Fig. 8.1
Barium swallow radiographs can be the first indication of an esophageal motility disorder as seen here in this classic corkscrew appearance of diffuse esophageal spasm
Hiatal or Paraesophageal Hernia
The assessment of a hiatal hernia is best done with the patient in prone position: the increased intraabdominal pressure produced in this position promotes displacement of the hernia above the diaphragm. It is a very important component of the preoperative surgical planning to understand the size and configuration of the hernia. A large hernia (>5 cm) or irreducible hiatal hernia may suggest a shortening of the esophagus, which could require an esophageal lengthening procedure (e.g., Collis gastroplasty) during the surgical repair. Reflux is not seen easily on VEG, and only rarely in patients with classic symptoms of GERD does the radiologist observe spontaneous reflux. If other pathology is suspected, a full-column technique with distension of the esophageal wall can rule out extrinsic compression of the esophagus, and a fully distended esophagogastric region is necessary to identify narrowing from a ring, stricture, or obstructing lesion (Fig. 8.2).
Fig. 8.2
Barium esophagram demonstrating a mod-esophageal stricture as a cause for dysphagia
Therefore, the videoesophagram is the first diagnostic and preoperative test in patients with GERD or the suspicion of GERD, and gives the first understanding of the anatomical and functional deficits of the patients underlying disease.
Esophagogastroduodenoscopy (EGD) and Biopsy Protocol
Endoscopic evaluation is a necessary part of the preoperative evaluation for anti-reflux surgery. The endoscopy can help to better understand several symptoms such as dysphagia, odynophagia, aspiration, unexplained laryngeal symptoms, unexplained chronic cough, or asthma. Other diseases can also be ruled out or diagnosed like peptic ulcer disease, gastritis, esophageal, and gastric cancer. However, the role of endoscopy in preoperative planning differs from standard esophagogastroduodenoscopy in that it should focus on anatomic details important in surgical decision making—a task most often best performed by the surgeon. Ideally, the contrast study should be performed prior to the endoscopy in order to provide a roadmap of the esophagus, and to direct attention to concerning areas, such as diverticula, ulcers, or possible cancer.
Performing a Pre-surgical EGD
After an appropriate fast, endoscopic evaluation of the esophagus starts with a careful view of the vocal cords and aryepiglottic folds (Fig. 8.3). The position of the crico-pharyngeal sphincter is best assessed on final withdrawal of the endoscope and is noted by an encroachment on the lumen as the scope is withdrawn. It is important to carefully view the entire esophagus as proximal findings are often missed (Zenker’s diverticulum, gastric inlet patch, etc.) (Fig. 8.4 a, b). The presence of retained food in the esophagus or stomach is abnormal. The gastroesophageal junction is defined by where the gastric folds meet the tubular esophagus. Observations such as retained food or saliva, strictures, rings, webs, candidiasis and esophagitis are particularly relevant for patients with dysphagia and should be documented (Fig. 8.5 a–e).
Fig. 8.3
Endoscopic view of the vocal cords
Fig. 8.4
Proximal esophageal findings that are often missed but have important relations to reflux. a Zenker’s diverticulum, b gastric inlet patch
Fig. 8.5
Relevant esophageal pathologies seen on upper endoscopy: retained food (a) esophageal diverticulum (b), ringed mucosal appearance of eosinophilic esophagitis (c), candidiasis (d), severe erosive esophagitis with distal stricture (e)
On entering the stomach the gastric mucosa is carefully inspected, and the scope further advanced into the duodenal bulb and second part of the duodenum to exclude other pathology. When the endoscope is retracted back into the stomach, it is retroflexed to give a view of the gastroesophageal junction. The stomach is insufflated to assess the competency of the sphincter and to grade the gastroesophageal flap valve, or musculomucosal fold at the Angle of His, according to Hill’s grading [3] (Fig. 8.6). The presence of an axial hiatal or paraesophageal hernia can be appreciated and measured which may alert the surgeon to the potential of a foreshortened esophagus. Signs of relative ischemia or mucosal damage such as Cameron’s Ulcer’s within the hernia should be noted (Fig. 8.7). Further, the locations of the diaphragmatic crura, the gastroesophageal junction, and squamocolumnar junction are measured and documented. The mucosa on the lesser and greater curvatures and the anterior and posterior aspect of the stomach are systematically and carefully inspected for any abnormalities. The stomach is deflated before the instrument is retracted for a final viewing of the esophagus.
Fig. 8.6
Gastroesophageal flap valve grading according to Hill
Fig. 8.7
Cameron’s ulcers are often seen in large hiatal hernias. Note the linear gastritis and ulceration at the hiatal brim
Careful scrutiny of the esophageal mucosa and obligatory biopsies constitute the final segment of the endoscopic examination. A minimum of 2 biopsies in the antrum (for diagnosis of Helicobacter pylori) and 4 biopsies at the squamocolumnar junction are mandatory. Discrepancy between the location of the squamocolumnar junction (SCJ) and the gastroesophageal junction (defined as the top of the rugal folds) indicates the presence of columnar lined metaplasia. Examination, under both white light and narrow band imaging (or equivalent), can help define subtle differences and is especially helpful in evaluating Barrett’s (Fig. 8.8). Biopsies at the SCJ are required to confirm or refute the presence of intestinal metaplasia (Barrett’s Esophagus) even if there is no measurable segment of columnar lined esophagus. If there is more that 1 cm difference between the SCJ and the GEJ, standard Barrett’s surveillance biopsies should be taken in 4 quadrants starting in the retroflex view of the gastroesophageal junction and the esophagus every 1–2 cm until the normal squamous mucosa is reached. It is important to obtain these biopsies prior to anti-reflux surgery because the surgery will alter the anatomy at the GEJ and may make it more difficult to evaluate in the future. Any suspicious areas should also be biopsied. In case of suspicion of candida esophagitis or eosinophilic esophagitis, biopsies of the more proximal esophagus are recommended.
Fig. 8.8
Narrow Band imaging (NBI) is helpful in delineating esophageal pathologies like Barrett’s. A non-circumferential segment of Barrett’s with ulceration is shown here in white light (a) and NBI (b)
Endoscopy is truly the essential part in the preoperative work-up in patients with GERD, as it can assess esophageal and gastric anatomy, function, and obtain histology in form of multiple biopsies.
Esophageal Function Testing
To determine if a surgical approach is appropriate, and, if so, which one, the surgeon depends upon the expertise of the esophageal function laboratory to provide esophageal manometry (conventional or high-resolution with impedance), esophageal pH monitoring, and multichannel intraluminal impedance testing.
The surgeon who treats benign esophageal diseases has a different mindset than the surgeon who merely excises the organ because it harbors a malignancy or is otherwise destroyed by disease. The former has to improve the function of the esophagus without removing it. Success in restoring function depends upon correct analysis of the underlying pathophysiology. The principal tool to aid the surgeon in this analysis is esophageal manometry. Manometry is critical in order to rule out achalasia or other motility disturbances (such as IEM, non-relaxing LES, or esophageal spasm) which may predispose to dysphagia after surgery.
Conventional esophageal manometry has undergone very few changes in conduct or interpretation since the 1960s. However, in the past few years, several newer methods of studying esophageal function have been introduced: these include High-Resolution Manometry (HRM) and Multichannel Intraluminal Impedance (MII). Further improvement of the HRM called high-definition manometry, in which the pressure transducers grouped in banks and rings are even closer spaced is in development to assess in even greater detail the characteristics of the lower esophageal sphincter, and the esophageal motility.
Esophageal Water-Perfused Motility
Pharyngeal and esophageal motor function disorders are a common cause of symptoms, particularly dysphagia, chest pain, and those associated with gastroesophageal reflux. Motor function can be assessed by a variety of recording techniques including radiology, scintigraphy, manometry, and most recently intraluminal electrical impedance monitoring. The gold standard, however, for the assessment of motor disorders remains manometry. Manometric measurement of esophageal pressure is the most direct method for assessment of motor function. Esophageal manometry is typically performed with a catheter with five pressure transducers placed 5 cm apart (Fig. 8.9). A typical catheter is 4–5 mm in diameter and contains eight channels oriented round the circumference, each 0.6–0.8 mm in diameter, and perfused at a rate of 0.3–0.6 ml/min in order to record esophageal pressure waves with sufficient fidelity.
