Surgery of Esophagus

Questions in  Surgery of Esophagus form about 10-15% of all questions in all major exams. At least one question can be expected in Carcinoma Esophagus, conduits, Barrett's esophagus, corrosive injuries GIST

Questions 6-10        Questions 11-15          Q 16-20                Q21-             GIST MCQs                   USMLE Questions

Q1. The usual incision given for surgery of  Zenker's diverticulum of esophagus is
a) Left Cervical incision
b) Right Cervical
c) Suprahyoid
d) Midline
 Q2. In Transhiatal  Vs Trans thoracic esophagectomy most common complication associated  with THE (Trans Hiatal esophagectomy) is
a) Pulmonary complications
b) Anastomotic leak
c) Bleeding
d) Injury to recurrent laryngeal nerve
Q3.Which  is the most disabling complication after three field esophagectomy?
a) Bronchorrhoea
b) Recurrent  laryngeal nerve palsy
c) Tracheal stenosis
Q4. What is the most common complication after  esophagectomy
a) Arrythmia
b) Pulmonary Collapse  and Consolidation
c) Recurrent laryngeal nerve injury
d) Massive bleeding
Q 5.Most important  investigation for preoperative evaluation of extensive corrosive stricture is
a) Endoscopic ultrasound
b) Barium study
c) CT Thorax
d) Pharyngoscopy

 Answers in Esophagus Surgery

1. a
Zenker's diverticulum is a pulsion diverticulum between the cricopharungeal muscle and inferior constrictor muscle in an area of weakness called Killian's dehiscence.
There may be other areas of weakness as well such as Killian Jamieson area between the oblique and transverse fibres of cricopharyngeal muscle and Laimer's triangle
formed between the cricopharyngeal muscle and most superior esophageal wall circular muscles.
The pharyngoesophageal diverticulum (Zenker’s diverticulum) (ZD) is the most common esophageal diverticulum.
1. Increased upper esophageal sphincter (UES) pressure
2. Failure of UES to relax
3.Incordination between hypophraynx and sphincter to relax
Other mechanisms proposed are
1. Fibrosis of cricopharyngeal muscle
2. Spasm of Cricophayngeus due to abonormal reflux (GERD)
There is loss of ATPase and energy
changes in patients with ZD.
Both neurogenic and myogenic abnormalities are present.
At this stage, poor UES compliance rather than
incoordination appears to be the most plausible explanation
Treatment can be done endoscopically or surgically.
A commonly used surgical approach is cervical
esophagomyotomy and resection of the diverticulum
performed through an oblique left cervical incision
that parallels the anterior border of the sternocleidomastoid
muscle or a transverse cervical incision centered
over the cricoid cartilage.
Complications of Surgery for Zenker's divertculum
Salivary fistula 3-25%
Recurrence of Zenker's diverticulum  2.5-20%
2. d
The transhiatal cervical anastomosis predisposes to a higher rate of leaks (13.6% for transhiatal vs. 7.2% for transthoracic)
Transthoracic resections, which involve a posterolateral thoracotomy, have a higher incidence of pulmonary complications compared with the transhiatal approach
A review of the literature with a meta-analysis,has shown that operative blood loss is significantly less during transhiatal esophagectomy compared with transthoracic esophagectomy
Now Orringer the proponent of Transhiatal esophagectomy has published that the use of stapled side to side esophagogastric anastomoses in THE has reduced the anatomotic leak rate to 3%
This means now recurrent laryngeal nerve injury is more in THE group than TTE group
3. a
Three field esophagectomy involves lymph node dissection in the cervical, mediastinal and abdominal
region. In contrast to the standard two field esophagectomy, japanese surgeons argue that three field esophagectomy leads to better prognostication and survival benefits without significantly increasing the morbidity and mortality.
Cervical lymphadenectomy included the paratracheal lymph nodes (deep internal nodes). The nodes lateral from the sternocleidomastoid muscle, ie, lateral to the internal jugular vein and supraclavicular nodes
Pulmonary complications occurred in 32.8%, cardiac dysrhythmias in 10.9%, and persistent recurrent nerve problems in 2.6%.

The management of corrosive esophageal stricture depends on the timing of presentation to the doctor. broadly it is at three times.

Emergency (Immediate management), Intermediate management and chronic long term management.

In the early phase - Investigations ordered are X ray chest, X ray abdomen to look for free air (perforation of esophagus or stomach) . Patients with fever, tachycardia, leukocytosis, metabolic acidosis are admitted in ICU and resuscitated urgently, and have the endoscopic assessment performed under general anesthesia in the operating room. 

Then after stabilization all symptomatic patients should undergo endoscopy. Endoscope should not be passed across the 1st sign of injury.


Endoscopic Grading of Caustic Injury
Grade 1

Mucosal edema or hyperemia

Grade 2

A: Friability, erosions, exudates

B: As above, plus deep or circumferential ulceration

Grade 3

A: Scattered areas of necrosis with black or grey discoloration

B: Extensive areas of necrosis

Barium and other imaging studies are of no immediate value.