Dieter C. Broering

Surgical Anatomy of the Esophagus

The esophagus is a part of the alimentary tract. It is a muscular tube approximately 25 cm long extending from the pharynx to the stomach. The esophagus begins at the lower margin of the cricoid cartilage opposite the sixth cervical vertebra and enters the gastric orifice at the level of the twelfth thoracic vertebra.

Proximal Gastrectomy with Distal Esophagectomy (Proximal Resection)

Indications for this surgical procedure are rare. Carcinoma of the cardia in the abdominal esophagus (below the diaphragm) in patients with high comorbidity Long strictures of the abdominal esophagus.

Reconstruction of Gastrointestinal Continuity by Jejunal Interposition following Total and Subtotal Esophagectomy

Benign strictures and malignant tumors of the esophagus, when the stomach or colon cannot be used as a substitute.

Preoperative Evaluation of the Operative Risk Profile

The primary goal of a preoperative risk analysis is the reduction of perioperative morbidity and mortality. The latter is still ranging up to 10% for esophageal cancer despite all progress in intensive care therapy and the refinement of surgical technique. The morbidity, in particular the incidence of pulmonary complications, is by far higher and amounts to approximately 50%.

Partial Abdominothoracic Resection of the Esophagus with Gastroplasty and Intrathoracic Anastomosis

Short distance peptic stenosis of the distal esophagus Boerhaave syndrome Short distance ruptures of the distal esophagus Carcinoma of the esophageal-gastric junction with tumor extension above the diaphragm Squamous cell carcinoma of the distal esophagus.

Colon Interposition after Total and Subtotal Esophagectomy

Patients with esophageal carcinoma after subtotal gastrectomy Locally advanced carcinoma of the cardia with infiltration of the lower esophagus Peptic stricture of the total esophagus, including strictures with extension to pharynx or stomach Long peptic stricture of the esophagus with severe esophagitis and esophageal fistula Extensive peptic stricture of the esophagus in patients after subtotal gastrectomy Any affection of the “neo-esophagus” after transpleural esophagectomy, gastric tube reconstruction with cervical esophagostomy (secondary reconstruction after gastric tube necrosis) Necrosis or inadequate length of the gastric or jejunal interposition for reconstruction.

Abdominothoracic Subtotal en bloc Esophagectomy and Reconstruction with Gastric Tube Transposition

Mid thoracic esophageal carcinoma Esophageal squamous-cell carcinoma in the lower third of the esophagus Long peptic stricture, if transhiatal resection is not possible.

Surgical Treatment of Esophageal Fistula and Perforation

Injuries of the esophagus may be caused by mechanical, chemical, and actinic damages. Usually, they are the consequence of a blunt trauma. The exceptions are perforations of the esophagus. Injuries of the esophagus by ingestion of a foreign body arise in physiologic narrow passages (pharyngoesophageal passage, in the middle third of the aortic arch, cardioesophageal passage). A decubitus of the esophagus can be seen if a foreign body remains longer in the esophagus. Diagnostic and therapeutic endoscopy measures may also lead to injuries of the esophagus. Esophagoscopy and bougienage of a cicatricial stricture, especially in an early phase after a corrosive injury, are the most frequent reasons for an iatrogenic perforation of the esophagus. Dilatation of the cardia with the Stark’s instrument can cause a laceration and perforation. Complications for pneumatic or hydrostatic dilatation are rarely seen.

Surgical Technique in Gastroesophageal Reflux Disease — Conventional Approach

Gastroesophageal reflux disease is characterized by unphysiologically long contact of gastric content with esophageal mucosa. This is caused by an insufficiency of the lower esophageal sphincter which can be verified by manometry and confirmed by 24-h pH metry.

Post-operative Complications of the Esophagus and Esophagus Bridge Graft

Due to the grave risk of insufficiency of the esophageal anastomosis and considering the severe operative trauma that is involved, surgery of the esophagus is one of the most dreaded operations in visceral surgery even today.