Surgery Lectures
(Esophagus )
Prof.Dr.Waleed Mustafa
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
(1)
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 .Auerbach’s (Myenteric ) plexus
located between the two muscles layers , while Meissner’s 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 .
(2)
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
difficulty in swallowing
2-Odynophagia
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.
(4)
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 patient’s 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.
(5)
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 .
(6)
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 .
(7)
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) .
(8)
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 .
(9)
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
------
Heller’s 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 )
(10)
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.
(11)
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
(12)
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
(13)
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 Barrett’s 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.
(14)
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
(15)
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 .
(16)
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
(17)
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 Belsy’s mark 1V repair
(18)
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) .
(19)
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)
Beksy’s mrak IV repair
(Thoracotomy )
(20)
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
esophagus.
True diverticulum contains all layers of the normal Esophagus.
False = = = consist primarily of only( mucosa& submucosa )
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 .
(21)
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)
(22)