Surgery chapters
Oesophagus: achalasia, GORD surgery, perforation and carcinoma
The surgical disorders of the oesophagus: dysphagia work-up, achalasia and other motility disorders, GORD, hiatus hernia and Barrett oesophagus, perforation including Boerhaave syndrome, pouches and webs, and oesophageal carcinoma.
- Achalasia is failure of the lower oesophageal sphincter to relax with absent peristalsis; barium shows a dilated oesophagus with a bird's beak, manometry confirms it, and Heller myotomy (with partial fundoplication), balloon dilatation or POEM treat it.
- GORD is treated with PPIs; surgery (fundoplication) suits volume reflux, PPI intolerance or young patients unwilling to take lifelong drugs; Barrett metaplasia raises adenocarcinoma risk.
- Boerhaave is a lower third, left posterolateral rupture after vomiting (Mackler triad); oesophageal cancer is squamous in the upper two-thirds (commonest worldwide) and adenocarcinoma in the lower third (rising, Barrett).
On this page
Overview
The oesophagus is a muscular tube about 25 cm long from the cricopharyngeus to the cardia. The upper third has striated muscle, the lower half smooth muscle, and it is lined by stratified squamous epithelium. It has no serosa, which is why leaks spread and why cancer invades early.
Two sphincters matter: the upper (cricopharyngeus) and the lower oesophageal sphincter (LOS), a 3-4 cm high-pressure zone helped by the crura and the angle of His.
The key symptom is dysphagia. Progressive dysphagia in an adult is cancer until proved otherwise.
Dysphagia: approach
| Pattern | Think of |
|---|---|
| Solids then liquids, progressive, weight loss, older | Carcinoma |
| Liquids and solids from the start, regurgitation of undigested food | Achalasia (motility disorder) |
| Long history of heartburn, then solids | Peptic stricture |
| Intermittent, with chest pain | Diffuse spasm |
| Gurgling neck lump, halitosis, regurgitation of old food | Pharyngeal pouch |
| Iron deficiency, middle-aged woman, upper dysphagia | Plummer-Vinson web |
| Choking, nasal regurgitation, coughing on swallowing | Oropharyngeal (neurological: stroke, MND, myasthenia) |
Investigations:
- Upper GI endoscopy with biopsy: first-line for most cases, especially to exclude cancer.
- Barium swallow: shows shape (achalasia, pouch, rings); use before endoscopy if a pouch is suspected, as the scope can perforate it.
- High-resolution manometry: the test for motility disorders.
- 24-hour pH (or pH-impedance) monitoring: the most accurate test for reflux; the probe sits 5 cm above the LOS, and pH below 4 counts as reflux.
- CT, endoscopic ultrasound (EUS) and PET-CT: staging of cancer.
Achalasia
Pathology
- Inhibitory neurons of the myenteric (Auerbach's) plexus in the lower oesophagus are lost; the cause is unknown.
- Result: LOS fails to relax on swallowing and the body loses peristalsis.
- Chagas disease (Trypanosoma cruzi) produces a similar picture.
- Pseudoachalasia: carcinoma of the cardia mimicking achalasia; always biopsy the cardia.
Clinical features
- Usually middle age; dysphagia for both liquids and solids, often worse with liquids.
- Regurgitation of undigested food, especially at night, with aspiration, cough and chest infections.
- Chest pain in the early, spastic (vigorous) type; slow weight loss.
- Long-standing disease raises the risk of squamous cell carcinoma (from stasis oesophagitis).
Investigations
| Test | Finding |
|---|---|
| Chest X-ray | Wide mediastinum, fluid level behind the heart, absent gastric air bubble |
| Barium swallow | Dilated, sometimes sigmoid oesophagus tapering smoothly to a "bird's beak" at the LOS |
| Manometry (diagnostic) | Incomplete LOS relaxation (raised integrated relaxation pressure), absent peristalsis; Chicago types I, II and III |
| Endoscopy | Retained food; tight cardia that "pops" open; essential to exclude cancer |
Treatment
Treatment only relieves the obstruction; peristalsis does not return.
| Option | Notes |
|---|---|
| Pneumatic balloon dilatation | 30-40 mm balloon tears the LOS muscle; works in most, best over age 45; risk of perforation; may need repeating |
| Laparoscopic Heller cardiomyotomy | Cuts the LOS and upper cardia muscle down to mucosa; add a partial (Dor or Toupet) fundoplication to prevent reflux; success above 90% |
| POEM (peroral endoscopic myotomy) | Endoscopic myotomy through a submucosal tunnel; more reflux afterwards |
| Botulinum toxin injection | Temporary; for elderly or unfit patients |
| Drugs (nifedipine, nitrates) | Weak, short-lived |
The diagnostic test for achalasia is manometry; the classic image is a bird's-beak barium swallow; the main complication of dilatation is perforation and of myotomy is reflux.
Other motility disorders
- Diffuse oesophageal spasm: chest pain and dysphagia; corkscrew oesophagus on barium.
- Hypercontractile ("nutcracker", jackhammer) oesophagus: very high-amplitude peristalsis.
- Systemic sclerosis (CREST): weak, aperistaltic lower oesophagus with an incompetent LOS, so severe reflux and strictures (the opposite of achalasia).
Gastro-oesophageal reflux disease (GORD) and hiatus hernia
Causes
Weak LOS, sliding hiatus hernia, obesity, pregnancy, smoking, fatty meals, delayed gastric emptying.
Hiatus hernia
| Type | Features |
|---|---|
| Sliding (type I), the commonest | Gastro-oesophageal junction moves up into the chest; causes reflux |
| Rolling (paraoesophageal) | Junction stays below the diaphragm; fundus rolls up beside the oesophagus; little reflux but risk of volvulus, obstruction, strangulation, bleeding |
| Mixed | Both components |
Symptomatic rolling hernias are repaired surgically because of these dangers.
Treatment of GORD
- Lifestyle: weight loss, stop smoking, avoid late meals, raise the head of the bed.
- Proton pump inhibitors (PPIs): the most effective drug treatment; heal oesophagitis in about 8 weeks, then step down to the lowest effective dose.
- Antireflux surgery.
Indications for surgery:
- Symptoms controlled by PPI but the patient (often young) does not want lifelong drugs, or has side effects.
- Volume reflux (regurgitation, aspiration) not helped by PPI.
- Complications: recurrent strictures, large or rolling hiatus hernia.
- Proven reflux on pH study before operating; manometry excludes a motility disorder.
Operation principles: restore an intra-abdominal oesophageal segment, repair the crura, and wrap the fundus around the lower oesophagus (fundoplication), usually laparoscopically.
| Fundoplication | Wrap |
|---|---|
| Nissen | Total 360 degree posterior wrap |
| Toupet | Partial 270 degree posterior wrap |
| Dor | Partial anterior wrap (used with Heller myotomy) |
Side effects: dysphagia, gas-bloat (inability to belch or vomit), flatulence, wrap slipping or herniating. A short oesophagus may need a Collis gastroplasty.
Do not do a full Nissen wrap in a patient with absent peristalsis (achalasia, scleroderma). The wrap will cause severe dysphagia; a partial wrap is used.
Complications of GORD
- Oesophagitis (Los Angeles grades A to D), ulcer, bleeding.
- Peptic stricture: short, smooth stricture at the squamocolumnar junction; endoscopic dilatation and PPI.
- Barrett's oesophagus: the squamous lining of the lower oesophagus is replaced by columnar epithelium, usually with intestinal metaplasia (goblet cells).
- Risk of adenocarcinoma about 0.5% per year (many times the general population).
- Surveillance endoscopy with biopsies; PPI.
- Dysplasia (high grade, or confirmed low grade) is treated endoscopically: endoscopic mucosal resection (EMR) followed by radiofrequency ablation (RFA). Oesophagectomy is now reserved for invasive cancer.
Barrett = Bad columns below: squamous turns to columnar, and columnar turns to adenocarcinoma.
Oesophageal perforation
Causes
| Cause | Notes |
|---|---|
| Instrumental (iatrogenic) | Commonest: dilatation, stent insertion, rigid endoscopy, biopsy of tumours; cervical site common at the cricopharyngeus |
| Spontaneous (Boerhaave syndrome) | Forceful vomiting against a closed glottis, often after a heavy meal or alcohol; full-thickness tear in the lower third, left posterolateral wall |
| Foreign bodies | Bones, dentures, button batteries (urgent removal) |
| Trauma, caustic injury, tumour erosion |
Mallory-Weiss tear is a mucosal tear at the gastro-oesophageal junction after retching that causes haematemesis; Boerhaave is a full-thickness rupture that causes mediastinitis and shock.
Clinical features
- Severe chest or upper abdominal pain after vomiting; breathlessness, fever, shock.
- Mackler triad: vomiting, lower chest pain, subcutaneous (surgical) emphysema.
- Surgical emphysema in the neck after an endoscopy is close to diagnostic.
- Often misdiagnosed as myocardial infarction, perforated ulcer or pancreatitis.
Investigations
- Chest X-ray: pneumomediastinum, left hydropneumothorax or pleural effusion, surgical emphysema.
- CT with oral contrast is the investigation of choice; water-soluble contrast swallow (gastrografin) where CT is unavailable.
- Pleural tap may show food particles and a high amylase.
Management
- Nil by mouth, IV fluids, broad-spectrum antibiotics, antifungals, PPI, nutrition (feeding jejunostomy or parenteral).
- Conservative: small, contained, instrumental leaks (especially cervical) with little sepsis.
- Surgical: Boerhaave syndrome, pleura breached, large septic load or shock. Early primary repair (within about 24 hours) with pleural drainage; later, drainage with T-tube, diversion or resection.
- Covered self-expanding stents are used for selected leaks and for perforated cancers.
The earlier a perforation is treated, the better: mortality rises steeply after 24 hours.
Pouches, webs and rings
| Condition | Key facts |
|---|---|
| Pharyngeal pouch (Zenker diverticulum) | Pulsion diverticulum through Killian's dehiscence between thyropharyngeus and cricopharyngeus; usually elderly men, projects to the left; dysphagia, gurgling, halitosis, regurgitation, aspiration; barium swallow diagnoses (scope can perforate it); treat by endoscopic stapling or open excision with cricopharyngeal myotomy |
| Plummer-Vinson (Paterson-Kelly) syndrome | Iron deficiency anaemia, glossitis, koilonychia and a post-cricoid web in middle-aged women; premalignant for post-cricoid squamous carcinoma; iron and dilatation |
| Schatzki ring | Thin ring at the squamocolumnar junction above a hiatus hernia; intermittent bolus obstruction ("steakhouse") |
| Caustic injury | Alkali causes liquefactive necrosis and deep oesophageal injury; no induced vomiting; early endoscopy to grade; late strictures and raised cancer risk |
Carcinoma of the oesophagus
| Feature | Squamous cell carcinoma | Adenocarcinoma |
|---|---|---|
| Site | Upper two-thirds (middle third commonest) | Lower third and cardia |
| Frequency | Commonest worldwide, including the Asian "cancer belt" and South Asia | Commonest in the west, rising fast |
| Risk factors | Smoking, alcohol, hot drinks, nitrosamines, betel or naswar use, achalasia, caustic stricture, Plummer-Vinson, tylosis, poor diet | GORD, Barrett's oesophagus, obesity, white men |
Clinical features
- Progressive dysphagia (solids then liquids) is the commonest symptom but appears late, when the lumen is already badly narrowed.
- Weight loss, regurgitation, odynophagia, anaemia.
- Signs of incurable disease: hoarseness (recurrent laryngeal nerve), Horner syndrome, supraclavicular nodes, tracheo-oesophageal fistula (cough on swallowing), liver metastases.
Investigations
- Endoscopy with multiple biopsies: diagnosis.
- CT chest, abdomen and pelvis: distant spread.
- PET-CT: occult metastases.
- Endoscopic ultrasound: depth (T stage) and local nodes.
- Bronchoscopy for upper and middle third tumours; staging laparoscopy for tumours involving the cardia (peritoneal spread).
Spread is early: longitudinally in submucosal lymphatics (so tumour extends beyond what is seen), to nodes from the neck to the coeliac axis, and by blood to liver, lung and bone. There is no serosa to hold it back.
Treatment
- Early (mucosal) tumours: endoscopic resection.
- Resectable, fit patients: neoadjuvant chemotherapy or chemoradiotherapy then oesophagectomy.
- Ivor Lewis: laparotomy plus right thoracotomy; anastomosis in the chest (lower and middle third).
- McKeown (three-stage): abdomen, right chest and neck; anastomosis in the neck (higher tumours).
- Transhiatal: abdomen and neck, no thoracotomy.
- Usual replacement: stomach tube (colon or jejunum if the stomach is unusable).
- Squamous cell carcinoma: definitive chemoradiotherapy is an alternative, especially for upper third tumours.
- Palliation (most patients): self-expanding metal stent for dysphagia, palliative radiotherapy or brachytherapy, chemotherapy, nutritional support.
Complications of oesophagectomy: anastomotic leak (most feared), chest infection, chylothorax (thoracic duct injury), recurrent laryngeal nerve palsy, conduit necrosis, late anastomotic stricture.
Squamous = Smoking and Spirits, upper two-thirds; Adeno = Acid (reflux), lower third.
Expect: achalasia pathology (Auerbach plexus), bird's-beak barium, absent gastric bubble, manometry as the diagnostic test and Heller myotomy with partial fundoplication; pH monitoring for GORD; indications for and types of fundoplication; sliding vs rolling hiatus hernia; Barrett metaplasia and adenocarcinoma; Boerhaave site and Mackler triad versus Mallory-Weiss; commonest cause of perforation (instrumentation) and CT or contrast swallow; pharyngeal pouch through Killian's dehiscence; Plummer-Vinson; risk factors and sites of squamous vs adenocarcinoma; Ivor Lewis oesophagectomy and stenting for palliation.
Quick revision
- Achalasia: non-relaxing LOS, aperistalsis, bird's beak, manometry, Heller plus Dor; dilatation risks perforation.
- GORD: PPI first; pH study before surgery; Nissen 360 degree, Toupet 270 posterior, Dor anterior.
- Rolling hiatus hernia: repair because of volvulus and strangulation.
- Barrett: columnar metaplasia; adenocarcinoma; EMR plus RFA for dysplasia.
- Perforation: commonest iatrogenic; Boerhaave = lower third, left side; CT with contrast; early surgery.
- Pharyngeal pouch: Killian's dehiscence, elderly, barium first.
- Cancer: SCC upper two-thirds, smoking and alcohol, commonest worldwide; adenocarcinoma lower third, Barrett.
- Hoarseness or supraclavicular nodes mean advanced disease; stent for palliation.
Written by The House Job from standard references (Bailey & Love).
FAQ
What is the most useful test to confirm achalasia?
Oesophageal manometry, which shows incomplete relaxation of the lower sphincter and absent peristalsis; endoscopy is still needed to exclude cancer at the cardia.
Why is a partial fundoplication added to Heller myotomy?
Cutting the sphincter muscle allows acid reflux, and a partial wrap reduces reflux without causing the dysphagia a full wrap would produce in an aperistaltic oesophagus.
Where does the oesophagus rupture in Boerhaave syndrome?
Usually through the left posterolateral wall of the lower third, just above the diaphragm, so the left pleura is often involved.
What is the commonest cause of oesophageal perforation?
Instrumentation, especially therapeutic endoscopy such as dilatation and stent insertion.
Which type of oesophageal cancer is commonest in Pakistan?
Squamous cell carcinoma predominates in South Asia and worldwide, while adenocarcinoma linked to Barrett's oesophagus is rising, mainly in western countries.