Esophagus Ppt Surgery Lect#2


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Dr. Simpson's 2nd surgery lecture on esophageal disease.

Published in: Health & Medicine

Esophagus Ppt Surgery Lect#2

  1. 1. Diseases of the Esophagus George A. Simpson, M.D.
  2. 2. Embryologic Development of the Esophagus
  3. 3. Embryologic Development of the Esophagus
  4. 4. Surgical Diseases of the Esophagus <ul><li>Hiatal Hernia </li></ul><ul><li>Reflux esophagitis </li></ul><ul><li>Esophageal motility disorders </li></ul><ul><li>Cancer </li></ul><ul><li>Esophageal disruption and trauma </li></ul>
  5. 5. Clinical Divisions of the Esophagus
  6. 6. Esophagus <ul><li>Upper 1/3 is skeletal muscle </li></ul><ul><li>Lower 1/3 is smooth muscle </li></ul><ul><li>middle is combo of both </li></ul><ul><li>Contains two sphincters </li></ul><ul><li>Lined by squamous epithelium </li></ul><ul><li>< 3 cm below diaphragm </li></ul>
  7. 7. Vascular Supply to Esophagus
  8. 8. Nerve Supply of the Esophagus
  9. 9. Motility -- Manometry
  10. 10. Esophageal Dysmotility
  11. 11. Factors Affecting Reflux
  12. 12. Esophageal Function Tests
  13. 13. Hiatal Hernia and Reflux Esophagitis <ul><li>Pathogenesis </li></ul><ul><ul><li>two major types of hiatal hernia </li></ul></ul><ul><ul><ul><li>type I or &quot;sliding&quot; hiatal hernia </li></ul></ul></ul><ul><ul><ul><li>type II paraesophageal hiatal hernia </li></ul></ul></ul>
  14. 14. Hiatal Hernia Types
  15. 15. Hiatus Hernia - Clinical Presentation <ul><li>Sliding hiatal hernias are more common than paraesophageal hernias by 100:1 </li></ul><ul><li>The lower esophageal sphincter mechanism becomes incompetent </li></ul><ul><li>Reflux of acid gastric juice produces a chemical burn </li></ul><ul><li>Degree of mucosal injury is a function of the duration of acid contact and not a disease of hyperacidity </li></ul>
  16. 16. Hiatus Hernia - Clinical Presentation <ul><li>Continued inflammation of the distal esophagus may lead to mucosal erosion, ulceration, and eventually scarring and stricture </li></ul><ul><li>Predominantly in women who have been pregnant </li></ul><ul><li>Men and women with increased intraabdominal pressure </li></ul>
  17. 17. Clinical Presentation – Type I hernia <ul><li>Type I hiatal hernia with reflux is frequently found in patients who are overweight. </li></ul><ul><li>Many patients with type I hiatal hernia have no symptoms. </li></ul><ul><li>A burning epigastric or substernal pain or tightness </li></ul><ul><li>Usually the pain does not radiate </li></ul><ul><li>May be described as a tightness in the chest and can be confused with the pain of myocardial ischemia </li></ul>
  18. 18. Clinical Presentation – Hiatus Hernia
  19. 19. Hiatus Hernia - Clinical Presentation <ul><li>Worse when the patient is supine or leaning over </li></ul><ul><li>Antacid therapy frequently improves the symptoms. </li></ul><ul><li>A lump or feeling that food is stuck beneath the xyphoid </li></ul><ul><li>Alcohol, aspirin, tobacco, and caffeine, may exacerbate the symptoms </li></ul><ul><li>Late symptoms of dysphagia and vomiting usually suggest stricture formation </li></ul>
  20. 20. Hiatus Hernia - Clinical Presentation <ul><li>Type II hernias </li></ul><ul><ul><li>Generally produce no symptoms until they incarcerate and become ischemic </li></ul></ul><ul><ul><li>Dysphagia, bleeding, and occasionally respiratory distress are the presenting symptoms. </li></ul></ul>
  21. 21. Clinical Presentation – Paraesophageal Hernia
  22. 22. Diagnosis - Hiatus Henia <ul><li>Usually suspected based on the patient's history </li></ul><ul><li>Weight loss is a feature due to distal esophageal stricture </li></ul><ul><li>Hiatal hernia and reflux esophagitis can be confirmed by fluoroscopy during a barium swallow </li></ul>
  23. 23. Barium Swallow – Type I hiatus Hernia
  24. 24. Diagnosis – Hiatus Hernia <ul><li>Esophagogastric endoscopy and biopsy of the inflamed esophagus </li></ul><ul><li>Manometry may show a loss of the lower esophageal high-pressure area </li></ul>
  25. 25. Treatment – Hiatus Hernia <ul><li>Medical Therapy </li></ul><ul><li>1. Avoidance of gastric stimulants (coffee, tobacco, and alcohol). </li></ul><ul><li>2. Elimination of tight garments that raise intraabdominal pressure, such as girdles or abdominal binders. </li></ul><ul><li>3. The regular use of antacids ( coat the esophagus), and antacid mints (Tums and Rolaids) to provide a steady stream of protection. </li></ul><ul><li>H 2 blockers, to increase the pH of the refluxed gastric juice </li></ul><ul><li>Metoclopramide (Reglan) to stimulate gastric emptying without stimulating gastric, biliary, or pancreatic secretions </li></ul>
  26. 26. Treatment – Hiatus Hernia <ul><li>4. Abstinence from drinking or eating within several hours of sleeping. </li></ul><ul><li>5. Sleeping with the head of the bed elevated to reduce nocturnal reflux. </li></ul><ul><li>6. Weight loss in obese patients. </li></ul><ul><li>About one third of patients fail to respond to initial medical treatment, and half of those who initially respond will ultimately relapse and require surgery. </li></ul>
  27. 27. Treatment Hiatus Hernia -- Surgical <ul><li>Correct the anatomic defect </li></ul><ul><li>Prevent the reflux of gastric acid into the lower esophagus by reconstruction of a valve mechanism </li></ul>
  28. 28. Treatment Hiatus Hernia -- Surgical
  29. 29. Treatment Hiatus Hernia -- Surgical
  30. 30. Hiatus Hernia <ul><li>Complications post surgery </li></ul><ul><ul><li>inability to belch or vomit- the &quot;gas-bloat&quot; syndrome </li></ul></ul><ul><ul><li>Dysphagia </li></ul></ul><ul><ul><li>Disruption of the repair with recurrent symptoms </li></ul></ul><ul><ul><li>intraabdominal infection </li></ul></ul><ul><ul><li>esophageal perforation </li></ul></ul><ul><ul><li>Splenic injury </li></ul></ul>
  31. 31. Bochdalek Hernia <ul><li>Congenital, left lateral area of diaphragm </li></ul><ul><li>Through the pleuroperitoneal foramen of Bochdalek </li></ul><ul><li>Symptoms of cyanosis, dyspnea, vomiting </li></ul><ul><li>Treatment: surgery in first 48 hours of life </li></ul><ul><li>Also – retrosternal hernia through foramen of Morgagni in older children </li></ul>
  32. 32. Diaphragmatic Hernia Bochdalek
  33. 33. Diaphragmatic Hernia Bochdalek
  34. 34. Esophageal Motility Disorders Achalasia <ul><li>Failure to relax </li></ul><ul><li>Not due to spasm </li></ul><ul><li>Failure of the high-pressure zone sphincter to relax </li></ul><ul><li>Painless dysphagia </li></ul><ul><li>Progressive dilation of the proximal esophagus </li></ul>
  35. 35. Esophageal Motility Disorders Achalasia -- Clinical Presentation <ul><li>Dysphagia </li></ul><ul><li>Regurgitation of undigested food </li></ul><ul><li>Weight loss </li></ul><ul><li>Pain in this condition is uncommon </li></ul><ul><li>Aspiration pneumonia is common </li></ul><ul><li>Complain of spitting up foul-smelling secretions when simply leaning forward </li></ul>
  36. 36. Esophageal Motility Disorders Achalasia -- Diagnosis <ul><li>Generally first confirmed roentgenographically by contrast studies of the esophagus </li></ul><ul><li>Dilation of the proximal esophagus is classic </li></ul><ul><li>Esophageal diverticula may be present at any level </li></ul><ul><li>Endoscopy -- one needs to be particularly careful to avoid diverticular perforation </li></ul><ul><li>Esophageal manometry </li></ul>
  37. 37. Esophageal Motility Disorders Achalasia -- Treatment <ul><li>Medical treatment has generally not been helpful </li></ul><ul><li>Invasive endoscopic procedure --forceful dilation </li></ul><ul><li>Surgical transaction of the muscle -- esophageal myotomy </li></ul>
  38. 38. Esophageal Motility Disorders Achalasia S shove this down your own throat
  39. 39. Esophageal Motility Disorders Achalasia
  40. 40. Esophageal Motility Disorders Achalasia
  41. 41. Esophageal Motility Disorders Achalasia
  42. 42. Esophageal Motility Disorders Esophageal Diverticulum <ul><li>The second most common manifestation of esophageal motility disorders </li></ul><ul><li>Pulsion or Traction, depending on the mechanism that leads to their development </li></ul>
  43. 43. Esophageal Motility Disorders Esophageal Diverticulum <ul><li>Upper third cervical esophageal diverticula - usually pulsion </li></ul><ul><li>Cervical diverticula, or Zenker's -- pulsion and are closely related to dysfunction of the cricopharyngeal muscle </li></ul><ul><ul><li>a) complain of regurgitation of recently swallowed food or pills, choking, or a putrid breath odor </li></ul></ul><ul><ul><li>b) treated by excision of the diverticula and myotomy of the cricopharyngeal muscle </li></ul></ul>
  44. 44. Esophageal Motility Disorders Esophageal Diverticulum – Zenker’s
  45. 45. Esophageal Motility Disorders Esophageal Diverticulum <ul><li>Middle-third esophageal diverticula are almost always traction, not related to an intrinsic abnormality in esophageal motility </li></ul><ul><li>a) Result of mediastinal inflammation (usually inflammatory nodal disease from tuberculosis or histoplasmosis, with formation and subsequent contracture that places &quot;traction&quot; on the esophagus </li></ul><ul><li>b) Usually asymptomatic and do not warrant </li></ul><ul><li>treatment. </li></ul>
  46. 46. Esophageal Motility Disorders Esophageal Diverticulum <ul><li>Diverticula of the distal third of the esophagus </li></ul><ul><li>a) associated with dysfunction of the esophagogastric junction due to chronic stricture from acid reflux, antireflux surgical procedures, achalasia </li></ul><ul><li>b) Excision of these diverticula should always be accompanied by correction of the underlying pathologic process </li></ul>
  47. 47. Esophageal Neoplasms Benign <ul><li>Exceedingly rare – in middle and distal 1/3 </li></ul><ul><li>Leiomyomas are the most common intramural tumors </li></ul><ul><ul><li>1) potential for malignant degeneration appears to be quite low </li></ul></ul><ul><ul><li>2) indent the lumen of the esophagus on contrast radiography </li></ul></ul><ul><ul><li>3) tend to grow progressively and cause dysphagia </li></ul></ul><ul><ul><li>3) Excised for possible dysphagia and malignancy </li></ul></ul>
  48. 48. Esophageal Neoplasms Malignant <ul><li>85% are squamous cell carcinomas </li></ul><ul><li>10% are adenocarcinomas </li></ul><ul><li>< 1% are malignant melanoma </li></ul><ul><li>Adenoid cystic tumors, sarcomas, APUDomas are rare </li></ul>
  49. 49. Esophageal Neoplasms Malignant <ul><li>Usually arises from squamous epithelium </li></ul><ul><li>Commonly occurs in association with alcohol and/or tobacco abuse </li></ul><ul><li>Etiology has been related to diet, vitamin deficiency, poor oral hygiene, surgical procedures, and a number of premalignant conditions, (caustic burns, Barrett's esophagus, radiation, Plummer-Vinson syndrome, and esophageal diverticula). </li></ul>
  50. 50. Esophageal Neoplasms Malignant <ul><li>Weight loss and pain may be present </li></ul><ul><li>Difficulty in swallowing </li></ul><ul><li>Acquired tracheoesophageal fistula due to erosion of the tumor into the trachea or bronchus </li></ul><ul><li>Frequent episodes of pneumonia due to recurrent aspiration </li></ul>
  51. 51. Esophageal Neoplasms Malignant -- Diagnosis <ul><li>Barium contrast studies of the esophagus </li></ul><ul><li>Endoscopy and biopsy of the lesion </li></ul><ul><li>The extent of tumor involvement assessed by computed tomography (CT) of the chest and upper abdomen . </li></ul>
  52. 52. Esophageal Neoplasms Malignant -- Diagnosis
  53. 53. Esophageal Neoplasms Malignant <ul><li>Approximately 10% of patients with Barrett's esophagus will develop adenocarcinoma </li></ul><ul><li>Symptoms produced by an esophageal malignancy </li></ul><ul><ul><li>frequently insidious at the onset, precluding early diagnosis and thus the opportunity for effective treatment </li></ul></ul><ul><ul><li>As the tumor enlarges progressive dysphagia becomes the predominant symptom </li></ul></ul>
  54. 54. Esophageal Neoplasms Malignant -- Treatment <ul><li>Tumors that involve the middle third of the esophagus are usually treated by a staged procedure with total thoracic esophagectomy and bypass </li></ul><ul><li>Cancer involving the lower third of the esophagus or proximal stomach is best treated by esophagogastric resection and an end-to-end anastomosis in the midchest. </li></ul>
  55. 55. Esophageal Neoplasms Malignant -- Treatment <ul><li>Squamous or adenocarcinomas of the esophagus - very poor prognosis </li></ul><ul><li>Palliation - restoration of effective swallowing </li></ul><ul><li>Radiotherapy - primary mode of treatment for cancer arising in the upper esophagus </li></ul><ul><ul><li>Surgical treatment of upper third usually requires extirpation of the esophagus en bloc with the larynx, permanent tracheostomy, and restoration of swallowing by a free microsurgically constructed vascular pedicle of jejunum or colon into the neck . </li></ul></ul>
  56. 56. Traumatic Rupture of the Diaphragm
  57. 57. Traumatic Esophageal Disorders Perforation <ul><li>Instrumentation by endoscopic and/or biopsy </li></ul><ul><li>Passage of blind nasogastric tubes </li></ul><ul><li>Instruments designed for dilation of strictures </li></ul><ul><li>Sengstaken-Blakemore tubes, balloon dilation for alchalasia </li></ul><ul><li>Boerhaave’s syndrome -- spontaneous perforation secondary to forceful vomiting (Plummer-Vinson) </li></ul><ul><li>Treatment requires aggressive surgical intervention </li></ul>
  58. 58. Traumatic Esophageal Disorders Perforation -- Symptoms <ul><li>May be dramatic or occult </li></ul><ul><li>Profound shock </li></ul><ul><li>Mediastinal sepsis </li></ul><ul><li>Severe chest or abdominal pain </li></ul><ul><li>Hypotension </li></ul><ul><li>Diaphoresis </li></ul><ul><li>Nausea/Vomiting </li></ul>
  59. 59. Corrosive Gastritis Due to Acetic Acid
  60. 60. Hydrochloric Acid Corrosion
  61. 61. Hydrochloric Acid Corrosion
  62. 62. Pyloric Obstruction after Lye Gastritis
  63. 63. Traumatic Esophageal Disorders Ingestion of Caustic Materials <ul><li>Medical Emergency </li></ul><ul><li>Drano, Liquid Plumber -- alkaline containing products </li></ul><ul><li>Inspect mouth to assess injury </li></ul><ul><li>Neutralization and induced emesis not usually recommended </li></ul><ul><li>Endoscopy, airway maintenance, patency of the esophagus </li></ul><ul><li>No steroids </li></ul>
  64. 67. Diaphragmatic Hernia Larrey
  65. 68. Diaphragmatic Hernia Larrey
  66. 69. Traumatic Rupture of the Diaphragm
  67. 70. Traumatic Rupture of the Diaphragm
  68. 71. Traumatic Rupture of the Diaphragm
  69. 72. Old Traumatic Rupture of the Diaphragm
  70. 73. Old Traumatic Rupture of the Diaphragm