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Cricopharyngeal Dysfunction and Zenker Diverticulum

Disorders at the cricopharyngeal level lead to oropharyngeal dysphagia , or transfer dysphagia . With this term, we usually refer to the difficulty in making the food progress from the oropharynx to the esophagus, through the upper esophageal sphincter (UES), mostly but not exclusively constituted by the cricopharyngeal muscle. With this term, we differentiate it from esophageal dysphagia, which we define as difficulty in the progression…

Novel Diagnostic Technologies: Mucosal Impedance, Optical Coherence Tomography, Endomicroscopy

Endoscopy remains the fundamental diagnostic technique for the evaluation of a wide spectrum of esophageal disease. Its cardinal purposes are to perform a comprehensive visual assessment of the esophagus, and to obtain tissue for histologic evaluation. The current standard for endoscopic evaluation, white-light endoscopy (WLE), suffers from several limitations. Key among these is its inability to identify subtle mucosal abnormalities and to detect pathology beneath the…

pH and Impedance Evaluation of the Esophagus

Gastroesophageal reflux disease (GERD) is a very common global disorder that poses a significant public health burden. GERD affects approximately 20% of the population of the Western world and has been ranked as the fourth most prevalent gastrointestinal disease and the most expensive disease of the alimentary tract. There can be no standard diagnostic criteria for the definition of GERD because the threshold distinction between physiologic…

High-Resolution Esophageal Manometry: Techniques and Use in the Diagnosis of Esophageal Motility Disorders and for Surgical Decision Making

Esophageal motility disorders may be implicated as an explanation for dysphagia and noncardiac chest pain after exclusion of esophageal structural lesions by endoscopy, with the caveat that eosinophilic esophagitis has been ruled out with histology. Gastroesophageal reflux disease (GERD) must also be carefully considered, and most patients will be given a course of proton pump inhibitor therapy or evaluated with a 24- or 48-hour pH monitoring…

Endoscopic Evaluation of the Esophagus and Endoscopic Ultrasonography of the Esophagus

The endoscopist who examines the esophagus evaluates a muscular tube whose primary function is to convey swallowed material from the mouth to the stomach. The esophagus is approximately 25 cm in length measured from its origin in the neck just below the cricoid cartilage (C6 level, approximately 15 cm from the incisor teeth as measured by the endoscopist) to its termination in the abdomen at the gastric cardia…

Radiology of the Esophagus: Barium, Computed Tomography Scan, Positron Emission Tomography Scan, Magnetic Resonance Imaging

Radiologic evaluation of esophageal diseases can be performed by fluoroscopic barium examination (esophagram), computed tomography (CT) scan, positron emission tomography (PET) scan, fused CT and PET images (PET/CT), and magnetic resonance imaging (MRI). These five imaging modalities constitute the radiologic options currently available for esophageal evaluation. Which test is best for the diagnosis of esophageal disease? It depends. The choice of esophageal imaging modality depends on…

Esophageal Symptoms and Selection of Diagnostic Tests

A surgeon evaluating a patient prior to a possible esophageal operation must spend enough time in conversation with that patient to ensure a clear understanding of their symptoms. Such dialogue not only illuminates potential causes of those symptoms, but more importantly, it indicates whether a given surgical procedure may resolve them. The spectrum of symptoms in esophageal disease is wide, ranging from common typical symptoms (e.g.,…

Relevant Anatomic Relations of the Esophagus

The primary purpose of the esophagus is to transport food from the mouth to the stomach, and the esophagus has no digestive or absorptive function. The esophagus is a muscular tube that starts at the inferior border of the cricoid cartilage in the neck and traverses the chest, ending as it enters the stomach in the upper abdomen. Esophageal surgeons need to be familiar with the…

Esophageal Mucosa in Health and Disease

Pathology has no clinical value at the present time in the diagnosis and management of gastroesophageal reflux disease (GERD) before the occurrence of visible columnar lined esophagus (vCLE). Its only value is in the diagnosis of intestinal metaplasia, increasing dysplasia and adenocarcinoma in the patient with Barrett esophagus. We will only consider GERD in this chapter. We will explore the pathophysiology of GERD through its entire…

Esophageal Body in Health and Disease

High-resolution manometry (HRM) is a well-established diagnostic tool that evaluates esophageal motility. It dynamically measures intraluminal pressure changes in the esophagus by using closely spaced pressure sensors. Data are acquired, displayed, and interpreted by esophageal pressure topography plots. The Chicago Classification aims to define esophageal motility disorders according to HRM findings. This classification was first proposed in 2008 and then updated in 2011 and in 2014.…

Esophageal Sphincters in Health and Disease

The esophagus is a muscular tube connecting the mouth with the stomach. The main function of the esophagus is transport of fluids and food to ensure regular nutrition of the body. At the proximal and distal end of the tube, special boundaries are necessary to fulfill complex functional tasks such as swallowing, belching, and vomiting and allowing breathing and coughing, while preventing substantial reflux of gastric…

Urologic Surgery

Urology is the surgical specialty that focuses on the diagnosis and management of conditions and diseases of the genitourinary system in adults and children and of the reproductive system in the male. Of the surgical subspecialties, urology shares the most in common with general surgery because of our operative approaches and techniques in the abdomen, retroperitoneum, pelvis, and genitalia. Like general surgeons, urologists treat patients with…

Fetal Surgery

Acknowledgements The authors would like to acknowledge the literature research and editorial assistance of Alexandra M. Iavorovschi in completing this chapter and Dr. Sarah Chen for making the illustrations for this chapter. The Birth of a New Surgical Specialty Not long ago, the idea of a surgeon operating on a human fetus within the womb was considered radical and heretical by the medical community. Pioneers and…

Surgery in the Pregnant Patient

The pregnant patient presents a unique clinical challenge for the general surgeon. About 7% of pregnancies are complicated by nonobstetric surgical problems, and an estimated 1 in 500 pregnancies will need an operation for nonpregnancy-related issues. Table 72.1 is adapted from a 10-year review of the hospital episode statistic of all admissions to English NHS hospitals. Of 6.5 million pregnancies, 47,600 nonobstetric surgeries occurred, and 12,500…

Gynecologic Surgery

Gynecologic procedures are among the most frequent surgical procedures done in the world. It behooves any surgeon to be familiar with the anatomy of the female reproductive tract and pelvis and with the most common gynecologic surgical diseases and procedures for these diseases. This chapter provides an overview of female reproductive tract and pelvic anatomy; discusses the most common surgical diseases of the vulva, vagina, cervix,…

Hand Surgery

This chapter describes the broad scope of hand surgery. It emphasizes core knowledge that is important to general surgeons. The origins of this important subspecialty are rooted within general surgery. It is a regional specialty bringing together general, plastic, and orthopedic principals. Although hand surgery fellowships traditionally receive trainees primarily with backgrounds in orthopedic surgery or plastic surgery, fellowship training in hand surgery may also be…

Plastic Surgery

Challenged by complex clinical problems, the pace of innovation in plastic surgery has accelerated steadily during the past 30 years. The specialty benefits from the absence of anatomic or organ system boundaries and from the collaboration with other surgical specialists. Plastic surgeons discover new reconstructive and aesthetic challenges and continuously make medical progress. With growing sophistication, plastic surgery has matured into areas of specialization, including surgery…

Neurosurgery

Neurosurgery is defined as surgery of the brain, spinal cord, peripheral nerves, and their supporting structures, including the blood supply, protective elements, spinal fluid spaces, bony cranium, and spine. This chapter is intended for nonneurosurgeons who want to initiate a framework on which to add further knowledge and experience. It is hoped that it will also help personnel in a community hospital emergency department, residents, advanced…

Pediatric Surgery

Despite the ever-evolving field of pediatric surgery, it remains the last bastion of true general surgery. Pediatric surgical conditions span prenatal (fetal) and neonatal to adolescent and young adult age groups. Pediatric surgeons must assess and manage a wide spectrum of surgical conditions with vastly different pathophysiology. Pediatric surgery covers a wide spectrum of organ systems, ranging from head and neck to thoracic and the gastrointestinal…

The Lymphatics

Embryology and Anatomy The primordial lymphatic system is first seen during the sixth week of development in the form of lymph sacs located next to the jugular veins. During the eighth week, the cisterna chyli forms just dorsal to the aorta, and, at the same time, two additional lymphatic sacs corresponding to the iliofemoral vascular pedicles begin forming. Communicating channels connecting the lymph sacs, which will…