The preoperative evaluation in some ways is more thorough and complex than a similar evaluation would be for a patient with esophageal cancer considering esophagectomy. This is largely because of the number of surgical options for benign disease. Although staging investigations are not required, the patient must undergo a complete physiologic esophageal and gastric evaluation. The primary goal of this evaluation is to determine whether the patient's symptoms may be palliated with esophagectomy or if a lesser intervention, surgical or not, will suffice.
Esophageal Function Testing
A comprehensive history by an experienced esophageal surgeon is likely to reveal a significant amount of information about the indications for esophagectomy before the objective evaluation begins. Obvious lines of questioning relate to aspiration events, food bolus impaction, severe dysphagia and odynophagia, and weight loss. It is often enlightening to ask the patient about their daily routines since they may have modified or adapted to their disorder in significant ways which seem normal to them but will strike outsiders as being somewhat unusual. Some examples include eating while standing up to make the food pass easier, keeping a bucket by the bedside for nighttime regurgitation, or eating the last meal of the day at 3 pm to avoid evening and nighttime symptoms of GERD.
On the basis of the history, objective tests are ordered to confirm our initial suspicions. These may include some or all of the following tests.
A contrast radiologic upper gastrointestinal evaluation (UGI) can be highly instructive if completed by an experience radiologist and performed with the surgeon in attendance or recorded for playback. The use of liquid barium and solids such as hamburger coated in barium replicate most eating scenarios. Often liquids produce minimal to no symptoms, but the addition of hamburger or egg salad sandwich can elicit pain when the bolus of food does not pass through the gastroesophageal (GE) junction and the patient reports severe pain (Fig. 36-1) or regurgitates from the stomach back up the proximal esophagus. Alternatively, the food bolus may pass relatively easily while the patient may be experiencing a variety of symptoms. Other pathologies such as the development of a diverticulum post long myotomy for diffuse esophageal spasm (DES) or achalasia (Fig. 36-2) may be documented. Peristalsis in the esophagus and particularly in the gastric antrum along with pyloric relaxation should be noted as a surrogate measure of intact vagal function.
Food-coated barium swallow. Barium swallow demonstrating hold up of the hamburger-coated barium (noted by arrow) at the gastroesophageal junction in a patient with achalasia and a reflux stricture.
Myotomy complicated by diverticulum. Barium swallow demonstrating an epiphrenic diverticulum 6 years after myotomy for achalasia now with recurrent episodes of aspiration.
A modification of the UGI is the timed barium swallow where patients are instructed to drink 250 mL of barium within 30 to 45 seconds.4 Spot films are taken under fluoroscopy at 1, 2, and 5 minutes with the height and width of the barium column along with the changes over time (emptying or stasis). This has been particularly useful in making decisions about esophagectomy in postmyotomy achalasia patients with symptoms of dysphagia and/or chest pain. In addition to showing end-stage esophageal function, it also can be used to correlate and educate patients about their symptoms and eating. Some patients may experience symptoms despite the complete passage of barium in normal time limits, whereas others have profound chest pain with transient hold up of barium and esophageal distension. The latter patient is more likely to benefit from reoperative surgery.
High-resolution manometry (HRM) should be repeated during preoperative evaluation to determine and confirm the current status of the motility disorder. This study is critical since it may demonstrate a recent change in the motility disorder. The spastic disorders (DES and nutcracker) can progress into achalasia, which would dictate a different surgical approach. In addition, postmyotomy dysphagia and partial fundoplication for achalasia may be due to a tight wrap, postsurgical scarring, herniation of a prior repair, or malpositioning of the repair (Fig. 36-3). More subtle findings such as bolus pressurization indicating outflow obstruction, a nonrelaxing LES, and absent body peristalsis not only may indicate the etiology of the symptoms, but also provide clues to severe esophageal dysfunction that is beyond repair. For patients with spastic disorders, it may be helpful to have patients with dysphagia ingest 5 × 1 cm cubes of bread in addition to the standard water swallows, and if necessary, a standard meal of rice and ground beef (125 mL) to replicate their symptoms and define the length of hypercontractile esophagus.
High-resolution manometry for postmyotomy achalasia. High-resolution manometry demonstrating an aperistaltic esophagus with distal pressurization and a high-pressure zone at the gastroesophageal junction in a previously myotomized patient with overly tight wrap.
pH testing via 24-hour nasal catheter, 48-hour wireless catheter, or 24-hour impedance-pH catheter is helpful since such testing can provide correlation between symptoms and acid and/or nonacid reflux in the case of impedance. In the case of GERD-positive symptoms, treatment should be directed at addressing the GERD with optimized medical therapy or with a surgical option other than esophagectomy since the motility disorder may be secondary to pathologic reflux.
Upper endoscopy with biopsy prior to surgery can also reveal more insights into the function of the esophagus and stomach. The presence of retained food, cobble-stoning of the esophagus, stricture, Barrett esophagus, and even cancer are possible findings. The former three findings suggest poor esophageal function due to delayed emptying and esophageal stasis, and this information may aid the decision to proceed with esophagectomy.
Other objective tests such as computed tomography, nuclear medicine gastric-emptying scans, and endoscopic ultrasound are ordered as appropriate. Colonoscopy is standard if a colon interposition is being considered. The role of mesenteric angiography is controversial in standard colon interposition, but in the setting of multiple previous surgeries and uncertainty regarding reconstruction options, we favor complete assessment of the celiac and both mesenteric systems.
Given the surgical physiologic impact of esophagectomies and often of the redo nature of surgeries in these settings, we believe every potential candidate should undergo full cardiac evaluation prior to esophagectomy. Pulmonary function tests including diffusing capacity should also be obtained.