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  • All intramural dissections without full-thickness perforation
  • Transmural dissections if:
  • Well contained
  • No malignancy
  • Not in abdominal cavity
  • No obstructive esophageal disease
  • No sepsis
  • Broad-spectrum antibiotics
  • NPO
  • Parenteral/enteral feeds
  • Monitor temperature, heart rate, WBCs
  • Correlation between GERD and ZD
  • Thought to be from cricopharyngeal spasm -> discoordination

References:

Esophageal Perforation/Repair

Heller Myotomy

Zenker's Diverticulum

Esophageal

Anatomy

  • ~25cm
  • Inferior cricoid cartilage (C6) to stomach (T11)
  • 3 constrictions
  • Cricopharyngeal sphincter (C6)
  • Aortic arch and L main bronchus
  • Diaphragmatic entrance
  • 3 anatomic divisions
  • Cervical (cricopharyngeus to suprasternal notch)
  • Thoracic (suprasternal notch to diaphragm)
  • Abdominal (diaphragm to gastric cardia)
  • Ernster, Joel. "Zenker Diverticulum." Medscape. Emedicine, 10 Aug. 2014. Web. 15 Sept. 2014. <http://emedicine.medscape.com/article/836858-overview#aw2aab6c11>.
  • Weksler, Benny. "Endoscopic Transoral Stapling of Zenker's Diverticula." Multimedia Manual of Cardio-Thoracic Surgery. Oxford Journals, 1 Jan. 2010. Web. 15 Sept. 2014. <http://mmcts.oxfordjournals.org/content/2010/0517/mmcts.2007.002923.full>.
  • Wiener, Daniel. "Minimally Invasive Esophageal Procedures." Surgical Council on Resident Education. Surgical Council on Resident Education, 1 Jan. 2014. Web. 15 Sept. 2014. <http://www.surgicalcore.org/chapter/24440#24469>.

Esophageal Perforation

Esophageal

Perforation Repair

Etiologies of

Esophageal

Perforation

Breakdown

  • Iatrogenic: 59%
  • Spontaneous 15%
  • Foreign body ingestion: 12%
  • Trauma: 9%
  • Other: 5%

59%

Iatrogenic

Boerhaave's Syndrome

41%

Non-

Iatrogenic

  • Operative trauma
  • Vagotomy
  • Pulmonary resection
  • Hiatal hernia repair
  • Esophagomyotomy
  • Endoscopy
  • Dilation
  • Intubation
  • Sclerotherapy

Workup

  • Barotrauma
  • Boerhaave Syndrome
  • Blunt trauma
  • Labor
  • Convulsions
  • Defecation
  • Penetrating Trauma
  • Corrosive injuries
  • Erosion from infection
  • Swallowed foreign body
  • High degree of suspicion
  • Symptoms previously described after endoscopy
  • Contrast esophagography
  • Water-soluble (50% C, 80% T)
  • Barium (60% C, 90%T)
  • Barium preferred in known TE fistula or aspiration risk due to hyperosmolar water-soluble agents causing pulmonary edema
  • Flexible esophagoscopy
  • Sens 100%
  • Spec 80%
  • Risk of insufflation converting to full-thickness injury
  • Transmural
  • Distinct from Mallory-Weiss syndrome

Nonoperative Management

Presentation:

Thoracic Perforation

Cervical Perforation

Abdominal

Perforation

  • Signs and symptoms of mediastinitis
  • Hamman Sign
  • Acute abdomen
  • Tachycardia
  • Tachypnea
  • Fever
  • Leukocytosis
  • Progression
  • Sepsis
  • Shock
  • Dysphagia
  • Neck pain
  • Dysphonia
  • Subcutaneous emphysema

Achalasia

Operative

Management

Presentation

  • Dysphagia
  • Solid ~50%
  • Liquid ~66%
  • Symptoms plateau as patients learn to adapt (postural, etc)

Lower Esophageal Sphincter

Treatment

Derek I. Thacker, M.D.

PGY-1

Goal: Reduce pressure across LES

  • Surgical myotomy
  • Pneumatic dilation
  • Pharmacologic agents

Workup

  • Chest pain ~50%
  • Regurgitation ~75%
  • Weight loss (late)

Upper Third:

  • Cervical drainage
  • +/- suture
  • NGT
  • NPO 1 week
  • Restudy

Heller Myotomy

Modern Heller Myotomy with fundoplication

  • Originally described in 1913 by Ernest Heller

  • 8-cm parallel myotomies (anterior and posterior)
  • No antireflux procedure

Middle Third:

  • R 5th intercostal thoracotomy
  • Intercostal muscle pedicled flap
  • Mucosal exposure and repair

Distal Third:

Left seventh intercostal thoracotomy

  • Pedicled flap

Zenker's Diverticulum

Presentation

  • Dysphagia
  • Halitosis
  • Palpable mass
  • Regurgitation
  • Recurrent aspiration pneumonia

Diverticulae

Workup

Barium swallow

When to Operate

  • Symptomatic
  • Generally, >2cm
  • Patients without precluding comorbids
  • Transverse incision at level of cricoid, extending laterally to SCM
  • Retract SCM and carotid sheath contents laterally; retract the thyroid/thyroid cartilage medially,turn them slightly away from dissection
  • Perform the dissection on the diverticulum if readily apparent; if the sac is not apparent, begin dissection posteriorly in the midline at the level of the inferior constrictor muscle, extending inferiorly until the sac is encountered
  • Then transect the sac neck either sharply or stapler
  • Perform CP myotomy
  • If sac sharply transected, perform closure with 3-0 or 4-0 absorbable suture
  • Place NG tube and nonsuction drain

Operative Management

  • Division of cricopharyngeus muscle
  • Elimination of diverticular pouch

Endoscopic Transoral Stapling

Pharyngocricopharyngeal dyscoordination

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