Surgery Lectures

Prof.Dr.Waleed Mustafa

(Esophagus )

Consultant Thoracic and Vascular Surgery

Anatomy :The Esophagus is a long muscular tube approximately 40 cm from the incisor teeth (25 cm from cricopharyngeus ) ,that extends from the pharynx at the level of 6th. Cervical vertebra to the stomach ,which it joins opposite the body of 11th. thoracic vertebra.It is arbitrary divided into Cervical ,Thoracic and Abdominal parts.

The esophagus has three distinct areas of naturally occurring anatomic narrowing .
1-The crico pharyngeal constriction 2-Broncho aortic constriction . 3-The diaphragmatic constriction .Between these areas the esophagus has a wide caliber and is termed superior & inferior dilatation .

Blood supply , segmental

Cervical esophagus supplied by Inf.thyroid Ar. Thoracic esophagus === esophageal branches (Aorta) segmental vessels (intercostal &phrenic ) .Abdominal (phrenic &left gastric) Venous drainage Cervical esophagus drain to inferior thyroid &vertebral V. Thoracic esophagus drain to azygous & hemi azygous Abdominal esophagus drain to gastric veins

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Lymphatics run longitudenally in the wall of the esophagus penetrating muscle layers to reach regional lymph nodes .The flow of the upper 2/3 is upward while the flow of the lower 1/3 is downward. Nerve supply It receives both sympathetic & parasympathetic ( Vagi ) .Each vagus nerve lies on either side of the esophagus forming a plexus but at the hiatus it forms two major trunks Anterior & posterior vagal trunk .The nerve supply to the normal esophagus is cholinergic and causes contraction every where except for the circular muscle of the cardia where its adrenergic and causes relaxation . Esophageal Hiatus :- It is a sling of muscle fiber that arises from the right crus in approximately 45% of the patients , however both right and left crus contribute to the hiatus . Esophageal wall It composed of an inner circular layer of muscles and outer longitudinal layer without a surrounding serosal covering .Striated muscle fibers predominate in the upper third , where as smooth muscle fibers predominated in the lower portion .Auerbachs (Myenteric ) plexus located between the two muscles layers , while Meissners plexus of nerve is located in the sub mucosa .Mucosal lining is made up of squamous epithelium ,with the distal 1,2 cm is lined by columnar epithelium .

Phreno esophageal membrane :-It is a fibro elastic sheet of tissues that extends circumferentially from the muscle margin of the diaphragmatic hiatus to the esophagus .

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Physiology :It is a muscular tube that begins proximally with upper esophageal sphincter (UES) and ends distally with lower esophageal sphincter (LES) .Its function is to transport the swallowed material from the pharynx down to the stomach . The voluntary act of swallowing stimulate wave of relaxation which travels down the esophagus .LES opens 1.5-2.5 seconds after swallowing .This wave of relaxation is followed by a wave of primary peristalsis & if emptying is incomplete , secondary peristalsis will be initiated by distension of the esophagus .

Clinical manifestation of esophageal diseases

1-Dysphagia 2-Odynophagia

difficulty in swallowing pain on swallowing

3-Regurgitation & vomiting 4-Drooling of saliva 5-Heart burn (substernal burning sensation )

6-Weight loss & cachexia

Investigations 1-Plain X-Ray chest :It may shows a dilated esophagus (especially in lateral view ) located between the trachea and the heart (anteriorly ) and the vertebral column posteriorly .It may shows changes in the lung (fluid level ) from the spill over of the esophageal content. It may shows a radio opaque foreign body . (3)

2-Barium swallow It is very essential and may be diagnostic in some esophageal diseases such as achalasia of the cardia . 3-Esophagoscopy :It is the direct visualization of the interior of the esophagus by either rigid esophagoscope , carried under GA or by the flexible esophagoscope ,carried under local anesthesia . History
Rigid Esophagoscopy was first used successfully in 1868 by Waldenberg , who examined the cervical esophagus and by Kussmaul , who in the same year used a modified urethroscope to diagnose a carcinoma of the thoracic esophagus Flexible Fiber optic Esophagoscope developed by Lo-Presti & Hilmi in 1964.

Indications of Esophagoscopy :1-Diagnostic:A- To evaluate symptoms of dysphagia ,odynophagia ,regurgitation ,hematemesis . B- To asses established esophageal pathology ,esophagitis , caustic injury or tumors . C- To define or confirm radiological abnormalities , stricture ,HH, esophagitis ,,diverticula ,varices , and extrinsic compression . D-It is of great value in assessment of post operative problems as anastomotic stricture ,tumor recurrence ,bleeding ,dysphagia and recurrent GER . EUS :- Endo scopic ultra sound , Combines (endoscopy and U/S )in order to obtain images & information about the esophagus and the surrounding tissues.

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2-Therapeutic Indications :1-Removal of foreign bodies 2-Dilatation of stricture Benign or malignant .congenital or acquired 3-Placement of endoluminal prosthesis (stent ) 4-Sclerotherapy 5-Laser photo coagulation for bleeding or tumor de bulking

Technique of Rigid Esophagoscopy

General anesthesia generally provides better relaxation, lowering the risk of perforation. The patient is positioned supine with head and shoulders over the end of the table. Introduce the esophagoscope into the right side of the mouth and rest the shaft on your left thumb. The scope is advanced behind the right arytenoid cartilage into the right pyriform fossa.Lower the patients head as the scope is advanced past the cricopharyngeus .Lower the head further and move to the right to pass through the gastro esophageal junction . Full examination is done on withdrawal, as folds of mucosa may hide pathology during advancement of the scope. Complications of rigid esophagoscopy Safe performance of esophagoscopy demands 1-Familiarity with normal esophageal anatomy , particularly the three areas of constriction and the course of the esophagus through the thorax . 2-Elective esophagoscopy should never be performed without prior barium esophagogram 1-Minor Complications -Laceration of the lips or tongue , Fracture or dislodgment of teeth -Pharyngeal laceration These are the result of poor technique and failure to adequately protect the gums , lips & teeth during the procedure.

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Major Complications

The leading and most important serious complication of esophagoscopy with or without dilatation of a stricture is Perforation which occurs in 1-2 % of patients after(F.B removal ,Dilatation of stricture or biopsy ) A basic surgical principle is Pain or fever after esophageal instrumentation represents an esophageal perforation until proven otherwise and is an indication for an immediate esophagogram. Mortality and morbidity of an esophageal perforation are directly related to the time interval between the occurrence of the injury and its diagnosis and repair or drainage .

Management -----Conservative ----- Operative In general perforations proximal to obstructing esophageal lesions are unlikely to heal primarily if repaired , and may be treated very effectively by emergency.

4-Manometry :It is the classical test to examine (LES) function. It is performed with electronic pressure sensitive transducer catheter with a side hole attached to a transducer outside the body .Hypertensive Lower Esophageal Sphincter is seen in achalasia of the cardia .Loss of the tone is seen in pregnancy & alcholism .

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2nd. Lecture

Disorders of esophageal motility

Functional disorders of the esophagus
Are those conditions that interfere with the normal act of swallowing or produce dysphagia without any associated intra luminal , mural organic obstruction or extrinsic compression .

Upper esophageal sphincter dysfunction :Crico pharyngeal dysfunction (oro pharyngeal dysphagia ) :Symptoms complex that result when there is a difficulty in propelling liquid or solid food from the pharynx into the upper esophagus .

Causes :1-Neuro genic CNS (MS) , vascular (CVA) ,tumors ,trauma 2-Myogenic myasthenia gravis , inflammatory (poly myositis) 3-Structural divertuculum

4-Mechanical intra or extra luminal 5-Iatrogenic surgical or irradiation .

6-Gastro esophageal reflux .

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Motor disorders of the body of the esophagus

1-Achlasia of the cardia . 2-Diffuse esophageal spasm & related hyper motility disorders )

Achalasia of the cardia

Is a disease entity of unknown etiology Characterized by absence of peristalsis in the body of the esophagus, a high resting pressure at the (LES) and failure of this sphincter to relax in response to swallowing .It is translated from Greek and means failure of relaxation . Pathology : In achalasia , the body and the upper segment of the esophagus become dilated, tortuous & hypertrophied .The most specific histological abnormality found by (E.M) is the degeneration or disappearance of the ganglion cells of the Auerbach s plexus.

Motility ; In achalasia , a hypertensive (LES) with incomplete or no relaxation on swallowing & aperistaltic esophageal body could be demonstrated by manometry.

Etiology : Many theories were advanced to explain the etiology of achalasia. The most widely acceptable & popular one attributes the condition to a neuromuscular dysfunction affecting both the narrowed and the dilated segments of the esophagus and not merely the (LES) .

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Clinical features : Achalsia can occurs at any age. The highest incidence is(25-60) . Mostly equal sex incidence or > in female. The duration of symptoms (Days to years) The onset ,sudden or insidious .sudden( emotional stress )

Symptoms : 1-Dysphagia 2-Regurgitation . 3-Pain . 4-Weight loss &Cachexia . 5-Emotional Disturbance . 6-Respiratory symptoms . 7-Heart burn ( bact. Fermentation) . Diagnosis : 1-CXR : -Absence of gastric air bubble. Visible Esophagus . Fluid level . 2-Barium Swallow : Diagnostic Dilated Esophagus ,full of barium , Normal mucosal lining ,food residue Little barium passed to the stomach Morphological forms : Cork-Screw, Cucumber ,Tortuous & Sigmoid Bird s beak appearance 3-Esophagoscopy; To confirm the diagnosis ,&to exclude other path. 4-Manometry ; Absence of peristalsis(body), high LES pressure .

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Differential diagnosis:Diffuse esophageal spasm Systemic sclerosis Organic obstruction( stricture , tumors)

Treatment :1- Medical treatment 2-Dilatation 3-Surgery -----adalat , isordil (bougienage) pneumatic or hydrostatic Hellers cardio myotomy ---Thoracic approach ----Abdominal approach Recently Laparoscopic cardio myotomy

Complications of achalasia

1- Those related to retention & stasis ( Retention esophagitis ) 2-Air way obstruction & repeated chest infection . 3-Pre malignant (squamous cell carcinoma )

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Perforation of the esophagus

1-Esophageal perforation following instrumentation either by the rigid esophagoscope or by bougienage 2-Traumatic perforation , Foreign bodies ingestion or blunt and penetrating trauma 3-Spontaneous rupture ( Boer-haave s syndrome ) due to the strian of emesis with or without predisposing disease . The sites of the normal anatomical constriction are the most common sites of perforation . The consequence of the perforation is the contamination of the peri esophageal space with the digestive fluids, food and bacteria ,can leads to extensive suppuration .Perforation of the cervical esophagus can extend into the mediastinum along the fascial planes . The upper 2/3 of the esophagus will perforate into the rt. Pleural cavity while the lower 1/3rd will perforate into the lt. Pleural cavity . Rarely the intra abdominal esophagus may perforate leading to peritonitis. Clinical manifestations : Pain ,Fever ,Dysphagia ,Cervical pain or crepitation , Dyspnea , Pneumothorax and in severe cases dyspnea and cyanosis . Chest X-ray :Mediastinal emphysema . Pleural effusion Barium study can localize the site of perforation .

Treatment ; Medical( NBM = NPO),IVF , Nasogasric feeding, Surgical to close the perforation.

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Stricture of the Esophagus

1-Caustic Strictures : It is the stricture resulting from the ingestion of solid or liquid caustics most frequently seen in children who have accidentally swallowed the material or in adult who have ingested the material for suicidal purposes . The chemicals included alkaline caustics, acids or acid- like & household bleaches .Strong alkalis (Na&KOH) It can burns of the pharynx,larynx,Esophagus &Stomach Symptoms : Ranges from(minimal to shock ) . Dyspnea may occur . Management :1-Identification of the etiological agent . 2-Administration of the neutralizing agent . 3-Assessment of the extent of the injury. 4-Early Esophagoscopy ! to determine whether there is Esophageal injury or not . 5-Cortico steroid decreases the degree of stricture . 6-Antibiotics . together with steroid for (3-6 week ) . 7-Barium swallow two weeks later to see if there is stricture or not . 8- Dilatation ( Bougenage) may be needed after(3-4 weeks) and many patients need regular dilatation . 9- May need Esophageal replacement .

ESOPHAGEAL STRICTURE IS A PRE MALIGNANT

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2-Reflux Esophagitis and Stricture

Esophageal stricture secondary to the reflux of acid or alkaline secretions into the esophagus caused by esophagogastric incompetence as a result of hypotensive (LES ) . Pathologically it is a continuous process of destruction And healing that may stop at any stage or may progress to fibrosis ,stricture with the resulting dysphagia.

Stricture secondary to reflux are of three types : 1-Low stricture occur at the esophagogastric junction. 2- High stricture occur at higher level ,associated with barrett esophagus; it is an acquired condition in which the squamous epithelium has been eroded by the damaging effects of GE reflux and has subsequently been replaced by columnar junctional epithelium, it is a rare ,but it is PRE MALIGNANT and the malignancy is adenocarcinoma . 3- long stricture rarest type .occur in postpartum vomiting .

Treatment :

1- Bougienage (Dilatation ) 2-Surgery : Resection

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3rd. Lecture

CARCINOMA ESOPHAGUS

Carcinoma of the esophagus is a disease of men between age) (50-70 . Two risk factors Smoking , High consumption of alcohol .

Predisposing lesions :
1-Achalasia 2-Barret esophagus 3-Corrosive stricture 4-Plummer Vinson syndrome.

Pathology
1-Squamous cell carcinoma > 95% most common (body) 2-Primary adenocarcinoma < 1-7% most common of them is adenocarcinoma arise in Barretts esophagus. 3-Mucoepidermoid &Adenocystic carcinoma . Rare . Most malignant lesions are ulcerating & encircling the esophagus .Malignant lesion involving the EG junctions adenocarcinoma of gastric origin .

Spread :
1-Direct extension 2-Lymphatic to cervical ,mediastinal and sub diaphragmatic. 3-Blood metastases liver ,lung &bone.

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Clinical manifestations :
Dysphagia ,to solid later to liquid ,Weight loss ,Aspiration pneumonia .Pressure symptoms .

Barium swallow : irregular ragged mucosal pattern with annular luminal

narrowing .

Esophagoscopy : to see the tumor , to take biopsy(tissue diagnosis) ,and

esophageal wash for cytology .

CT with oral contrast Treatment :

1-Chemo-therapy little value 2-Radio-therapy useful but it may cause post radiation stricture ,radiation pneumonitis . 3-Surgery a- palliative b- Resection partial gastrectomy ,partial esophagectomy &gastro esophageal anastomosis (Ivor lewis operation ) through lapratomy & thoracotomy .

Approaches left thoracotomy

laparatomy & right thoracotomy laparatomy & cervical incision Thoracoabdominal

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Gastro Oesophageal Reflux Disease (GORD)

Heart burn GORD

Heartburn:-Mild , intermittent reflux of gastric content into the esophagus without tissue injury .Common among adult . GORD :-Esophagitis with varying degree of erythema , edema & friability of the distal esophageal mucosa . Aetiology :1- Lower esophageal sphincter (LES ) incompetence . 2-Gastric outlet obstruction . 3- 50% of patients with GORD have an associated hiatal hernia . 4-Defective esophageal function (Scleroderma )

Mechanism of Anti Reflux

1-High resting pressure in the distal esophagus (10-20 mm Hg) which is greater than the adjacent stomach acting as a barrier . 2-Muscle sling , the looping of the muscle fiber of the right crus of the diaphragm around the esophago -gastric junction . 3-The phreno esophageal membrane which anchor the esophagus within the hiatus . 4-The presence of the intra abdominal segment of the esophagus .It is subjected to a highly positive intra abdominal pressure . 5-The oblique angle of insertion of the esophagus into the stomach (angle of His ) . 6-The small diameter of the esophagus entering abruptly into the large diameter (stomach) Law of Laplace .

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Clinical features :1- Epigastric or retro sternal pain , after meal or at night 2- Pain similar to angina . 3-Reflux of food or gastric content , occurs with bending . 4-Odyno phagia 5- Pulmonary aspiration , nocturnal cough

Diagnosis :1- History and physical examination 2-Barium swallow . 3-Oesophago gastro dudenoscopy (OGD ) & biopsy . 4 Ambulatory 24 hours PH monitoring . 5- Esophageal manometry ,when motility disorders is suspected

Treatment 1- Medical :Weight reduction Change diet (light frequent meal ) Stop smoking Elevate the head of the bed (4-5 inches ) . Anti acid Metoclopromide increase LES pressure & gastric emptying H2 receptor blockers Ranitidine (Zantac )

Proton pump inhibitor omperazole

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2- Surgical Indications :1- Failure of medical treatment . 2-Presence of complications (stricture , respiratory symptoms) . 3-Patient preference . Surgery

Laparoscopic Nissen s fundoplication Lapratomy Nissen s fundoplication

Thoracotomy Belsys mark 1V repair

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Esophageal hiatal hernia

It is the herniation of the stomach through the esophageal hiatus of the diaphragm. Hiatal Hernia are of two types ;

1-Type 1 axial (sliding H.H.) is common , usually

insignificant ,in which there is hiatus opening dilatation and or stretching of phrenoesophageal membrane , so that a portion of the fundus will slide upward into the hiatus .No true sac. In some patients a large pouch can occur producing abnormal degree of GE reflux (significant) .

2-The Para-esophageal (rolling) :

less common but more significant ,there is a defect of phreno esophageal mm. So this allows protrusion of the peritonium through the fascia (true hernial sac ) .this will lead to progressive enlargement of the hernia .the entire stomach may herniated. May lead to gastric volvulus, strangulation and intrathoracic gastric distention.

3-Combined H.H. In which herniation of the cardia well above the

diaphragm in addition to paraesophageal hernia .Increased incidence of reflux .

4-Multiorgan H.H. other organs herniated (colon , small intestine) .

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Clinical presentation ;
Heart burn &Regurgitation aggravated by posture

Commonly after meal , Dysphagia , Aspiration into the chest can occur often awaken the patient , can lead to lung abscess .

Barium- swallow in trendlenburge position .

Esophagoscopy :

Treatment :
the principal indication for H.H.repair is paraesophageal type (II) H.H. (Surgery) .No indication for repair of type(I) unless severe reflux. Medical treatment should started once reflux diagnosed . Surgical Treatment :Nissen s fundoplication (lapratomy or laparascopic) Beksys mrak IV repair (Thoracotomy )

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Esophageal divertuculae
Are epithelial -lined mucosal pouches that protrude from the esophageal lumen. Almost All are acquired and occur predominantly in adults. Classified according to the site 1-Pharyngo esophageal (at the junction of pharynx &Esophagus .) 2-Parabronchial(midesophageal),near the tracheal bifurcation. 3-Epiphrenic(Supra diaphragmatic) from the distal 10cm of the True diverticulum contains all layers of the normal Esophagus. False = = = consist primarily of only( mucosa& submucosa ) esophagus.

Miscellaneous conditions

Sideropenic Dysphagia (Plummer-Vinson or Patterson-Kelly syndrome ) .

1-Cervical dysphagia in patients with iron deffiency .Anemia. 2-Usually edentulous women over the age of (40) years . 3-Have atrophic oral mucosa with glossitis . 4-Brittle spoon-shaped finger nails(Koilonychia.) 5-The presence of a cervical esophageal web. 6- It is regarded as (pre malignant) condition. Treatment. Dilatation &correction of anemia .

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Schatzki s Ring ;(Distal esophageal web)Commonly seen in patient with a sliding H.H.,appearing as annular strictures projecting into the lumen. Mallory-Weiss Syndrome ; (Emetogenic mucosal laceration ) A history of emesis followed by either melena or hematemesis . May occur in pregnancy ,alcoholism, bowel obstruction .

Thank you
Prof.Dr. Waleed Mustafa Hussen Consultant Thoracic And Vascular Surgeon M.B.Ch.B., MS,FIBMS(Th.C.V.S).,FACS.,MRCS.,FRCS(Glasgow)

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