SCORE 7-9

IRP greater than 15 mm Hg (upper limit of normal) and absent or impaired esophageal peristalsis.

normal IRP and early contractions in the distal esophagus, resulting in uncoordinated peristalsis in more than 20% of swallows.

two swallows with a DCI of more than 8000 mm Hg.

calcium channel blocker, followed by botulinum toxin (Botox) injections or nitric oxide contributing drug (isosorbide or sildenafil)

1. Endoscopy
2. High resolution manometry
3. Barium esophagram

1. UGI endoscopy and biopsy , CT CAP with PO and IV contrast, PET + EUS , biospy , bronchosocpy if at or above carina

cT1a - endoscopic resection / esophagectomy
cT1b - cT2 --> esophageactomy
cT2, No , LVI, poorly differentiated - preop chemoradiation (for non cervical esophagus), definitive chemoradiation for cervical esophagus
cT4b (invading aorta and shit) - definitive chemoradiation

1. Posteroanterior and lateral chest as well as upright abdominal x-rays can be used to identify pleural effusion, pneumomediastinum, and subcutaneous emphysema.
2. Esophagography with water-soluble contrast (Gastrografin) should follow x-ray. If this study is positive, the next step is treatment. If this study is unclear or negative, the next step is a barium swallow, and special care is taken to prevent mediastinitis and prolonged retention.
3. Computed tomography (CT) is useful when entertaining several diagnoses. If there is high suspicion for esophageal perforation, oral contrast can be used. Findings include air in the mediastinal soft tissue around the esophagus, abscess cavities adjacent to the esophagus, and communication of the air-filled esophagus with adjacent mediastinal or paramediastinal air-fluid collections.
4. Endoscopy can help further define the location, length, and the number of perforations and preexisting diseases of the esophagus and the stomach. In addition, it may guide treatment options.

Treatment of contamination
Wide local drainage
Source control
Enteral feeding access

NPO status, with intravenous fluid resuscitation
Administration of intravenous antibiotics, with broad-spectrum antibiotics, including antifungal agents
Nutritional assessment and total parenteral nutrition if indicated

myotomy should be performed on the side opposite to the perforation. An antireflux procedure should be performed.

esophagogastroduodenoscopy (EGD), a pH probe study, esophageal manometry, and a barium swallo

Nonneoplastic metaplasia: every 3 years
Low-grade intestinal metaplasia: every 6 to 12 months
High-grade intestinal metaplasia: every 3 months

Have the patient (usually) in the reverse Trendelenburg position.
Insert the ports and liver retractor.
Perform reduction of the displaced organs, with dissection and excision of hernia sac. (Be able to identify that traction should be placed on the hernia sac, not the stomach.)
Take down the short gastric vessels superiorly.
Open the gastrohepatic ligament and dissect the hernia sac off the right crus.
Preserve the anterior and posterior vagi.
After retroesophageal dissection, assess for adequate intra-abdominal esophageal length (at least 2.5-3 cm of distal esophagus mobilized without tension).
Create an antireflux barrier, typically a Nissen fundoplication.
Repair the hiatus using a tension-free crural closure. Occasionally, mesh buttressing is needed.
Note that some surgeons perform an anterior gastropexy to decrease recurrence.

Emergent endoscopy is required in patients with complete esophageal obstruction and in those with disk batteries or sharp objects in the esophagus.
Urgent endoscopy (within 24 hours) is recommended for patients with nonsharp esophageal foreign objects, sharp objects in the stomach or duodenum, nonobstructing esophageal food impaction, or magnets within endoscopic reach.
Nonurgent endoscopy may be considered for asymptomatic patients with coins in the esophagus (after up to 24 hours of observation).

Complete: Nissen (posterior 360-degree wrap). The most commonly used type in the United States is a 360-degree fundoplication.
Partial: Toupet (posterior 270-degree wrap)
Anterior: Dor (90-degree wrap)
Hill: posterior gastropexy with recreation of the angle of His
Belsey Mark IV: transthoracic 240-degree wrap

At first, try additional mediastinal mobilization.
If still inadequate, perform a Collis gastroplasty (vertical staple line on the fundus parallel to left border of esophagus).

Inferiorly by the upper border of the cricopharyngeal muscle
Laterally by the oblique fibers of the inferior constrictor muscles of the pharynx

The patient is placed supine with a shoulder roll, and the head is angulated backward with the chin turned toward the right side.
The incision is made overlying the anterior border of the sternocleidomastoid muscle (SCM).
The SCM is retracted laterally and the middle cervical visceral fascia is entered medial to the carotid sheath.
The posterior surfaces of the pharynx and esophagus are exposed with blunt dissection and the diverticulum is encountered.
If there is difficulty finding the diverticulum because of scarring, a rubber catheter can be passed down the esophagus with air injected into the catheter.
Myotomy of the cricopharyngeal muscle is performed by extending 1 to 2 cm of the inferior constrictor cephalad and 4 to 5 cm of the cricopharyngeal muscle caudally.
The cricopharyngeal muscle is divided, and care is taken to avoid the two recurrent laryngeal nerves that may lie on either side of the diverticulum.
If a small diverticulum is detected, a diverticulopexy can be performed by suturing the diverticulum to the prevertebral fascia.
If a diverticulum persists and is fairly redundant, it is pulled away from the cervical esophagus and divided at the neck with a linear stapler, taking care not to narrow the esophageal lumen. Placement of a bougie (45 French) at the time of transection prevents luminal narrowing.
A row of horizontal sutures is made to close the muscular defect between the inferior constrictors and the cricopharyngeal muscle.

The patient is positioned supine with a mayo stand over the patient’s chest for support of the suspension arm.
The tip of the diverticuloscope is advanced slightly into the esophageal introitus to engage the cricopharyngeus muscle.
The distal blades are opened so the posterior blade engages the inferior aspect of the inferior constrictor muscle to maximize exposure of the diverticulum.
A 0- or 30-degree scope is advanced to visualize the operative field.
A nasogastric tube can be advanced through the esophageal introitus to confirm that it is the esophagus.
The stapler should be placed with the staple cartridge anteriorly to maximize the amount of common wall engaged.
The stapler is fired, creating a common lumen between the sac and esophageal introitus.

During a transhiatal esophagectomy, the stomach is prepared for transposition into the chest by detaching the gastrohepatic ligament, dividing the short gastrics, dividing the gastrocolic attachments, preserving the right gastroepiploic and right gastric arteries, and performing a Kocher maneuver.
The distal esophagus is mobilized after the mediastinum is entered through the phrenoesophageal membrane. This is most commonly performed with the surgeon's hand during open surgery and with instruments during laparoscopic or robotic surgery.
The lymph nodes from the gastrohepatic ligament near the celiac axis and the paraesophageal areas are removed.
The stomach is divided. A pyloric drainage procedure (pyloromyotomy, pyloroplasty, or botulinum toxin injection) is performed.
The neck is opened, and the esophagus is dissected free and then divided. The esophagus and the proximal stomach are sent to pathology.
The stomach is brought up to the neck and anastomosed to the proximal esophagus.
A nasogastric tube is placed, and the neck is drained. A jejunal feeding tube may be used.

An anastomotic leak in the neck can usually be treated conservatively by opening the cervical incision and performing drainage. The patient should be made NPO and started on antibiotics. The conduit should be evaluated for necrosis by CT or endoscopy.
Undrained collections should be drained.
Anastomotic leaks are associated with a high rate of anastomotic stricture formation.

dietary modification includes small, frequent meals, separation of liquids and solids, avoidance of simple sugars, and increasing dietary fiber.
Medical management of dumping syndrome generally focuses on symptom management (atropine/diphenoxylate for diarrhea, promethazine for nausea); diazoxide is an option to inhibit insulin secretion and lessen hypoglycemia in late dumping syndrome. Somatostatin analogues have been shown to be efficacious in short-term studies.

targeting acid secretion, including antacids, proton pump inhibitors, H2 blockers, and sucralfate. Additionally, cholestyramine may help bind excess bile acids.

conversion to a Roux-en-Y gastrojejunostomy (GJ) can be performed. If a simple GJ was initially performed and the gastric channel is open, the GJ can be taken down. However, this is rarely encountered.

subtotal gastrectomy and either Billroth II or Roux-en-Y GJ reconstruction.

reversed jejunal interposition 10 cm in length and located approximately 100 cm distal to the ligament of Treitz. This option is problematic, however, as it can lead to bowel obstructions or bacterial overgrowth.

identification of the point of obstruction with appropriate management (ie, lysis if adhesions, closure of mesenteric defect, excision of redundant loop/stricture/marginal ulcer). One option in patients with a previous Billroth II would be the addition of a Braun enteroenterostomy.

D1: perigastric nodes along the lesser and greater curvature of the stomach (stations 1-6, N1 level)
D2: D1 plus the nodes along the left gastric artery, common hepatic artery, celiac trunk, splenic hilum, and splenic artery (stations 7-11, N2 level)

Computed tomography (CT) of the abdomen and pelvis is required to rule out metastatic disease and can help with T and N staging.
Endoscopic ultrasound is superior for T staging and possible nodal involvement. It is recommended if no M1 disease is present on CT (National Comprehensive Cancer Network [NCCN] guidelines). Fine needle aspiration of suspicious lymph nodes, which increases staging accuracy, should be performed.
Positron emission tomography (PET)/CT may be clinically indicated or recommended by a multidisciplinary board.
Serologic markers can aid in decision making and surveillance; these include carcinoembryonic antigen, cancer antigen (CA)-125, CA 19-9, and alpha fetoprotein.

Administer a twice-daily IV proton pump inhibitor (PPI), and continue oral PPI therapy for 2 weeks to stabilize the clot and accelerate mucosal healing.
Hold anticoagulation medications until the patient has stabilized.
Somatostatin/octreotide should be considered for patients with variceal bleeding.
Antibiotic therapy should be considered for patients with a history of cirrhosis.
Antiemetics are usually reserved for patients with persistent nausea or vomiting.

BMI >40 kg/m2
BMI >35 kg/m2 with an associated medical comorbidity worsened by obesity
Failed dietary therapy
Psychiatrically stable without alcohol dependence or illegal drug use
Knowledgeable about the operation and its sequelae
Motivated individual
Medical problems not precluding probable survival from surgery

Once the omentum is mobilized, the ligament of Treitz is identified.
A location approximately 30 to 50 cm distal to the ligament is chosen for division of the jejunum.
The mesentery is then further divided down.
The length of the Roux limb is influenced by the patient’s weight in some practices, as it can vary between 75 and 150 cm.
The jejunojejunostomy is created, and the mesenteric defect is closed.
The Roux limb can be brought up in a retrocolic or antecolic fashion.
Exposure of the angle of His allows division of the peritoneum between the top of the spleen and the gastroesophageal junction with the ultrasonic scalpel.
The lesser sac is entered through the gastrohepatic ligament, 3 to 4 cm below the gastroesophageal junction.
A 10- to 15-mL proximal gastric pouch is formed, and a gastrojejunostomy is created.

PPI plus clarithromycin plus amoxicillin or metronidazole (concomitant nonbismuth therapy) for 14 days
PPI plus bismuth plus metronidazole plus tetracycline (bismuth quadruple therapy) for 10 to 14 days

intermittent obstruction of the afferent limb of a gastrojejunostomy, causing distention, abdominal pain and cramps, abrupt decompression of intestinal contents into the stomach, and bilious emesis. Blind loop syndrome can result from bacterial overgrowth, causing vitamin B12 deficiency.

Acute afferent loop obstruction is a surgical emergency, putting the bowel at risk for ischemia and perforation.
Diagnosis can be suggested on esophagogastroduodenoscopy with difficulty gaining entry to the afferent limb.
Correction involves redo of the gastrojejunostomy or Roux-en-Y reconstruction.

It is diagnosed with either esophagogastroduodenoscopy or upper gastrointestinal contrast study showing absent contrast transit.
It requires surgical correction because it is usually due to internal herniation or adhesive disease.

This condition results from reflux of bile into the stomach. It is more common with gastrojejunostomy than with gastroduodenostomy.
It can be diagnosed clinically or via endoscopy or HIDA scan.
Bile acid sequestrants such as cholestyramine may help, but Roux-en-Y conversion may be required.

All ulcers should be biopsied, because malignancy must be ruled out.
If the patient is stable, a resection of the ulcer can be performed depending on the location.
An antrectomy is performed for lower ulcers, including vagotomy for type II and type III ulcers, with reconstruction.
For perforated ulcers closer to the GE junction, wedge or total/subtotal gastrectomy is performed with reconstruction.
If the patient is unstable, biopsy and source control with an omental patch may be all that is tolerated.
Treatment is based on type:
Type I: wedge resection or antrectomy with Billroth I anastomosis
Types II and III: distal gastrectomy with truncal vagotomy due to increased acid levels
Type IV: depends on the size and distance from the GE junction; distal gastrectomy, subtotal, or total gastrectomy

Smaller ulcers (1-3 cm) can be repaired with a Graham patch. Primary closure of small ulcers (< 1 cm) before patching may be considered. However, some concern exists over decreased adherence of the omentum on serosa versus mucosa.
Larger ulcers (> 3 cm) can be repaired with a jejunal serosal repair (Thal patch) to decrease the risk of recurrent leakage. A drain should be placed.
After patch repair, pyloric exclusion with gastrojejunostomy (Billroth II or Roux-en-Y) should be considered to assist with healing of larger ulcers. A jejunostomy tube should also be placed at the time of operation.
Thorough abdominal lavage should be performed at the completion.

Resection of the ulcer segment should be performed as feasible with caution given to the ampulla of Vater if the ulcer occurs past the first segment of the duodenum.
Antrectomy is performed with Billroth I/II or Roux-en-Y reconstruction. Tension may limit the use of Billroth I reconstruction.

In general, patients without anatomic risk factors (length > 2 cm, palpable abnormality, fibrous bands) should not undergo resection. Older individuals (> 50 years) and those with medical comorbidities should not undergo resection unless there is a palpable abnormality or other significant risk factors.
Incidentally discovered Meckel diverticula without palpable abnormalities and those causing adhesive small bowel obstruction can be successfully managed with diverticulectomy.
Symptomatic Meckel diverticula or those with palpable lesions are best managed by segmental small bowel resection and primary anastomosis.

1. Anti-inflammatory medications, antidiarrheal agents
2. Antibiotics if bacterial overgrowth suspected
3. Cholecystramine to bind bile acid

1. Serum chromogranin A
2. 24 hour urine 5-HIAA

Open the incision to the fascia, and determine whether the midline fascia is intact. Institute antibiotic treatment, and observe the patient for any signs of enteric leak.
Bedside drainage and irrigation and debridement with isotonic solution is indicated in the setting of a superficial surgical site infection.
Visualization of the underlying fascia is necessary to ensure there is no dehiscence, which is often associated with copious serous drainage.
Wounds should be packed in a "wet-to-dry" fashion, with moistened gauze packed into the wound and covered with dry gauze.
If there is surrounding cellulitis or purulent drainage, antibiotic treatment is indicated.
Drainage of succus from the incision indicates intestinal damage or fistula.