‫כירורגית חזה‬
‫מ‪.‬ר קפלן‬
‫‪‬‬
‫‪‬‬
‫צינור שרירי באורך ‪ 25‬ס"מ‬
‫מחולק ל‪ :3-‬צוארי‪ ,‬חזי‪ ,‬בטני‬
‫‪ ‬בתמט במנוחה‬
‫‪ ‬נמתח עד ‪ 2-3‬ס"מ‬
‫בבליעה‬
‫‪ ‬שטוח ב‪ 2/3-‬העליונים‬
‫ומעוגל ב‪ 1/3-‬התחתון‬
‫‪ ‬מתחיל מגובה ‪ C6‬ועד כ‪-‬‬
‫‪ 3‬ס"מ מתחת לסרעפת –‬
‫‪T11‬‬
‫‪‬‬
‫האיבר הצר ביותר‬
‫במערכת העיכול למעט‬
‫התוספתן‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪ 1/3‬עליון הוא שריר מפוספס‬
‫‪ 1/3‬תחתון הוא שריר חלק‬
‫‪ 1/3‬אמצעי הוא שילוב של השניים‬
‫מכיל שני ספינקטרים‬
‫מכוסה באפיתל קשקשי‬
‫ שכבות‬4 ‫לושט‬
Mucosa 
Submucosa 
Muscularis propria 
Adventitia 
‫ אין‬- ‫ בניגוד לשאר מע' העיכול‬
‫סרוזה‬

‫‪‬‬
‫‪‬‬
‫‪‬‬
‫אזורים פונקציונליים ולא אנטומיים‬
‫ניתן לזהות ע"י מדידות לחץ‬
‫‪:UES‬‬
‫‪‬‬
‫‪‬‬
‫אזור לחץ גבוה באורך ‪ 2-3‬ממ בין‬
‫הפארינקס לושט‬
‫סמוך ל‪cricopharyngeal muscle -‬‬
‫‪‬‬
‫‪:LES‬‬
‫‪ ‬אזור לחץ גבוה באזור ה‪-‬‬
‫‪GEJ‬‬
‫‪ ‬בד"כ כ‪ 3-‬ס"מ מתחת‬
‫להיאטוס‬
‫‪‬‬
‫‪‬‬
‫השכבות השריריות‬
‫אחראיות לפריסטלטיקה‬
‫של הושט‬
‫שתי שכבות – פנימית‬
‫צירקולרית וחיצונית‬
‫אורכית‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫מע' אנסטומוזות נרחבת‬
‫מע' ניקוז תת רירית‬
‫הכרחי להתפשטות מהירה של גידולים‬
‫‪ ‬שליחת גרורות לפני חסימה של החלל‬
‫‪ ‬שיעור הישנות גבוה‬
1.
Hiatal Hernia
2.
Reflux esophagitis
3.
Esophageal motility disorders
4.
Cancer




Sliding hiatal hernias are more common – 95%
The lower esophageal sphincter mechanism
becomes incompetent
Reflux of acid gastric juice produces a chemical
burn
Degree of mucosal injury is a function of the
duration of acid contact

Continued inflammation of the distal
esophagus may lead to
mucosal erosion
 Ulceration
 eventually scarring and stricture
 Intestinal metaplasia (Barrett`s esophagus)






Hiatal hernia with reflux is frequently found
in patients who are overweight.
Many patients with hiatal hernia have no
symptoms.
A burning epigastric or substernal pain or
tightness
Usually the pain does not radiate
May be described as a tightness in the chest
and can be confused with the pain of
myocardial ischemia

Aggravate


Allevaite


supine or leaning over, alcohol, aspirin, tobacco,
and caffeine
Antacid therapy
Late symptoms of dysphagia and vomiting
usually suggest stricture formation






Anamnesis
Weight loss is a feature due to distal
esophageal stricture
Manometry - loss of the lower esophageal highpressure area
24-h pH-monitoring – gold standard for GERD
Upper-GI series
Esophagogastric endoscopy - Bx
Medical Therapy




Avoidance of gastric stimulants (coffee,
tobacco, and alcohol)
Weight loss
Avoid eating several hour before bedtime
PPI



Failure of PPI treatment
Correct the anatomic defect
Prevent the reflux of gastric


Complications post surgery
3-10%

inability to belch or vomit- the "gas-bloat"
syndrome
 Vagal injury
 The wrap itself
Dysphagia
 Disruption of the repair with recurrent
symptoms – 5%
 esophageal perforation
 Splenic injury
 Penumothorax





Failure of the high-pressure zone sphincter to
relax
Not due to spasm
Painless dysphagia
Progressive dilation of the proximal esophagus






Dysphagia
Regurgitation of undigested food
Weight loss
Pain is uncommon
Aspiration pneumonia is common
Complain of spitting up foul-smelling
secretions when simply leaning forward




Generally first confirmed by contrast studies of the
esophagus
Dilation of the proximal esophagus is classic
Esophageal diverticula may be present at any level
Esophageal manometry – gold standard


Medical treatment has generally not been
helpful
Invasive endoscopic procedure



forceful dilation – effective - 60%. 4% perforations
Botoxtm – 50% recurrence within 6 months
Surgical


Transaction of muscle - Heller myotomy
Esophagectomy – sigmoid esophagus, failure of
more than one myotomy, or an undilatable stricture


The second most common manifestation of
esophageal motility disorders
Pulsion or Traction, depending on the
mechanism that leads to their development


Upper third cervical esophageal diverticula usually pulsion
Cervical diverticula, or Zenker's
 pulsion
 related to dysfunction of the cricopharyngeal
muscle


complain of regurgitation of recently swallowed
food
putrid breath odor
Treat the underlying condition!
• Excision of the diverticula
• Myotomy of the cricopharyngeal
muscle






Middle-third esophageal diverticula
Traction
Not related to esophageal dysmotility
Result of mediastinal inflammation
Usually asymptomatic and do not warrant
treatment.


Diverticula of the distal third of
the esophagus
Dysfunction of the esophagogastric junction





Stricture
antireflux surgical procedures
Achalasia
Excision of the diverticula
Always - correction of the underlying
pathologic process


Exceedingly rare – in middle and distal 1/3
Leiomyomas are the most common
intramural tumors
1) potential for malignant degeneration appears to
be quite low
2) indent the lumen of the esophagus on contrast
radiography
3) tend to grow progressively and cause dysphagia
3) Excised for possible dysphagia and malignancy




GERD - Chronic acid reflux
Columnar intestinal metaplasia
40 times risk for AdenoCA
May progress to



Low grade dysplasia
High grade dysplasia (stage 0 carcinoma)
Invasive AdenoCA

30% are squamous cell carcinomas

70% are Adenocarcinomas

< 1% are



malignant melanoma
Adenoid cystic tumors
Sarcomas

Origin
SCC – squamous epithelium
 AdenoCA – Barrett`s esophagus



Commonly occurs in association with alcohol
and/or tobacco abuse
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, esophageal diverticula).





Vague symptoms at early stages
Weight loss and pain may be present
Dysphagia – obstruction of >30%
Odynophagia
Iron deficiency anemia

Endoscopy and biopsy of the lesion

Endoscopic US – T & N staging

Chest & Abdominal CT – M staging

PET CT

T1 lamina propria or
submucosa





T1a muscularis mucosae
T1b submucosa
T2 - muscularis propria
T3 - adventitia
T4 - adjacent structures
• N0 - No regional
lymph node
metastasis
• N1 - 1 to 2 regional
lymph nodes
• N2 - 3 to 6
• N3 - >6

Early disease – stage I,(IIa ?)


Surgery
Locally advanced disease – stage IIb, III


Neoadjuvant therapy
Surgery

Surgical techniques
 Transhiatal esophagectomy
 Transthoracic esophagectomy
 En-block esophagectomy
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫טיפול כירורגי למטרת ריפוי‬
‫טיפול כירורגי כפליאציה?‬
‫כירורגיה‪Gold standard -‬‬
three field esophagectomy - ‫ ושט צווארי‬
jejunal flap/ stomach )‫ כירורגיה‬+‫ חזה‬+‫ג‬.‫א‬.‫) א‬
three field esophagectomy - ‫ ושט חזי‬
Ivor Lewis/ lt thoracotomy
Trans Hiatal ‫ או‬Ivor Lewis - ‫ ושט תחתון‬
lt thoracotomy ‫ או‬Ivor Lewis - "‫ "צומת ושט קיבה‬
‫במשלב עם כריתת קיבה‬
‫טכניקה כירורגית‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫כניסה?‬
‫כמה ושט לכרות? כמה בלוטות להסיר?‬
‫"תחליף ושט"? טכניקת השקה?‬
‫מאפייני מטופל‬
‫מיקום השאת?‬
‫מאפייני מטופל?‬
‫ניסיון כירורגי?‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫גישה נפוצה‬
‫‪ 2‬חתכים‬
‫‪OPEN/ LAP‬‬
‫‪‬‬
‫יתרונות‬
‫השקה בצוואר‬
‫תחלואה‬
‫‪‬‬
‫חסרונות‬
‫אונקולוגיה‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫יתרונות‬
‫אונקולוגיה‬
‫תחליף ושט‬
‫‪‬‬
‫חסרונות‬
‫תחלואה‪ ,‬תמותה‪.‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
Rt Thoracotomy
Laparotomy
Cervical
Esophagectomy






Combined thoracoscopic / laparotomy
Combined thoracoscopic / laparoscopic
Laparoscopic transhiatal
‫‪‬‬
‫קיבה‬
‫‪‬‬
‫מעי גס‬
‫‪‬‬
‫מעי דק‬

Major complications
 Perioperative
 Mortality – 4-7%
 Anastomotic leak – 5-15%
 Vocal cord paralysis
 Chylothorax
 Empyema
 Long term
 Stricture