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The esophagus is a muscular tube whose function is to transport ingested material from the pharynx to the stomach. Its function is the result of a complex symphony of neuromuscular coordination. The esophagus is subject to a variety of disorders, both congenital and acquired. This chapter deals with the most common benign disorders encountered by the surgeon. These include paraesophageal hernias (PEHs), esophageal diverticula, and motility disorders. Our goal is to provide a logical and efficient approach to the evaluation and management of these disorders. Esophageal malignancy and gastroesophageal reflux disease (GERD) are addressed elsewhere in this book.
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Paraesophageal hernias (PEHs) result from a defect at the diaphragmatic hiatus. Upward displacement of abdominal contents into the mediastinum occurs due to widening of the hiatal aperture between the right and left crura. The negative pressure of the chest creates a downward pressure gradient from the abdomen further facilitating this shift. Herniation may result from congenital anatomic causes, or it may be a result of trauma or iatrogenic causes. Prior surgery involving the gastroesophageal junction (GEJ), including esophageal mobilization, crural repair, or fundoplication, can result in PEH formation. The stomach is the organ most frequently involved; other organs including the colon, omentum, spleen, liver, and pancreas may also be associated.
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Etiology and Anatomic Classification
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Hiatal hernias are classified according to the location of the GEJ in relation to the diaphragmatic hiatus and also by the contents of the hernia sac. Type I hiatal hernias are by far most common and are characterized by cephalad displacement of the GEJ above the hiatus into the mediastinum (Fig. 14-1). Type I hiatal hernias are often referred to as sliding hiatal hernias and are typically reducible. Patients with type I hiatal hernias often suffer from gastroesophageal reflux (GER) as a consequence of the altered anatomy and mechanical function of the lower esophageal sphincter (LES) and hiatal complex. Loss of intra-abdominal esophageal length and alteration of the angle of His contribute to this. If type I hiatal hernias enlarge significantly, they may become fixed above the hiatus.
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Type II hiatal hernias are considered true paraesophageal hernias and result from cephalad displacement of the fundus of the stomach into the mediastinum. The GEJ itself remains in its normal intra-abdominal location (Fig. 14-2). Dysphagia is a common symptom associated with a type II hiatal hernia, usually due to compression of the esophagus by the stomach. These types of hernia are also referred to as “rolling” hernias. Herniated portions of the stomach are typically found in the posterior mediastinum. These are the least common type of hiatal hernia.
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