Esophagus

Educational Objectives

The purpose of this program is to improve surgical and nonsurgical management of disorders of the esophagus. Upon listening to and assimilating this program, the clinician will be better able to:

1.   Discuss the principles of repair of complex esophageal strictures.

2.   Review the goals of dilation of complex esophageal strictures.

3.   List the basic tenets of managing esophageal perforations.

4.   Explain the use of growth induction in the management of surgical atresia.

5.   Determine which patients with paraesophageal hernias can be managed with watchful waiting.   

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of in­terest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose.

Acknowledgements

Drs. Boyce, Peters, and Foker were recorded at 73rd Annual Surgery Course: Advances in Gastrointestnial and GI Laparo­scopic Surgery, held June 10-13, 2009, in Minneapolis, MN, and sponsored by the University of Minnesota School of Med­icine. Dr. Pryor spoke at Surgery of the Foregut 2009, held February 15-18, 2009, in Miami, FL, and sponsored by the Cleveland Clinic Foundation, the German Society of Visceral Surgery, the Federation of Latin American Surgeons, the Eu­ropean Surgical Institute, and the Latin-American Society of Endoscopic Surgeons. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Management of Complex Esophageal Strictures

H. Worth Boyce, MD, Professor of Medicine and Director of Center for Esophageal and Swallowing Disorders, University of South Florida College of Medicine, Tampa

Definitions: stenosis  —  any narrowing or stricture of duct or canal; stricture  —  decrease in caliber of canal, duct, or other passage resulting from deposition of abnormal tissue (cicatrix, fibrosis, or neoplasm); spasm, inflamma­tion, compression, and cancer usually respond poorly or not at all to dilation

Classification of fibrotic strictures: simple  —  usually involve only mucosa or submucosa; <1 cm long; most com­monly associated with reflux; can be dilated in several ways; complex  —  usually transmural or deep injury into muscularis propria through esophageal wall; >1 cm in length; lumen diameter <10 mm; may be angulated or ir­regular; total occlusion of esophagus or pharyngoesophageal junction; may occur secondary to irradiation, che­motherapy, or surgery for head and neck cancer

Therapeutic options: steroid injections rarely helpful; electrocautery (only by experienced electroendoscopist); stents under proposal (long-term value questionable)

Management: balloon dilation of radiotherapeutic, ischemic, nasogastric (NG) tube, or caustic strictures “destined to fail”

Principles of therapy: good history and physical examination can reveal etiology and help predict pathogenesis; in­juries from pills or gastroesophageal reflux disease (GERD) may complicate primary etiology; identify patho­logic anatomy with barium esophagography, then conduct endoscopy and obtain biopsy; “rule of 3”  —  first dilator with moderate or greater resistance considered first dilation; use progressively larger dilators until moder­ate or greater resistance encountered 3 times, then discontinue session; does not apply to through-the-scope (TTS) balloons or other methods that do not involve tactile sense; do not use with eosinophilic esophagitis (stric­tures have little resistance and often tear)

Technique: start with clean esophagus; instruct patient to discontinue anticoagulant medication 4 to 5 days before procedure; know anatomy beyond stricture; understand guidewire design and importance of proper placement; guidewire in antrum should show 3 mark on dilator shaft at start; fluoroscopy recommended; lubricate only 3 to 4 cm of dilator tip; use proper head position to minimize pressure on postpharyngeal wall (flex head back, keep­ing neck as straight as possible); speaker removes mouthpiece for dilators larger than 12 to 14 mm (mouthpiece necessitates increased force on posterior pharynx); pass largest diameter of dilator over stricture; deep or trans­mural injuries may be associated with inflammation for 12 to 24 mo; suggests cicatrix not yet mature; maturation associated with better response to dilation; speaker recommends prescribing  double doses of proton pump inhib­itors for patients requiring NG tubes

Ringed strictures and eosinophilic esophagitis: incidence of eosinophilic esophagitis increasing rapidly; perforation risk unknown but high; warn patients not to regurgitate voluntarily to clear food bolus from esophagus; dilator can induce tear with very little resistance

Etiology of complex strictures: usually iatrogenic; radiation therapy may be most common cause; other causes in­clude Bernstein tests, anastomoses, fundoplication, endoscopic mucosal resection, NG tubes, and pill esophagitis

Goal of dilation: to establish lumen compatible with patient’s needs; normal esophageal diameter equal to that of quarter; maximum achieved with dilation rarely >18 mm; evaluate patency by asking if patient can eat fresh (un­toasted) bread, steak, and apple (unpeeled); dilation should be continued to >13 mm to avoid outcome of solid-food dysphagia; even at 18 mm, patients cannot eat normal diet

Aphagia: increasingly common; often results from failure to dilate esophagus after radiation therapy; no evidence that post-radiation therapy dilation more dangerous than other dilations; speaker and colleagues go through gastros­tomy site; perform rigid endoscopy from above simultaneously; pull string through mouth and retrieve through nose; usually perform retrograde dilation with Tucker dilators before retrieving string; tie string, leaving it attached to chest; have patient return for repeat dilation every few days over next few weeks

Esophageal Perforations: Diagnosis and Treatment

Jeffrey H. Peters, MD, Professor and Chair, Department of Surgery, University of Rochester School of Medi­cine and Dentistry, Rochester, NY

Basic tenets of management: do not feed patient; close hole as soon as possible and try to confirm closure; drain spillage; ensure that patient has appropriate antibiotic therapy for oral flora; check for distal obstruction (may add proximal pressure; prevent or treat whenever possible); check for factors that may keep hole open (eg, tumor, for­eign body, infection); consider diversion and resection as last resorts if ongoing sepsis present (diversion alone usu­ally not performed)

Risk factors for mortality: age of perforation  —  2 to 3 times higher with perforations >24 hr old, compared to <24 hr; site  —intrathoracic worse than intra-abdominal; intra-abdominal worse than intracervical; many cervical perfo­rations managed nonoperatively, or with drainage only; presence of neoplasms  —more lethal if malignant than if benign; risk higher with benign disease than with normal esophagus; pleural integrity   —determine through chest x-ray; air or fluid in pleural cavity associated with higher risk for widespread contamination and mortality than with intact cavity

Treatment

Primary nonoperative management: appropriate if patient stable, with minimal and controllable pain; disruption should be contained within mediastinum and drain back into esophagus; patient should be without signs of sep­sis, significant fever, significant tachycardia, or leukocytosis; indicated particularly if clinician knows when per­foration occurred (eg, during pneumatic dilation for achalasia)

Primary repair and drainage: indicated if patient has free flow of material or clear leak into pleural cavity, widely patent leak into mediastinum, or ill without extensive pleural contam-ination; recommended technique  —  myotomize esophagus around perforation; trim mucosal defect; close mucosa separately, then close muscle over mucosal defect, thereby creating 2-layer closure; buttress with omentum, stomach, pleural, or intercostal muscle patch (Grillo flap recommended)

Resection: indicated for perforations in setting of malignancy, refractory stricture, or significant underlying pathol­ogy; best approach if indication existed before perforation; substernal reconstruction usually recommended 3 to 6 mo after resection; other indications include persistent uncontrolled mediastinal sepsis or moribundity; several studies report lower mortality with resection than with repair

Conservative (nonoperative) management: suggested by Vogel et al as preferred approach in most cases; of 28 pa­tients with thoracic perforations managed conservatively, mortality rate 0, compared to 2 deaths among 6 surgi­cally treated patients; according to speaker, advent of expandable removable plastic stents “has probably changed the paradigm of the management of esophageal perforation”; stents can often close hole; surgery necessary only to remove abcess; stent migration and need for replacement most significant drawback

Primary Repair of Long Atresias and Strictures

John E. Foker, MD, Robert L. and Sharon G. Kaster Professor of Cardiovascular and Thoracic Surgery, Uni­versity of Minnesota Medical School, Minneapolis

Difficulty in achieving primary repair: distance between ends presents greatest challenge with atresia or after stric­ture resection; long-gap atresia  —  “gap that’s too long for primary repair”; most attempts at repair involve inter­position; with pediatric patients, goal for duration of repair >70 yr

Treatment options: myotomy  —  simple, but may lead to large diverticulum; gastric transposition or pull-up  —  easiest method, but may lead to obligatory cervical esophageal reflux, Barrett’s esophagitis, or atrophic gastritis (ie, incompatible with long-term cure); other complications include dumping syndrome and low iron stores; gas­tric tube interposition  —  in one series of 14 patients, Barrett’s-type changes appeared after 8 yr; colonic interposition  —formerly common, but late complications include lack of peristalsis and associated aspiration; je­junal interposition  —more difficult to perform, but achieves best results among interposition procedures; consid­eration recommended for young adult patients

Induction of esophageal growth: solution suggested by speaker; may need to perform anastomosis under tension; recommended for atresias of nongenetic origin and in which growth ability retained; clinician need only provide correct growth signal (for esophagus, stress applied to long axis; mimics growth of spinal column); requires one op­eration to stimulate growth, waiting period while growth occurs, and second operation for repair; reflux and stric­tures treated actively; goal to restore patient to normalcy as soon as possible; speaker’s definition of true primary repair  —patient has native esophagus only, with gastroesophageal (GE) junction below diaphragm, and no myoto­mies

University of Minnesota series: no patient refused; gap >4.5 cm too long for primary repair; only posterior incision used; lower esophageal segment found and traction sutures (generally, 4) placed to stimulate growth (avoid lumen);  sutures brought out through chest wall; tension exerted once or twice daily produces “remarkable growth”; for moderate gaps, traction exerted in operating room; longer gaps require internal traction; external traction used for longest gaps; primary repair achieved in all 61 patients treated; some required anastomosis un­der tension; achieved by suturing entire back row, then crossing sutures and slowly bringing ends together so su­tures can be tied individually off-tension; procedure repeated for anterior row; complications included avulsion of traction sutures; 6 deaths (none related to repair)

Lessons learned: cardinal principles not necessarily true; well-constructed anastomosis withstands tension and rarely leaks; GE junction should be below diaphragm

Remaining issues: treatment of reflux strictures varies widely nationally and internationally; with growth induction, resulting function good in upper segment and uncoordinated in lower segment (with satisfactory emptying); most serious problem GE reflux (fundoplication recommended); anastomotic strictures also common, but often relent; speaker recommends balloon dilation (with overdilation so esophagus can open normally); goal to achieve nor­mal esophageal contour; covered removable stent can be used with balloon dilation, left in place for 1 to 2 wk, and repeated if necessary; does not solve problem of underlying disease; resistant strictures  —  treatment depends largely on parents’ wishes; short strictures can be resected; long ones retract when resected; growth induction possible, but anastomosis necessary to prevent material from leaking into chest; staged resection indicated; lye burns  —resection indicated

Conclusions: all patients responded with adequate growth and can eat normally; “there’s no reason to think these will deteriorate with time”

Repair of Paraesophageal Hernia

Aurora D. Pryor, MD, Associate Professor of Surgery, Duke University School of Medicine, Durham, NC

Hiatal hernia: upward protrusion of stomach or other viscera through esophageal hiatus into mediastinum; simple sliding hiatal hernia most common type; true paraesophageal hernias comprise 1% to 2% of hiatal hernias

Sliding hernia (type 1): GE junction migrates into chest; often happens as complication of increased abdominal pressure (secondary to pregnancy or obesity) or with aging; most commonly seen in people >40 yr of age

Paraesophageal hernia: female preponderance; occurs with aging; complications such as gastric incarceration may be lethal; type 2  —  pure paraesophageal hernia; may occur with fundus, greater curvature, or pylorus; with pro­gression over time, stomach may migrate to upside-down position in chest; type 3  —  mixed; GE junction and stomach may slide into chest; type 4  —  other viscera involved; barium studies can help define anatomy

Presentation: £30% may be asymptomatic; »50% of patients have chronic symptoms; 20% have acute symptoms with life-threatening complications

Diagnosis: asymptomatic hernias often detected on chest x-ray; chronic symptoms include anemia, pain, or full­ness; when patients present to emergency department with acute symptoms (eg, significant chest pain), techni­cians often find that contrast agent for barium study will not pass through

Indications for surgical repair of paraesophageal hernia: in past, all hernias surgically repaired; thinking has evolved to limit repair to symptomatic hernias and asymptomatic large hernias in fit patients; small hernias can be observed over time; in 2002, Rattner and colleagues calculated that, for patients with minimal symptoms, an­nual risk of requiring emergency surgery 1.5%; conclusions  —  watchful waiting “reasonable” for asymptomatic patients; studies reveal that acute symptoms often resolve upon compression with NG tube, and that true emer­gent repair “very unusual”; current data suggest worst-case operative mortality rate of »15%

Patients most likely to develop life-threatening complications: those with stomach in chest, torsion, and gastric vol­vulus, with resulting obstruction, strangulation, and perforation; presenting symptoms retching and chest pain; inability to pass NG “the only true surgical emergency”

Management of chronic symptoms: data suggest even high-risk patients undergo laparoscopic surgery with only minor complications and symptom resolution; surgical treatment for symptomatic relief “reasonable”; upper gas­trointestinal series and endoscopy diagnostic gold standards; patient should also undergo evaluation under anes­thesia, including cardiac and pulmonary evaluation

Suggested Reading

Boyce HW: Dilation of difficult benign esophageal strictures. Am J Gastroenterol 100:744, 2005; Devaney EJ et al: Esophagectomy for achalasia: patient selection and clinical experience. Ann Thorac Surg 72:854, 2001; Foker JE et al: Development of a true pri­mary repair for the full spectrum of esophageal atresia. Ann Surg 226:533, 1997; Foker JE et al: Long-gap esophageal atresia treated by growth induction: the biological potential and early follow-up results. Semin Pediatr Surg 18:23, 2009; Gangopadhyay N et al: Outcomes of laparoscopic paraesophageal hernia repair in elderly and high-risk patients. Surgery 140:491, 2006; Giever T, Gottlieb K, Merg A: Endoscopic repair of a complete post-radiation esophageal obstruction. J Gastrointestin Liver Dis 17:335, 2008; Kot­zampassakis N et al: Esophageal leaks repaired by muscle onlay approach in the presence of mediastinal sepsis. Ann Thorac Surg 88:966, 2009; Mao JC et al: Conservative management of iatrogenic esophageal perforation in head and neck cancer patients with esophageal stricture. Otolaryngol Head Neck Surg 140:505, 2009; Rice TW et al: Worldwide esophageal cancer collaboration. Dis Esophagus 22:1, 2009; Stylopoulos N et al: Paraesophageal hernias: operation or observation? Ann Surg 236:492, 2002; Till H et al: Staged esophageal lengthening with internal and subsequent external traction sutures leads to primary repair of an ultralong gap esophageal atresia with upper pouch tracheoesophageal fistula. J Pediatr Surg 43:E33, 2008; Vogel SB et al: Esophageal perforation in adults: aggressive, conservative treatment lowers morbidity and mortality. Ann Surg 241:1016, 2005.