- 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%
Iatrogenic
Boerhaave's Syndrome
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
- 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
Zenker's Diverticulum
Presentation
- Dysphagia
- Halitosis
- Palpable mass
- Regurgitation
- Recurrent aspiration pneumonia
Diverticulae
Workup
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