Professional Documents
Culture Documents
Diseases
Essential Esophageal
Anatomy
Essential Esophageal
The upper 1/3 is composed
of striated muscle and is
Anatomy
innervated by the vagus and its recurrent branch. The lower
Esophageal Spasm
Syndromes
Esophageal Spasm
Syndromes
Pain is the Predominant Symptom
1.
DES
Esophageal Spasm
Syndromes
Pain is the Predominant Symptom
2.
HAPC (Nutcracker esophagus)
Esophageal Spasm
Syndromes
Pain is the Not the Predominant Symptom
1.
Achalasia
Achalasia
Achalasia is best confirmed by:
1.
A birds beak appearance on barium
esophagogram
2.
Aperistalsis of the cervical esophagus
3.
Failure of the LES to relax on swallowing
4.
LES pressure < 5 mmHg
5.
Biopsy proven esophagitis on flexible
endososcopy
Achalasia
Characteristics of
Achalasia
Manometry
1.
2.
3.
4.
Esophagogram
1.
2.
3.
Esophageal dilation
Air/Fluid level
Birds beak or Sigmoid esophagus
Endoscopy
1.
2.
3.
Esophageal dilation
Retained food
Frequently normal
Treatment of Achalasia
Traditionally, the primary therapeutic approach for
achalasia involves pharmacological agents,
endoscopic botulinum toxin into the LES and
pneumatic dilatation of the LES
Pharmacologic Agents
1.
Calcium channel blockers and long acting Nitrates
both decrease LES resting pressure. Usually poor,
short-lived response, side effects limit their
effectiveness
2.
Endoscopic botulinum toxin is successful in 80% of
patients in relieving dysphagia. However, symptoms
return in 50% in 6 months. Retreatment is successful
in 50% of original responders
Treatment of Achalasia
Pneumatic Dilatation
Disrupts LES muscle fibers and produces relief
of symptoms in 50-85% of patients. However,
most patients require multiple dilatations,
increasing the risk of perforation (up to 8%).
Long term relief of symptoms in 40-65%
Pneumatic Dilation vs Surgical Myotomy
Only one randomized controlled trial with long
term follow-up (dysphagia relieved in 91% vs
65%)
Treatment of Achalasia
Surgical Myotomy
Transabdominal vs Transthoracic
Dysphagia relief about 90% at 2 years
Recurrent dysphagia within 2 months likely due
to incomplete myotomy, torsion of the repair or
scarring of the mucosa from cautery
Late-onset dysphagia due to mucosal stricture
from reflux, or the latent effects of delayed
gastric emptying. These patients ultimately need
gastric or esophageal resection
Treatment of Achalasia
Surgical Myotomy
A resting LES > 36 mm Hg is associated with a
good surgical outcome
Patients with esophageal dilation > 6 cm or with
loss of the esophageal axis (i.e. sigmoid, tortuous or
convoluted esophagus) will need an esophagectomy
Addition of an Anti-Reflux Procedure?
Reflux symptoms occur in up to 30% of patients. A
partial fundoplication should be added.
No difference between a 180-degree Dor or a 270degree Toupet partial fundoplication
Esophageal Spasm
Syndromes
Pain is the Not the Predominant Symptom
2.
Hypertensive Lower Esophageal Sphincter
(HLES)
Esophageal Spasm
Syndromes
Pain is the Not the Predominant Symptom
3.
Esophageal Spasm
Syndromes
1.
2.
3.
4.
5.
Esophageal Diverticulum
1.
2.
3.
4.
5.
Esophageal Diverticulum
Epiphrenic Diverticulum
Usually pulsion diverticulum located within the distal 10
cm of the thoracic esophagus
Usually right sided
Most are found incidentally, however, the most common
symptoms are dysphagia, regurgitation
Barium esophagogram remains the best test for diagnosis
Endoscopy, 24 Hr PH and manometry should be performed
Symptomatic, anatomically dependent and enlarging
diverticulum should be surgically repaired
Surgical therapy includes diverticulectomy, myotomy and a
partial fundoplication as indicated (Transthoracic or
Transabdominal)
Esophageal Diverticulum
Zenkers Diverticulum
Most common esophageal diverticulum
Killians triangle is usually the site of weakness
Symptoms include regurgitation, halitosis,
chocking, aspiration, nocturnal coughing,
laryngitis. Motility determines symptoms and not
the pouch size
Diagnosis made on barium swallow
Endoscopy to rule out malignancy
Surgical treatment recommended if symptomatic
Treatment consists of cervical esophagomyotomy
and pouch resection
Esophageal Diverticulum
Midesophageal Diverticulum
Usually traction diverticulum
These are due to TB and histoplasmosis. Most
asymptomatic and need no intervention
Midesophageal pulsion diverticulum are due to an
underlying motility disorder and are due to pulsion.
Manometry is helpful to define the extent of myotomy
Surgical intervention for large (> 5 cm) and
symptomatic diverticulum
Buttress repair with pleura, pericardial fat or
omentum
Esophageal Perforation
65 yr old female with achalasia complains of back
pain after pneumatic dilation. The CXR is normal
post procedure. The next best course of action is:
1.
Repeat endoscopy to identify any mucosal injury
2.
VATS/or thoracotomy and operative repair as you
suspect an esophageal perforation
3.
Infectious disease consult for the prompt
administration of antibiotic therapy
4.
Contrast study of the esophagus
5.
Admit to ICU, IV hydration. If stable and CXR normal,
upper GI endoscopy or gastrografin swallow the next
morning
Esophageal Perforation
Common Causes of Esophageal Perforation
Endoscopy, esophageal dilation, NG tube
insertion, trauma
Operative procedures associated with
perforation: anterior spine surgery (cervical),
gastric fundoplication, thyroidectomy,
pneumonectomy
Common Sites of Esophageal Perforation
Cricopharyngeus, aortic knob, gastro esophageal
junction
Esophageal Perforation
Presentation and Diagnosis
Differential diagnosis includes myocardial infarction, pancreatitis,
perforated peptic ulcer disease, aortic dissection, acute gastric
volvulus
Symptoms vary depending on site, mechanism and interval to
presentation. However, pain is the most common complaint
Fever, tachycardia, leucocytosis, subcutaneous emphysema and
crepitus, dysphagia, pleural effusion, peritonitis, sepsis
Rapid diagnosis is the key: mortality of untreated esophageal
perforation increases from 10-20% to 40-60% after the first 24 hours
CXR: mediastinal emphysema, pleural effusion, hydropneumothorax
Gastrografin swallow (10% missed injuries), followed by thin barium
CT may be helpful in equivocal cases and to help guide non-operative
treatment
Esophageal Perforation
When to Manage an Esophageal Perforation NonOperatively?
Minimal Symptoms
Esophageal Perforation
Operative Management of Cervical Perforation
Drainage usually is sufficient
Incision made anterior to the sternocleidomastoid
muscle
Mediastinoscopy can be used to drain the middle
mediastinum
Neck drained with closed suction or penrose drains
Direct operative repair if perforation easily
localized
May be combined with thoracic drainage if
extensive mediastinal and pleural soilage present
Esophageal Perforation
Operative Management of Thoracic Perforation
Widely open the mediastinal pleura and drain the pleural cavity
Paraesophageal Hernias
Classification
Type I: Sliding, fundus only, 1-5 cm, no rotation
Type II: True Paraesophageal, fundus/body, 1-5 cm, organoaxial
rotation
Type III: Mixed, fundus and body, or more of stomach,
organoaxial and mesoaxial rotation
Type IV: Mixed with other organs, fundus and body plus other
organs, or more of stomach and colon, organoaxial and
mesoaxial rotation
Paraesophageal Hernias
Symptoms and Signs
50% are asymptomatic, although minor
symptoms are usually overlooked
Typical symptoms include epigastric pain, postprandial discomfort in the chest, heartburn,
regurgitation, vomiting, weight loss, dyspnea
Important signs include anemia, pneumonia
An incarcerated intrathoracic stomach is a
surgical emergency. These patients present with
acute chest or epigastric pain and retching, but
the inability to vomit
Paraesophageal Hernias
Diagnosis
CXR shows a retro cardiac air bubble, with or
without an air fluid level
Barium swallow confirms the diagnosis and
usually shows a large, intrathoracic upside down
stomach
Endoscopy helpful to evaluate for ulcers,
Barretts and neoplasms
Esophageal motility studies helpful in an elective
setting to help guide decisions regarding a wrap
Paraesophageal Hernias
Treatment
All patients with symptoms or signs should undergo
elective repair in the absence of prohibitive
surgical risk
Paraesophageal Hernias
Treatment
All patients with symptoms or signs should
undergo elective repair in the absence of
prohibitive surgical risk
Need for esophageal mobilization and
lengthening
The importance of sac excision
The role of gastrostomy and gastropexy
The need for mesh in crural repair
Caustic Ingestion
A 7 year old boy swallowed some ammonia (glass
cleaner). He is crying, complaining of pain and
is drooling. Which of the following is true:
1.
The patient should immediately be intubated to
secure his airway
2.
Endoscopy is contraindicated, as it could exacerbate
the injury
3.
Sodium hypochlorite (bleach) ingestion has the
highest likelihood of perforation
4.
Gastrografin swallow is performed at 3 weeks and
helps guide dilation of strictures
5.
Steroids help decrease the incidence of strictures
Gastroesophageal Reflux
Disease
True statements regarding an abdominal approach
versus a thoracic approach to anti-reflux
surgery include:
1.
A Collis gastroplasty for a shortened esophagus is
easier performed through the abdomen
2.
Large hernias are easier repaired laparoscopically
with better results
3.
Redo operations are better performed through the
abdomen
4.
There is a lower incidence of esophageal perforation
5.
The Nissen repair is easier performed
transabdominally
Gastroesophageal Reflux
Disease
Preoperative Work-up
1) esophagogastroduodenoscopy
2) esophageal manometric evaluation.
3) 24-hour intraesophageal pH monitoring
4) barium cineradiography
Gastroesophageal Reflux
Disease
Indications for Surgery
Gastroesophageal Reflux
Disease
Types of Repairs:
Nissen
Hill
Toupet
Dor
Belsey Mark IV
Collis Gastroplasty
Barretts Esophagus
1.
2.
3.
4.
5.
Esophageal Cancer
Presentation
1.
90% present with dysphagia
2.
70% present with weight loss
3.
50% present with substernal or epigastric pain
4.
Hoarseness is rare
Esophageal Cancer
Role of EUS in T Stage Assessment
Esophageal Cancer
Esophageal Cancer
Staging
T1: invades lamina propria or sub mucosa
T2: invades muscularis propria
T3: invades adventitia
T4: invades adjacent structures
N0: no lymph nodes
N1: regional lymph nodes
M1: distant metastasis, including celiac or cervical nodes
Esophageal Cancer
Staging
T1: invades lamina propria or sub mucosa
T2: invades muscularis propria
T3: invades adventitia
T4: invades adjacent structures
N0: no lymph nodes
N1: regional lymph nodes
M1: distant metastasis, including celiac or cervical nodes
Stage I
Stage 2A
Stage 2B
Stage 3
Stage 4
: T1 N0
: T2 N0 and T3 N0
: T1 N1 and T2 N1
: T3 N1 and T4 any N
: M1
Esophageal Cancer
Neoadjuvant Therapy
5 yr survival with surgery alone is 25%
Although 7 randomized trials have been done,
only one 1996 study (Walsh) shows a survival
benefit at 3 years
We employ neoadjuvant therapy for Stage 2B or
higher
Chemotherapy is 5FU and Cisplatin
Radiation is about 40G
Esophageal Cancer
Surgical Approaches
Transhiatal esophagectomy
Ivor-Lewis esophagectomy
Esophagectomy with cervical
anastomosis
Thoracoabdominal with left chest
anastomosis
Esophageal Cancer
1.
2.
3.
4.
5.