Surgery Esophagus Tg

Surgery Esophagus Dr. Teresa Galdona PA-C

Esophagus
A) Function:
1)passaje for ingested food
2)emesis
3)conduit for endoscopic evaluation
4)evaluation of aorta and heart (TEE)
B) Anatomy:
Originates at cricoid cartilage
and pharynx in the neck

Esophagus
B) Anatomy:
Posterior mediastinum behind aortic
and (L) mainstem bronchus.
Enters abd. cavity through esophageal
hiatus of diaphragm.
Mucosa and 2 muscular layers
mucosa is stratified squamous epithelium

Esophagus
B) Anatomy(cont)
2 muscular layers, inner layer is circular outer layer is longitudinal. There is not serosal layer
Musculature of upper 1/3 is skeletal and musculature of the lower 2/3 is smooth muscle.
2 sphincters: one is physiological one in the neck call upper esophageal sphincter, the other is located at the diaphragm called lower esophageal sphyncter

Esophagus
C) Physiology:
food is propelled down the esophagus by a peristaltic wave.
LES relaxes in anticipation of food, allows food enter stomach then returns to its high resting pressure, to prevent reflux.
Pathophysiology:
LES is to prevent reflux of gastric content.

Esophagus
D) Pathophysiology:
1) Alteration of the mechanism of LES allows reflux of acid content, on an epithelial surface that is rich in sensory innervation
2) Failure of LES to relax, causes proximal dilation with contractile disorders

Esophagus
E) S/S:
1) esophageal disorders per se
2) other organ manifestation disorders
like angina pectoris, asthma, Pneumonia.
3) signs of systemic Ds, like collagen Ds or neurological Ds, like scleroderma (systemic sclerosis, LES,smooth muscle) in CREST syndrome, or in stroke and other neurologic diseases.

Esophagus
in CREST syndrome. Also in polymyositis/dermatomyositis, where ¼ of pts have dysphagia that involves UES (striated muscle) or in stroke and other neurologic diseases.

Esophagus
F) Clinical presentation:
Dysphagia: difficulty with transition of ingested food
Odynophagia: painful swallowing
Globus ictericus: lump in the throat,evaluate carefully sensation b/c it may represent a mass lesionand no a psychological symptom
Pyrosis or water brash associated with GERD,achalasia and esophageal strictures
Regurgitation,vomiting

Esophagus
Pyrosis or water brash associated with GERD,achalasia and esophageal strictures
Regurgitation: passive return of ingested food to oropharynx.
Vomiting: active return of stomach content

Esophagus
Recurrent episodes of bronchitis or pneumonia ( very young, elderly, may be sing of recurrent aspiration of esophageal or gastric content b/c of esophageal obstruction, congenital malformation, diverticula, or motility disorder).

Esophagus
Also,
Anemia (ulcerative esophagitis mcc of esophageal bleeding, occult blood in stools)
Hiccups or singultus (sign of diaphragmatic irritation and early sign of
stomach dilation, MI or diaphragmatic hernia)

Esophagus
Esophageal diseases may mimic other process like angina pectoris. Must do cardiac and esophageal evaluation simultaneously b/c both processess are common diseases.
G) esophagus examination:
1) H/P

Esophagus
2) stools (check for blood)
3) xray: PA and lateral to r/o thoracic pathologies
4) Barium swallow: esophageal anatomy and function. It is safe and highly cost-effective.
5) CT scan: relation to other anatomic structures and, mediastinum, esophgeal cancer.
6) MRI (no advantage over CT)
7) Esophagoscopy: allows direct visualization of lumen of esophagus, can get directed Bx and treat like esophageal varices (injecting sclerosing substances)
8) Manometry and fluoroscopy

Esophagus
7) Esophagoscopy: allows direct visualization of lumen of esophagus, can get directed Bx and treat like esophageal varices (injecting sclerosing substances)
8) Manometry and fluoroscopy, mostly for Dx of esophgeal motility disorders.

Esophagus
H) Pathologies:
1) Hiatal Hernia:
MCC in women who have been pregnant, and in both women and men when there is increased intraabdominal pressure, for example obesity, it predisposes to reflux of gastric acid into distal esophagus. It is important to know that GERD and HH are separated conditions. Although, 80% of pts with reflux have demostrable HH.

Esophagus
type I: sliding hernia
Allows the GEJ and a portion of the stomach to slide into the mediastinum.
Only important when there is association with reflux of gastric acid into the lower esophagus.

Sliding Hiatal Hernia

Esophagus
Type II: paraesophageal hernia.
GEJ is normal in position, reflux is uncommon.
Portion of the gastric fundus that herniates alonside esophagus is prone to herniation and incarceration.
Surgical repair is necessary to avoid strangulation or incarceration.

Esophagus
Sliding and paraesophageal Hiatal hernia

Hiatal Hernia
Figure 1 shows a normal connection between the esophagus in the chest cavity and the stomach in the abdomen. Figure 2 shows a small portion of the stomach pushing upward into the chest cavity from the abdomen, causing a hiatal hernia.

Esophagus
Type III: combination of I and II.
It is a very large defect at esophageal hiatus.
Other abdominal organs may be found in the mediastinum like stomach.
Surgical repair is necessary.
I) Pathophysiology:
Loss of anatomic relationship between the diaphragmatic hiatus and esophagus

Esophagus
Reflux of gastric acid causes burn of esophageal mucosa.
Very important the degree of mucosal injury is due to duration of acid contact and not to excessive gastric acidity (normal acid in the wrong place).
Continue inflammation of distal esophagus may cause mucosal erosion, ulceration, scarring, stricture, chronic reflux, transformation of epithelium to columnar ( Barret’s esophagus), to Ca (adenocarcinoma)

Esophagus

Esophagus
J) Most commonly presentation is:
Reflux,(GERD) a burning epigastric or substernal pain or tightness. 10% of pts can be confused with MI.Becomes worse when supine or leaning over.
GERD symptoms are non specific and can mimic other processes for example:
a) angina of cardiac origin must be evaluated if pt has a sensation of substernal pressure that is not relieved by belching or antiacids.

Esophagus
b) Occult blood in stools due to erosive esophagitis.
c) Schatzki ring is a variant of GERD, it is a muscular constriction of distal esophagus due to irritaton of circular muscle by refluxed acid. 10% becomes fibrotic and requires dilation and or excision.
d) Dysphagia is a symptom of oropharyngeal Ca or altered esophagial motility 2 nd to achalasia or stroke.

Esophagus
f) DGER is bile and pancreatic enzimes reflux, this process can complicate GERD when both processes coexist.
Recurrent pneumonia may indicate advance GERD and distal esophageal stricture

Esophagus
Immunocompromised pts with GERD may present with candida esophagitis, CMV or Herpes virus infection.
Gastric irritants and stimulants like chocolate, caffeine, alcohol, tobacco, ASA,
NSAID’s,can increase symptoms.

Esophagus
Other way of presentation can be chronic aspiration pneumonitis, asthma or chronic laryngitis.
Other presentation can be a complain of a “lump or food stuck” below xiphoid process due to muscular spasm of esophagus.
Many pts with type I have no sympyoms.

Esophagus
Other forms of presentations are vomiting and dysphagia (suggest stricture).
Type II HH give symptoms mostly when incarcerated and isquemic, and presents with dysphagia, bleeding and respiratory distress.
K) Dx:
Barium swallow (mostly for Dx. of HH type I and II)

Esophagus
EGD (esophagogastroduodenoscopy) and
Bx (mostly for reflux esophagitis).
L) Tx: medical, 80% respond to medical treatment and only 20% do not respond to it and ½ of this (10%) require surgery.
Medical treatment:
No gastric irritants like
Alcohol, chocolate, caffeine, tobacco

Esophagus
Avoid tight gardments that rise intraabdominal pressure
Avoid drinking or eating within several hours of sleeping
Regular use of: antiacids, H2 blokers, PPI’s.
Elevation of head’s bed at least 6 inches
to avoid nocturnal reflux.

Esophagus
Weight loss in obese pts.
Surgical Tx is to correct or repair the anatomic defect and prevent reflux,
2) Achalasia is the MC motility disorder of esophagus and it means “failure to relax”. The affected area is distal esophageal circular muscle.

Esophagus
It is caused by failure of relaxation of high pressure zone sphincter, the proximal esophagus dilates resulting in a painless dysphagia.
Symptoms are dysphagia, regurgitation of indigested food, some weight loss, pain is not a hallmark.
Drinking large amounts of liquid necessary to push down food.

Esophagus
Aspiration pneumonia is common.
Very common complain of spitting up foul smelling secretions when lean forward.
Dx is made by Barium swallow, by dilation of proximal esophagus, “bird-beak” deformity.
Tx : is surgical, 95% pts have complete relief. Procedure is known as esophageal myotomy (Heller myotomy). Medical Tx can use CCBlokers, and dilation at the esphagogastric junction

Achalasia
Bird-beak

Esophagus
3) Diverticula.
2 nd MC motility disorder. It is an out-pouching of all or part of the wall of the esophagus. May ocurred at any level in esophagus. Can be classified as pulsion (as cervical Zenker’s diverticula) and traction.
Symptoms same as achalasia like regurgitation, choking, or putrid breath odor.
Pts with traction diverticula are asymptomatic, which is the contrary for pulsion diverticula

Diverticula
Mid-esophageal diverticulum

Diverticula
Epiphrenic diverticulum

Esophagus
Tx is mostly excision of diverticula.
Other disorders of esophagus:
Scleroderma: 70% of pts have esophageal abnormalities with progressive decline in muscular contractility towards LES.
Dx is made by Barium swallow xrays.
MC GI symptom is dysphagia.
Progressive reflux, ulceration of distal esophagus, strictures.

Esophagus
Nutcracker esophagus:
Painful diffuse esophageal spasm of circular muscle through the length of esophagus that can be confused with angina pectoris.
Dysphagia :
associated with stress, or psychological factors.

Esophagus
4)Esophagus tumors:
Benign tumor: leiomyoma
Most common in middle and distal thirds, usualy asymptomatic.
Malignant tumors:
Most common are:
Squamous Ca ---- 85%
Adenocarcinoma ----10%

Esophagus
Sarcomas ----0.8%
Primary esophgeal lymphoma ----very rare
APUDomas (tumors of amine precursor uptake and decarboxilation system) 0.8%,
very malignant (already met when initial presentation).
Epidemiology:
Environmental factors are involved as etiology.

Esophagus
Low dietary levels of ascorbic acid, alphatocoferol, retinol, riboflavine, high levels of nitrosamines in fungus infected food are associated with Esophageal cancer in China.
In Western hemisphere (USA and other countries) alcohol, tobacco, achalasia, Barret’s esophagus and caustic injuries play as etiologies for esophageal cancer.

Squamous cell Ca

Esophagus
Also, poor oral hygiene, surgical procedures and pre-malignant conditions besides Barret’s esophagus, like radiation, or Plummer-Vinson syndrome (iron anemia, esophageal webs).
Great risk factor is consumption of alcohol of more or equal to 9 g of ethanol and same if person smokes more than 20 cig per day.

Esophagus
10% of pts with Barret’s will develop adenocarcinoma.
Tylosis (hyperkeratosis of palms and soles) is the only genetic disorder associated to esophageal cancer, 95% chance of esophageal cancer if live long.

Esophagus
Squamous cell Carcinoma of esophagus arises from squamous epithelium,from the upper part of esophagus
Adenocarcinoma of esophagus arises from transformation of columnar epithelium that replaces normal squamous epithelium of distal esophagus as a result of chronic acid reflux. Metaplasia like this is known as Barret’s esophagus

Esophagus
S/S of esophgeal malignancy:
Slow onset
Dysphagia (MC symptom)
Starts with solids to liquids
2 nd MC symptom is odinophagia (retrosternal pain with swallowing)
Rare symptom is constant mid-back or midchest pain

Esophagus
Hoarseness (when Tumor invade locally)
Can have episodes of aspiration pneumonia.
When Ds is too advance pts can’t swallow
their own saliva.
Very important is that no serosa layer in esophagus it allows tumors spread early to adjacent structures like aorta, lymph nodes.

Esophagus
Dx:
Barium contrast studies, “apple core” image.
Endoscopy
Bx
Ct scan used to stage esophageal Ca.
PET (positron emission tomography) for staging mediastinal and distant mts.

Esophagus
Tx:
When possible, depending of stage, surgical approach is definitely the treatment. It may depend of level of the lesion and if pt has a curable lesion. Taking this in consideration upper esophagus lesions require surgical removal of esophagus en bloc with larynx, permanent tracheostomy and restoration of swallowing

Esophagus
In lesions that involve middle third of esophagus are treated by stage procedure, total thoracic esophagectomy and bypass.
Lower third of esophagus is treated by esophagogastric resection and end to end anastomosis in the mid-chest.
When prognosis is not good then radiation and /or intubation are the Tx

Esophagus
SCC and ADC have per se bad prognosis.
Cure rate for a favorable case is only 20%, but in general cure rate for esophageal cancer is about 5%
Because SCC and ADC of esophagus have a very poor prognosis treatment is directed to restore swallowing.
Radiation and/or intubation are more used Tx for advanced cases.

Esophagus Strictures
MCC = sequelae of GERD –induced esophagitis
Causes:
Diffuse esophageal spasm (DES)
Scleroderma
Rings & Webs
Hiatal Hernia
Dysfunctional LES
Motility Disorders
Cancer
Dx:
Manometry (records pressures)
Tx:
Pneumatic (balloon dilation)

Esophagus Mallory-Weiss Tear
Repeated strenuous retching or vomiting may be responsible for the tears in the mucosa
results from prolonged and forceful vomiting, coughing or convulsions
Significant hemorrhage can occur
It may occur as a result of excessive alcohol ingestion.
This is an acute condition which usually resolves within 10 days without special treatment.

Esophagus
Esophageal perforation :
Instrumentation 1 st cause: endoscopy,
biopsy, nasogastric tube, dilation procedures, inflation of devices to tamponade esophageal varices (Seng-staken- Blakemore tube), balloon dilation for achalasia, or spontaneous perforation due to forcefull vomiting or retching that increases intraesophageal pressure (Boerhaave’s syndrome)

Esophagus
In esophageal perforation you will find a pt that after few hours of perforated presents with deep shock due to mediastinal sepsis,
and death.
Other presentation is almost immediately the pt goes with severe pain chest, hypotension, diaphoresis, nausea and vomiting then collapse and death.

Esophagus
Tx is aggressive surgical intervention.
Mortality is directly directed to time between perforation and intervention.
Foreign body :
Toddlers, mentally ill adults.
Dx. is confirm based on imaging studies (plain films, detect radio opaque object, and/or barium swallow)

Esophagus
Tx:
Endoscopic removal.
Ingestion of caustic material:
Accidental
Intentional
Most damaging are alkaline containing products (Drano, Liquid Plumr). Alkalinity above pH12.0 very corrosive

Esophagus
They destroy from lips to small intestine. Acidic material are a bit less damaging.
1 st )identification (early) of product.
each product has different approach.
2 nd ) Thorough H/P to stimate damage.
Pt presents with burning pain in upper GI tract, nausea, vomit, difficulty swallowing and breathing.
3 rd )Xrays, emergency endoscopy.

Esophagus
TX:
A glass of water in case of caustic and mlik and/or water for acids
No induced vomit (aspiration and/or further damage).
Airway and
esophagus patency
Steroids to avoid strictures if no perforation
Use of ANTB controversial
Long term dilation in case of strictures.

Esophagus
Very important:
caustic or alkaline substances cause liquefaction necrosis
Acidic substances cause coagulation necrosis

Surgery Esophagus Tg

by Miami Dade on May 19, 2009

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Surgery Esophagus Tg — Presentation Transcript