1 M0 IIAT2 N0 M0 IIBT3 N0 M0 GX Lower/upper/middle IIBT3 N0 M0 Any Location


Surgery_Schwartz

Surgery_Schwartz. T Any N M1 IVBClinical (cTNM)When And And Then the cT is... cN is... M is... stage group is...Tis N0 M0 0T1 N0 M0 IT1 N1 M0 IIAT2 N0 M0 IIBT3 N0 M0 GX Lower/upper/middle IIBT3 N0 M0 Any Location X IIBT1 N1 M0 Any Any IIBT1 N2 M0 Any Any IIIAT2 N1 M0 Any Any IIIAT2 N2 M0 Any Any IIIBT3 N1–2 M0 Any Any IIIBT4a N0–1 M0 Any Any IIIBT4a N2 M0 Any Any IVAT4b N0–2 M0 Any Any IVAAny T N3 M0 Any Any IVAAny T Any N M1 Any Any IVB(Continued)ADENOCARCINOMAT2 N1 M0 IIIT3 N0–1 M0 IIIT4a N0–1 M0 IIIT1–4a N2 M0 IVAT4b N0–2 M0 IVAAny T N3 M0 IVAAny T Any N M1 IVBBrunicardi_Ch25_p1009-p1098.indd 107101/03/19 6:05 PM 1072SPECIFIC CONSIDERATIONSPART IITable 25-11American Joint Committee on Cancer (AJCC) Staging Schema for Esophageal CancerPostneoadjuvant Therapy (ypTNM)When yp And yp And Then the stage T is... N is... M is... group is...T0–2 N0 M0 IT3 N0 M0 IIT0–2 N1 M0 IIIAT3 N1 M0 IIIBT0–3 N2 M0 IIIBT4a N0 M0 IIIBT4a N1–2 M0 IVAT4a NX M0 IVAT4b N0–2 M0 IVAAny T N3 M0 IVAAny T Any


Surgery_Schwartz

Surgery_Schwartz. Then the stage T is... N is... M is... group is...T0–2 N0 M0 IT3 N0 M0 IIT0–2 N1 M0 IIIAT3 N1 M0 IIIBT0–3 N2 M0 IIIBT4a N0 M0 IIIBT4a N1–2 M0 IVAT4a NX M0 IVAT4b N0–2 M0 IVAAny T N3 M0 IVAAny T Any N M1 IVBUsed with the permission of the American College of Surgeons. Amin MB, Edge SB, Greene FL, et al. (Eds.) AJCC Cancer Staging Manual, 8th Ed. Springer New York, 2017.Pathological (pTNM)When And And And Then the stage pT is... pN is... M is... G is... group is...Tis N0 M0 N/A 0T1a N0 M0 G1 IAT1a N0 M0 GX IAT1a N0 M0 G2 IBT1b N0 M0 G1–2 IBT1b N0 M0 GX IBT1 N0 M0 G3 ICT2 N0 M0 G1–2 ICT2 N0 M0 G3 IIAT2 N0 M0 GX IIAT1 N1 M0 Any IIBT3 N0 M0 Any IIBT1 N2 M0 Any IIIAT2 N1 M0 Any IIIAT2 N2 M0 Any IIIBT3 N1–2 M0 Any IIIBT4a N0–1 M0 Any IIIBT4a N2 M0 Any IVAT4b N0–2 M0 Any IVAAny T N3 M0 Any IVAAny T Any N M1 Any IVB*Could include combined Rx and chemo neoadjuvant therapyprior to resection to increase resectability and potentialsurvival in patients 75 or under.Curative enbloc


Surgery_Schwartz

Surgery_Schwartz. T N3 M0 Any IVAAny T Any N M1 Any IVB*Could include combined Rx and chemo neoadjuvant therapyprior to resection to increase resectability and potentialsurvival in patients 75 or under.Curative enbloc resectionIntraoperativestagingAgePhysiologicfitnessClinical stagingEndoscopicultrasoundPalliation75 yearsPalliation FEV1 1.25 Ejection fraction 40%PalliationRecurrent nerve paralysisHorner's syndromePersistent spinal painParalysis of diaphragmFistula formationMalignant pleural effusionEndoscopic tumor length 9 cmAbnormal esophageal axisMultiple enlarged nodes or distantorgan metastasis on CTMore than 20% weight lossLoss of appetite (relative)PalliationTransmural tumors with 4enlarged nodesPalliationUnresectable primaryCavitary spreadDistant metastasisExtension through mediastinal wallMultiple gross lymph node metastasesMicroscopic nodal metastasis at margins ofthe en bloc dissectionPalliative symptomsDysphagiaObstructionPain of ulcerationBleedingInfectionAnxietyRequirements for


Surgery_Schwartz

Surgery_Schwartz. gross lymph node metastasesMicroscopic nodal metastasis at margins ofthe en bloc dissectionPalliative symptomsDysphagiaObstructionPain of ulcerationBleedingInfectionAnxietyRequirements for palliative transhiatal resection* Free of distant organ metastases Complete excision of primary tumor possibleNonsurgicalpalliationFigure 25-67. Algorithm for the evaluation of esophageal cancer patients to select the proper therapy: curative en bloc resection, palliative transhiatal resection, or nonsurgical palliation. CT = computed tomography; FEV1 = forced expiratory volume in 1 second. (Reproduced with permission from DeMeester TR: Esophageal carcinoma: current controversies, Semin Surg Oncol. 1997 Jul-Aug;13(4):217-233.)shown that 50% of the local recurrences in patients with esopha-geal cancer who are resected for cure occur in the intrathoracic stomach along the line of the gastric resection. Considering that the length of the esophagus ranges from 17 to 25 cm, and


Surgery_Schwartz

Surgery_Schwartz. with esopha-geal cancer who are resected for cure occur in the intrathoracic stomach along the line of the gastric resection. Considering that the length of the esophagus ranges from 17 to 25 cm, and the length of the lesser curvature of the stomach is approximately 12 cm, a curative resection requires a cervical division of the esophagus and a >50% proximal gastrectomy in most patients with carcinoma of the distal esophagus or cardia.Age. Resection for cure of carcinoma of the esophagus in a patient older than 80 years is rarely indicated because of the additional operative risk and the shorter life expectancy. Despite this general guideline, octogenarians with a high-performance status and excellent cardiopulmonary reserve may be consid-ered candidates for esophagectomy, and recent case series have established its success in highly selected patients. It is in this group of patients that the lesser physiologic impact of minimally (Continued)Brunicardi_Ch25_p1009-p1098.indd


Surgery_Schwartz

Surgery_Schwartz. case series have established its success in highly selected patients. It is in this group of patients that the lesser physiologic impact of minimally (Continued)Brunicardi_Ch25_p1009-p1098.indd 107201/03/19 6:05 PM 1073ESOPHAGUS AND DIAPHRAGMATIC HERNIACHAPTER 25LocationIncidenceCervicalUpperthoracicMiddlethoracicLowerthoracicCardia8%3%32%25%32%Figure 25-68. Incidence of carcinoma of the esophagus and cardia based on tumor location.induction chemoradiation therapy, more pronounced dysphagia and associated malnutrition should be addressed before the initiation of chemoradiation. A laparoscopic jejunostomy tube can be placed prior to induction therapy or at the time of esophagectomy. There are emerging data that 5 days’ pretreatment with immune-enhancing nutrition, rich in fish oils, decreases cardiac and other complications, following esophagectomy.Clinical Staging. Clinical factors that indicate an advanced stage of carcinoma and exclude surgery with curative intent are recurrent


Surgery_Schwartz

Surgery_Schwartz. cardiac and other complications, following esophagectomy.Clinical Staging. Clinical factors that indicate an advanced stage of carcinoma and exclude surgery with curative intent are recurrent nerve paralysis, Horner’s syndrome, persistent spinal pain, paralysis of the diaphragm, fistula formation, and malig-nant pleural effusion. Factors that make surgical cure unlikely include a tumor >8 cm in length, abnormal axis of the esopha-gus on a barium radiogram, more than four enlarged LNs on CT, a weight loss more than 20%, and loss of appetite. Stud-ies indicate that there are several favorable parameters associ-ated with tumors <4 cm in length, there are fewer with tumors between 4 and 8 cm, and there are no favorable criteria for tumors >8 cm in length. Consequently, the finding of a tumor >8 cm in length should exclude curative resection; the finding of a smaller tumor should encourage an aggressive approach.Preoperative Staging With Advanced Imaging. For years, clinical staging,


Surgery_Schwartz

Surgery_Schwartz. >8 cm in length should exclude curative resection; the finding of a smaller tumor should encourage an aggressive approach.Preoperative Staging With Advanced Imaging. For years, clinical staging, contrast radiography, endoscopy, and CT scan-ning formed the backbone of esophageal cancer staging. More recently, preoperative decision making is guided by endoscopic ultrasonography and PET scanning.EUS provides the most reliable method of determining depth of cancer invasion. In the absence of enlarged LNs, the degree of wall invasion dictates surgical therapy. If a small focus of esophageal cancer is confined to the mucosa, endoscopic mucosal resection (EMR) is a preferable option. If the tumor invades into the submucosa, without visible lymph node involvement, most individuals would suggest esophagectomy with LN dissection, as positive nodes can be found in 20% to 25% of those with cancer limited to the mucosa and submucosa. If EUS demonstrates spread through the wall of the esophagus,


Surgery_Schwartz

Surgery_Schwartz. esophagectomy with LN dissection, as positive nodes can be found in 20% to 25% of those with cancer limited to the mucosa and submucosa. If EUS demonstrates spread through the wall of the esophagus, especially if LNs are enlarged, then induction chemoradiation therapy (neoadjuvant therapy) should be strongly considered. Lastly, when the EUS demonstrates invasion of the trachea, bronchus, aorta, or spine, then surgical resection is rarely indicated. If there is invasion into the pleura (T4a), then surgical resection can be considered in the absence of a malignant effusion. Thus, it can be seen that the therapy of esophageal cancer is largely driven by the findings of an endoscopic ultrasonography. It is difficult to provide modern treatment of esophageal cancer without access to this modality.PET scanning, usually combined with an axial CT scan (CTPET), usually is performed on patients with locally advanced cancer or questionable lesions on CT scan to deter-mine whether metastases are


Surgery_Schwartz

Surgery_Schwartz. scanning, usually combined with an axial CT scan (CTPET), usually is performed on patients with locally advanced cancer or questionable lesions on CT scan to deter-mine whether metastases are present. The PET scan uses the injection of radiolabeled deoxyglucose, which is taken up in metabolically active tissues such as cancer. PET-positive areas must be correlated with the CT scan findings to assess the sig-nificance of “hot spots.” CTPET scanning has been especially useful before the initiation of chemoradiation therapy. An early response to chemoradiotherapy, by PET scan, improves the prognosis whether or not resection is ultimately performed. Conversely, if a PET-avid tumor shows no change in metabolic activity after 2 weeks of induction chemoradiation therapy, it is unlikely that further chemoor radiation therapy will be of invasive surgery may reduce the morbidity and mortality associ-ated with open twoor three-field esophagectomy.Cardiopulmonary Reserve. Patients undergoing


Surgery_Schwartz

Surgery_Schwartz. further chemoor radiation therapy will be of invasive surgery may reduce the morbidity and mortality associ-ated with open twoor three-field esophagectomy.Cardiopulmonary Reserve. Patients undergoing esophageal resection should have sufficient cardiopulmonary reserve to tol-erate the proposed procedure. The respiratory function is best assessed with the forced expiratory volume in 1 second, which ideally should be 2 L or more. Any patient with a forced expi-ratory volume in 1 second of <1.25 L is a poor candidate for thoracotomy because he or she has a 40% risk of dying from respiratory insufficiency within 4 years. In patients with poor pulmonary reserve, the transhiatal esophagectomy should be considered, as the pulmonary morbidity of this operation is less than is seen following thoracotomy. Clinical evaluation and electrocardiogram are not sufficient indicators of cardiac reserve. Echocardiography and dipyridamole thallium imaging provide accurate information on wall motion,


Surgery_Schwartz

Surgery_Schwartz. Clinical evaluation and electrocardiogram are not sufficient indicators of cardiac reserve. Echocardiography and dipyridamole thallium imaging provide accurate information on wall motion, ejection fraction, and myocardial blood flow. A defect on thallium imaging may require further evaluation with preoperative coronary angiogra-phy. A resting ejection fraction of <40%, particularly if there is no increase with exercise, is an ominous sign. In the absence of invasive testing, observed stair-climbing is an economical (albeit not quantitative) method of assessing cardiopulmonary reserve. Most individuals who can climb three flights of stairs without stopping will do well with two-field open esophagectomy, espe-cially if an epidural catheter is used for postoperative pain relief.Nutritional Status. The factor most predictive of postoperative complication is the nutritional status of the patient. Profound weight loss, more than 20 lb, associated with hypoalbuminemia (albumin <3.5 g/dL) is


Surgery_Schwartz

Surgery_Schwartz. factor most predictive of postoperative complication is the nutritional status of the patient. Profound weight loss, more than 20 lb, associated with hypoalbuminemia (albumin <3.5 g/dL) is associated with a much higher rate of complications and mortality than patients who enter curative surgery in better nutritional condition. Because malnourished patients generally have locally advanced esophageal cancer, if not metastatic disease, one should consider the placement of a feeding tube before the beginning of induction chemoradiation therapy. Although mild amounts of dysphagia are improved by Brunicardi_Ch25_p1009-p1098.indd 107301/03/19 6:05 PM 1074SPECIFIC CONSIDERATIONSPART IIany benefit. These patients have a worse prognosis and may be referred for resection or palliation without incurring the morbid-ity or expense of a full course of chemoand radiation therapy.Palliation of Esophageal CancerPalliation of esophageal cancer is indicated for individuals with metastatic esophageal


Surgery_Schwartz

Surgery_Schwartz. the morbid-ity or expense of a full course of chemoand radiation therapy.Palliation of Esophageal CancerPalliation of esophageal cancer is indicated for individuals with metastatic esophageal cancer or cancer invading adjacent organs (T4b) who are unable to swallow, or individuals with fistulae into the tracheobronchial tree. Aortic esophageal fistulas are extremely rare and nearly 100% lethal. Dysphagia as a result of esophageal cancer can be graded from grade I, eating normally, to grade VI, unable to swallow saliva (Table 25-12). Grades I to III often can be managed with radiation therapy, usually in combination with chemotherapy. When surgical resection is not anticipated in the future, this is termed definitive chemoradia-tion therapy and usually is palliative. Radiation dose is increased from 45 Gy to 60 Gy administered over 8 weeks, rather than the 4 weeks given for chemoradiation induction therapy. In 20% of patients, a complete response to chemoradiation therapy will not only


Surgery_Schwartz

Surgery_Schwartz. from 45 Gy to 60 Gy administered over 8 weeks, rather than the 4 weeks given for chemoradiation induction therapy. In 20% of patients, a complete response to chemoradiation therapy will not only palliate the symptoms but will also leave the patient with undetectable cancer of the esophagus. Although some of these patients are truly cured, cancer will recur in many either locally or systemically 1 to 5 years following definitive chemo-radiation. In a few patients, definitive chemoradiation will be successful in all sites but the esophagus. After a 12-month wait from initial treatment and no other sites of tumor detectable except the esophagus, some of these patients may be candidates for salvage esophagectomy.For individuals with dysphagia grades IV and higher, addi-tional treatment generally is necessary. The mainstay of therapy is in-dwelling esophageal stents. Covered removable stents may be used to seal fistulae or when stent removal becomes desir-able in the future. When large,


Surgery_Schwartz

Surgery_Schwartz. is necessary. The mainstay of therapy is in-dwelling esophageal stents. Covered removable stents may be used to seal fistulae or when stent removal becomes desir-able in the future. When large, locally invasive tumors or meta-static esophageal cancer precludes any future hope of resection, uncovered expandable metal stents are the treatment of choice. The major limitations to stenting exist in cancers at the GEJ. A stent placed across the GEJ will result in severe gastroesopha-geal reflux and heartburn that can be quite disabling. In cancers at this level, radiation therapy alone may be preferable. If feed-ing access is desirable, a laparoscopic jejunostomy is usually the procedure of choice.Surgical TreatmentThe surgical treatment of esophageal cancer is dependent upon the location of the cancer, the depth of invasion, LN metastases, the fitness of the patient for operation, and the culture and beliefs of the individuals and institutions in which the treatment is performed. In an


Surgery_Schwartz

Surgery_Schwartz. the cancer, the depth of invasion, LN metastases, the fitness of the patient for operation, and the culture and beliefs of the individuals and institutions in which the treatment is performed. In an ideal world, there would be a single, stage-specific method of treating esophageal cancer because the evidence would be unassailable and noncontroversial. Randomized clinical trials and meta-analyses would prove beyond a shadow of a doubt the value of surgery vs. nonoperative therapy and would dictate the type and extent of surgery that would optimally balance immediate morbidity and mortality with duration and quality of life conferred by the procedure and the perioperative management of the esophagectomy patient. Despite many noble attempts to establish this high level of evidence, many questions relating to the appropriate therapy of esophageal cancer remain. About the only area of complete agreement is that esophagectomy should not be performed if an R0 resection is not possible. In


Surgery_Schwartz

Surgery_Schwartz. relating to the appropriate therapy of esophageal cancer remain. About the only area of complete agreement is that esophagectomy should not be performed if an R0 resection is not possible. In other words, if the surgeon does not believe he or she can remove all LNs invaded by cancer and provide a tumor-free radial margin and esophagus and stomach margins that are tumor free, then a resection should not be performed.Mucosally Based Cancer. In patients with BE, and especially those with high-grade dysplasia, subcentimeter nodules are frequently discovered. Nodules should be resected in entirety, as they often harbor adenocarcinoma. Five years ago, such resection was performed with a transhiatal esophagectomy, but more recently EMR offers another method for removing intramucosal cancer. In this clinical situation, EMR is typi-cally combined with EUS to rule out more invasive disease. EUS, however, is unable to differentiate between cancer that is confined to the mucosa (T1a) and that


Surgery_Schwartz

Surgery_Schwartz. this clinical situation, EMR is typi-cally combined with EUS to rule out more invasive disease. EUS, however, is unable to differentiate between cancer that is confined to the mucosa (T1a) and that which invades the submu-cosa (T1b). Tumors invading the submucosa are not amenable to endoscopic mucosal resection because of the high-frequency (20–25%) concurrent finding of positive LNs, which cannot be removed without esophagectomy. On the other hand, intramu-cosal cancers have little risk of spreading to regional LNs. The current approach used involves performing EMR on all nodules identified in a field of Barrett’s esophagus, and then T staging is performed by histologic analysis. This approach dictates the need for future therapy such as esophagectomy.For this reason, small intramucosal carcinomas may be removed with EMR in the following manner. The area beneath the nodule is infiltrated with saline through a sclerotherapy needle. A specialized suction cap is mounted on the end of


Surgery_Schwartz

Surgery_Schwartz. carcinomas may be removed with EMR in the following manner. The area beneath the nodule is infiltrated with saline through a sclerotherapy needle. A specialized suction cap is mounted on the end of the endoscope, and the nodule is drawn up into the cap; a snare is then applied to resect the tissue. Alternatively, a rubber band can be delivered, and the snare can be used to resect above the level of the rubber band. This specimen is then removed and sent to pathology. As long as the tumor is found to be confined to the mucosa and all margins are negative, the resection is complete. A positive margin or involvement of the submucosa warrants esophagectomy. Most importantly, these patients are at high risk for developing small nodular carcinomas elsewhere in their Barrett’s segment, and routine surveillance on a 3to 6-month basis must be continued indefinitely. Alternatively, one can consider radiofrequency ablation of the remainder of the high-grade dysplasia after careful surveillance


Surgery_Schwartz

Surgery_Schwartz. surveillance on a 3to 6-month basis must be continued indefinitely. Alternatively, one can consider radiofrequency ablation of the remainder of the high-grade dysplasia after careful surveillance biopsy specimens demonstrate no further sign of cancer. This approach to the early esophageal cancer Table 25-12Functional grades of dysphagiaGRADEDEFINITIONINCIDENCE AT DIAGNOSIS (%)IEating normally11IIRequires liquids with meals21IIIAble to take semisolids but unable to take any solid food30IVAble to take liquids only40VUnable to take liquids, but able to swallow saliva7VIUnable to swallow saliva12Data from Takita H, Vincent RG, Caicedo V, et al. Squamous cell carcinoma of the esophagus: a study of 153 cases, J Surg Oncol. 1977;9(6):547-554.Brunicardi_Ch25_p1009-p1098.indd 107401/03/19 6:05 PM 1075ESOPHAGUS AND DIAPHRAGMATIC HERNIACHAPTER 25should not be used when there is any suspicion of mediastinal or abdominal lymphadenopathy. Although it is currently rare that EMR provides


Surgery_Schwartz

Surgery_Schwartz. 6:05 PM 1075ESOPHAGUS AND DIAPHRAGMATIC HERNIACHAPTER 25should not be used when there is any suspicion of mediastinal or abdominal lymphadenopathy. Although it is currently rare that EMR provides definitive therapy of small nodular esophageal cancers, this may become more of the norm as greater surveillance reveals earlier cancers and proficiency of the technique by surgeons and gastroenterologists increases.Minimally Invasive Transhiatal Esophagectomy. Minimally invasive transhiatal esophagectomy is an increasingly popular procedure; however, the number of these operations performed around the world remains small. Mini-invasive surgery (MIS) transhiatal esophagectomy was first performed by Aureo DePaula in Brazil and has been modified and adopted by many individuals around the world. This operation combines the advantages of transhiatal esophagectomy at minimizing pulmonary complications with the advantages of laparoscopy (less pain, quicker rehabilitation). Several variations of


Surgery_Schwartz

Surgery_Schwartz. This operation combines the advantages of transhiatal esophagectomy at minimizing pulmonary complications with the advantages of laparoscopy (less pain, quicker rehabilitation). Several variations of MIS transhiatal esophagectomy have been developed. For the earliest lesions, such as high-grade dysplasia or intramucosal carcinoma, a vagal sparing procedure can be entertained. In such a procedure, the vagal trunks are separated from the esophagus at the level of the diaphragm and the lesser curvature dissection of the stomach allows the vagus and left gastric pedicle to remain intact. Clearly, this dissection, which hugs the stomach and esophagus, provides no LN staging and is thus inadequate for all high-grade dysplasia and intramucosal cancer.MIS transhiatal esophagectomy is usually performed through five or six small incisions in the upper abdomen and a transverse cervical incision for removing the specimen and performing the cervical esophagogastrostomy. To remove the esophagus


Surgery_Schwartz

Surgery_Schwartz. through five or six small incisions in the upper abdomen and a transverse cervical incision for removing the specimen and performing the cervical esophagogastrostomy. To remove the esophagus from the posterior mediastinum, especially the area behind the pulmonary vessels and the tracheal bifurcation, which cannot be visualized even with a long laparoscope placed in the posterior mediastinum, it is preferred to use a vein stripping “inversion” technique (Fig. 25-69A). The details of this operation are too lengthy to include in this text, but include the laparoscopic creation of a neo-esophagus (gastric conduit) along the greater curvature of the stomach using the right gastroepiploic artery as the primary vascular pedicle. The conduit can be created through a mini-laparotomy or laparoscopically. A Kocher maneuver releases the duodenum, and a pyloroplasty may be performed (optional). Retrograde esophageal stripping is performed by dividing the esophagus below the GEJ and sliding a vein


Surgery_Schwartz

Surgery_Schwartz. A Kocher maneuver releases the duodenum, and a pyloroplasty may be performed (optional). Retrograde esophageal stripping is performed by dividing the esophagus below the GEJ and sliding a vein stripper from the neck down into the abdomen followed by an inversion of the esophagus in the posterior mediastinum and removal through the neck (Fig. 25-69B). This technique is reserved for patients with high-grade dysplasia. For small cancers at the GEJ, the esophagus can be stripped in an antegrade fashion by sliding the vein stripper down from the cervical incision and out the tail of the lesser curvature (Fig. 25-69C). The tail of the lesser curvature is pulled out a port site high in the epigastrium while the esophagus is inverted into itself. For GEJ cancers, a wide celiac access LN dissection, splenic artery, hepatic artery, and posterior mediastinal LN dissection can be performed as well or better than through a laparotomy. The gastric conduit is pulled up to the neck with a chest tube


Surgery_Schwartz

Surgery_Schwartz. splenic artery, hepatic artery, and posterior mediastinal LN dissection can be performed as well or better than through a laparotomy. The gastric conduit is pulled up to the neck with a chest tube and anastomosed to the cervical esophagus in an end-to-side fashion using a surgical stapler or with a handsewn anastomosis. Complications of this technique are primarily limited to leak from the esophagogastric anastomosis, which is self-limited and usually heals within 1 to 3 weeks, spontaneously.Figure 25-69. A. Laparoscopic retrograde inversion. B. Laparo-scopic antegrade inversion. A silk suture holds the tunnel after the esophagus is removed. C. The esophageal conduit is returned to the neck after passing a chest tube down the tunnel and suturing the conduit to the chest tube.Brunicardi_Ch25_p1009-p1098.indd 107501/03/19 6:05 PM 1076SPECIFIC CONSIDERATIONSPART IIOpen Transhiatal Esophagectomy. Transhiatal esophagec-tomy, also known as blunt esophagectomy or esophagectomy without a


Surgery_Schwartz

Surgery_Schwartz. 107501/03/19 6:05 PM 1076SPECIFIC CONSIDERATIONSPART IIOpen Transhiatal Esophagectomy. Transhiatal esophagec-tomy, also known as blunt esophagectomy or esophagectomy without a thoracotomy, was first performed in 1933 by a British surgeon, but was popularized in the last quarter of the 20th century by Mark Orringer from the University of Michigan. Although this operation may violate many of the principles of cancer resec-tion, including extended radical LN dissection, this operation has performed as well as any of the more radical procedures in randomized trials, and in large database analyses. With transhia-tal esophagectomy, the elements of dissection are similar to that described in the section entitled Minimally Invasive Transhiatal Esophagectomy, including the creation of the gastric tube and the posterior mediastinal dissection through the hiatus. Because this dissection is performed with the fingertips rather than under direct vision with surgical instruments, it requires an


Surgery_Schwartz

Surgery_Schwartz. tube and the posterior mediastinal dissection through the hiatus. Because this dissection is performed with the fingertips rather than under direct vision with surgical instruments, it requires an enlargement of the diaphragmatic hiatus. The lower mediastinal LN basins can be resected as can the upper abdominal LNs, making this an attrac-tive option for GEJ cancers. The mediastinal LNs above the infe-rior pulmonary vein are not removed with this technique, but they rarely result in a point of isolated cancer recurrence.Of all procedures for esophageal cancer, this operation is the quickest to perform in experienced hands and lies in an intermedi-ate position between minimally invasive esophagectomy and the Ivor Lewis procedure with respect to complications and recovery.Minimally Invasive Twoand Three-Field Esophagectomy. After a rocky start, minimally invasive esophagectomy using a thoracic dissection through VATS has become reasonably popular. In general, this operation is performed


Surgery_Schwartz

Surgery_Schwartz. Three-Field Esophagectomy. After a rocky start, minimally invasive esophagectomy using a thoracic dissection through VATS has become reasonably popular. In general, this operation is performed with an anastomosis created in the neck (three-field), but it may be performed with the anastomosis stapled in the high thorax (two-field). Both procedures will be described.With a minimally invasive three-field esophagectomy, the patient is placed in the left lateral decubitus position. Double lumen intubation is required. Videoscopic access to the thorax is obtained in the midaxillary line in the ninth intercostal space and an angled telescope illuminates the chest superiorly. A mini-thoracotomy at about the sixth intercostal space anteriorly allows introduction of conventional surgical instruments, and a high trocar allows retraction of the lung away from the esophagus. In a three-field approach, the esophagus is dissected along its length to include division of the azygos vein and