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Preface
The first edition of Current Surgical Therapy was published in 1984. The textbook has thus been in existence for more than 35 years, and this is the thirteenth edition. In each edition, we have updated the material to reflect the continuing evolution of the field of general surgery. The textbook continues to be perhaps the most popular surgical book in the United States, and as long as it fulfills a need we plan to continue the publication every 3 years. It has been a special privilege and honor for the two editors to be able to review contributions from surgeons around the country and, indeed, from around the world, on what they believe is the current surgical therapy for virtually all general surgical topics. It is an enjoyable task and keeps two surgeons who care for surgical patients current on all general surgical topics. The thirteenth edition contains 263 chapters. This represents a decrease of about 20 chapters from the twelfth edition. There have been comments in recent years that the text was becoming too big to easily manage. We have responded by eliminating the section on minimally invasive surgery; instead, authors have incorporated this approach in each chapter, where appropriate. In addition, some chapters have been eliminated and new ones added. As with prior editions, nearly every chapter has been written by a new author. All authors have contributed their specific and personal thoughts on the current surgical therapy of the disease about which they are experts. Therefore, to obtain a broad view of the topic, the reader may want to review the contributions of the other experts in the last two or three editions of Current Surgical Therapy. As with the past editions, disease presentation, pathophysiology, and diagnosis are discussed only briefly, with the emphasis on current surgical therapy.
When an operative procedure is discussed, an effort has been made to include brief and concise descriptions with figures and diagrams when possible. Current Surgical Therapy is written for surgical residents, fellows, and fully trained surgeons in private practice or in an academic setting. Many have told us that it is an excellent textbook to review before taking the general surgical boards or recertifying. In addition, medical students have given us feedback that they believe the text is of value to them. However, Current Surgical Therapy is not written principally for medical students. We believe a more classic surgical textbook with substantial sections on disease presentation, diagnosis, and pathophysiology is more appropriate for medical students.
We remain grateful to the many surgeons throughout the country, as well as to the international surgeons, who participated in creating this textbook. Most of the potential authors whom we solicit respond enthusiastically to the opportunity to present their expert views. Their efforts obviously are what make this textbook a success. In addition, we could not have compiled this textbook without the herculean efforts of Ms. Irma Silkworth, who has been involved with virtually all of these editions. Ms. Katie DeFrancesco at Elsevier has also been a terrific help and stands out in the publishing industry. Both editors continue to enjoy and thrive in our chosen profession of general surgery. In recruiting medical students into our specialty over the last 40 years, I have used the statement, “If you pick a profession you love, you never have to work the rest of your life.” In our view, that profession is surgery. Finally, we would like to dedicate this edition, as with the others, to the surgical house staff and fellows at the Johns Hopkins Hospital, who are “the best of the best.
Esophagus
Esophageal Function Tests
Richard J. Battafarano, MD, PhD
The swallowing mechanism is a dynamic process between the muscles of the esophageal wall and its neural innervation and involves the coordinated interplay between the upper esophageal sphincter and lower esophageal sphincter (LES) that allows the propagation of a bolus of food from the oropharynx to the stomach. Esophageal dysfunction can lead to a number of symptoms, including dysphagia, odynophagia, regurgitation of food or liquid, and gastroesophageal reflux. One cannot underestimate the importance of taking a detailed history directly from a patient with esophageal disease because it is often a constellation of symptoms that suggest the true source of the patient’s problem. Gastroesophageal reflux disease (GERD) is so prevalent that many patients with any esophageal symptoms are simply treated with antacid therapy for long periods of time before other sources for their esophageal symptoms are sought. This chapter provides a brief overview of the most commonly encountered esophageal function disorders and a review of the indication and interpretation of the esophageal function tests used in their diagnosis
DISORDERS OF ESOPHAGEAL FUNCTION
Consensus guidelines have provided direction in using esophageal function test findings toward defining the mechanisms of esophageal symptoms. The Chicago Classification describes specific criteria in diagnosing esophageal motility disorders. The Lyon Consensus characterizes the results from esophageal testing for the diagnosis of gastro esophageal reflux disease, and further establishes a motor classification of GERD. The esophageal function tests utilized in the diagnosis of esophageal disorders are flexible fiber optic endoscopy, high resolution esophageal manometer (Box 1), ambulatory reflux monitoring, contrast radiography of the esophagus, and occasionally, end luminal functional lumen imaging probe (Endo-FLIP). The specific contribution that each of these tests plays in the diagnosis and management of esophageal diseases will be discussed below.
Achalasia
Achalasia is the best-defined primary motor disorder of the esophagus. Patients present with dysphagia to solids and liquids and associated weight loss. Although many patients may have had upper endoscopy or contrast esophagography (Fig. 1) to rule out mechanical reasons for their dysphagia, high-resolution esophageal manometry is the best test for the diagnosis of achalasia. With high-resolution manometer, a plot of esophageal peristalsis is generated in response to a 5-mL water swallow and is bounded superiorly by the upper esophageal sphincter and inferiorly by the lower esophageal sphincter within the esophagogastric junction (EGJ). Esophageal motor function is then evaluated using three different metrics. The integrated relaxation pressure (IRP) is the nadir pressure over 4 seconds when EGJ relaxation is expected within a 10-second window after upper esophageal sphincter relaxation. The distal contractile integral (DCI) is an assessment of the strength of esophageal smooth muscle contraction, incorporating length, amplitude, and duration of the contracting segments of the esophagus. The distal latency is the measure of the timing of esophageal peristalsis and is measured from upper esophageal sphincter relaxation to the contractile deceleration point, where fast esophageal body peristaltic progression transitions to slower EGJ emptying function.
Within the Chicago Classification, achalasia is characterized by IRP values above the upper limit of normal (generally 15 mm Hg in many systems). However, in the setting of absent peristalsis, an IRP cutoff of 10 mm Hg may indicate type I achalasia (Figs. 2 and 3). In addition, absent peristalsis with at least 20% of swallows with pan esophageal pressurization should raise suspicion for type II achalasia regardless of IRP. Type III achalasia (spastic) is associated with premature or spastic distal esophageal contractions in at least 20% of swallows (Fig. 4). There is a subset of patients with elevated IRP with preserved peristalsis that are best described as having EGJ outflow obstruction (Table 1). The standard treatment for achalasia has been a distal esophageal myology combined with a partial fundoplication (either Dor or Toupee), with success rates (improvement in dysphagia and the ability to regain weight) of 80% for type I achalasia and 95% for type II achalasia. Lower success rates (60%) have been reported for distal esophageal myology in patients with type III achalasia, most likely because the length of the myology is inadequate. Paroral endoscopic myology (POEM) increasingly has been used in the management of these patients. A submucosa tunnel is created in the esophagus approximately 10 cm proximal to the gastro esophageal junction, and a myology of circular muscle layers is distally extended to 2 cm into the cardia. The short-term follow-up results with POEM in most series have shown results that are equivalent in symptom relief to a distal esophageal myology. However, there is a much higher incidence of gastro esophageal reflux disease (as high as 40%) because patients do not have an associated ant reflux procedure at the time of the myology
ESOPHAGOGASTRIC JUNCTION OUTFLOW OBSTRUCTION
EGJ outflow obstruction was formerly called hypertensive lower esophageal sphincter. Using a definition of EGJ outflow obstruction based solely on the IRP with the exclusion of achalasia allows this diagnosis to be combined with another diagnosis dependent on the esophageal body motility. EGJ outflow obstruction may be
