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General Surgery
Benign Esophageal Disorders
Built from Maingot's Abdominal Operations
What’s inside
5 sections · 180 slides
Overview
- The esophagus as a transport tube
- Scope of the topic
- Abbreviations used throughout
Paraesophageal Hernia
A hole at the diaphragm that lets the stomach climb into the chest.
- Mechanism of hiatal herniation
- Causes of a widened hiatus
- Contents of the hernia sac
- Classification of hiatal hernias
- Type I sliding hiatal hernia
- Type II paraesophageal hernia
- Type III mixed hiatal hernia
- Gastric volvulus in a large hernia
- Type IV hiatal hernia
- Clinical presentation
- Severe pain as a warning sign
- Iron deficiency anemia and Cameron's ulcers
- Natural history and how these hernias are found
- Physical examination findings
- Chest x-ray findings
- Barium swallow in hernia assessment
- Role of computed tomography
- Upper gastrointestinal endoscopy
- Manometry and pH testing before repair
- Preoperative pH testing has limited predictive value
- How the indications for surgery evolved
- Modern data on watchful waiting
- Selecting patients for elective repair
- Areas of continuing disagreement
- Universal steps of paraesophageal hernia repair
- Open access routes compared
- Advantages of the laparoscopic approach
- A caution about laparoscopic repair
- Why crural repair decides the outcome
- Randomised trials of mesh at the hiatus
- Complications of prosthetic mesh at the hiatus
- Biologic mesh as a buttress
- Evidence supporting biologic mesh
- Rationale for routine fundoplication
- Patient positioning for hiatal surgery
- Port placement for hiatal access
- Opening the hernia sac
- Structures at risk during dissection
- Identifying the distorted esophagus
- Mediastinal mobilisation and sac excision
- Closing the crura
- When posterior sutures angle the esophagus
- Buttressing the closure with mesh
- Setting up the fundoplication
- The shoeshine manoeuvre
- Completing the Nissen fundoplication
Spastic Motility Disorders
When the squeeze is too strong, too fast, or out of order.
- Primary esophageal motility disorders
- Reflux disease as a mimic
- Secondary causes of esophageal dysmotility
- Sequence of assessment for suspected dysmotility
- Two ways of recording a swallow
- Normal swallow on conventional manometry
- Normal swallow on high-resolution manometry
- Reading a normal swallow
- Diffuse esophageal spasm
- Manometric criteria for diffuse esophageal spasm
- Diffuse esophageal spasm on conventional manometry
- Diffuse esophageal spasm on high-resolution manometry
- Treatment of diffuse esophageal spasm
- Nutcracker esophagus
- Nutcracker esophagus on conventional manometry
- Nutcracker esophagus on high-resolution manometry
- Surgical results in nutcracker esophagus
- Selecting patients in nutcracker esophagus
- Medical treatment of nutcracker esophagus
- Hypertensive lower esophageal sphincter
- Hypertensive lower esophageal sphincter on conventional manometry
- Hypertensive lower esophageal sphincter on high-resolution manometry
- Medical treatment of a hypertensive sphincter
- Choosing an operation for a hypertensive sphincter
- Summary of the spastic disorders
Achalasia
The squeeze disappears and the valve refuses to open.
- Achalasia as a primary motor disorder
- Pathology of achalasia
- Proposed causes of ganglion cell loss
- Pathophysiology of achalasia
- Who develops achalasia
- Manoeuvres patients use to swallow
- Consequences of chronic regurgitation
- Pseudoachalasia
- Barium swallow findings in achalasia
- Sigmoid esophagus in long-standing disease
- Manometric findings in achalasia
- Achalasia on conventional manometry
- Achalasia on high-resolution manometry
- Endoscopy and pH testing in achalasia
- Aim of treatment in achalasia
- Drug treatment of achalasia
- Botulinum toxin injection
- Drawbacks of repeated botulinum toxin
- Pneumatic balloon dilation
- Durability and risk of pneumatic dilation
- Endoscopic options compared
- Surgical myotomy: origins and results
- From open surgery to minimally invasive myotomy
- Why the laparoscopic route won
- Adding an antireflux procedure to myotomy
- Partial wrap or full wrap after myotomy
- Dor versus Toupet
- The debate over myotomy length
- Extended myotomy
- Medium-term results of extended myotomy
- Why an extended myotomy needs a wrap
- Steps of laparoscopic Heller myotomy
- Preparing for laparoscopic myotomy
- Exposure before the myotomy
- Performing the myotomy
- Working through the muscle layers
- Bleeding and thermal injury during myotomy
- Recognising and repairing mucosal injury
- Checking the myotomy with endoscopy
- Constructing the Toupet fundoplication
- Operative view of the completed repair
- Anterior (Dor) fundoplication
- Complete and partial fundoplication wraps
- Complete 360-degree wrap in cross-section
- Anterior partial wrap in cross-section
- Posterior partial wrap in cross-section
- Postoperative care after myotomy
- Follow-up after myotomy
- Summary of the motility disorders
Esophageal Diverticula
Pouches that balloon out where the wall is weak and the pressure is high.
- Esophageal diverticula by site
- True and false diverticula
- Zenker's diverticulum: naming and site
- Areas of weakness at the pharyngoesophageal junction
- Killian's triangle and why the pouch forms
- Presentation of Zenker's diverticulum
- Examination and workup for Zenker's diverticulum
- What endoscopy is looking for
- How treatment has evolved
- When open surgery is required
- Positioning and incision for open diverticulectomy
- Exposure of the cervical esophagus
- Myotomy and resection of the pouch
- Planning and performing the cervical myotomy
- Stapled resection of the pouch
- Closure and recovery after open repair
- Results of open surgery for Zenker's diverticulum
- History of endoscopic treatment
- The principle behind endoluminal treatment
- Endoscopic stapled division of the septum
- Rigid and flexible endoscopic platforms
- Outcomes of endoluminal treatment
- Who is unsuitable for endoluminal treatment
- Summary of Zenker's diverticulum
- Epiphrenic diverticula
- Why an epiphrenic diverticulum forms
- Presentation and workup
- Deciding who to treat
- Principles of surgical treatment
- Results with open thoracotomy
- Minimally invasive results
- Why laparoscopy is preferred
- Preparation for laparoscopic diverticulectomy
- Exposing the distal esophagus
- Freeing the diverticulum
- Stapled resection of the diverticulum
- The completed resection
- Completing the operation
- Postoperative course after diverticulectomy
- Summary of epiphrenic diverticula
- Key points: paraesophageal hernia
- Key points: motility disorders
- Key points: diverticula
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- References (continued)
- Maingot's Abdominal Operations, 12th Edition