I.
Introduction.
Esophageal diverticula are epithelial-lined mucosal pouches that protrude from the esophageal lumen. Almost all of them are acquired and occur predominantly in adult caustic ingestions remain a significant health threat and affect between 5000 and 26000 citizens annually. The majority of the patients with caustic injury are children younger than 5 years of age and adolescents and adults with suicide attempt.
Esophageal perforation remains a true emergency and a therapeutic challenge for the general and thoracic surgeon because delay clearly affects survival.
II.
General aim of the lesson
General aim of the lesson includes:
1.
acquiring knowledge about etiology and clinical symptoms of the esophageal diverticula, perforation and caustic injury of the esophagus.
2.
acquiring the practical skills of the patients’ objective examination
3.
mastering of the main instrumental examination used in these pathology
4.
determine the indication for different kind of medical and surgical treatment
Tasks for self-training
After individual studying of the material every student has to: a) know:
1.
etiology of esophageal diverticula, perforation and caustic injury
2.
clinical pictures of these diseases
3.
instrumental methods for diagnostic, such as: X-ray examination, esophagoscopy, laboratory tests
4.
surgical and medical treatment of esophageal diverticula, perforation and caustic injury b) be able:
1.
to find out main complains and assess the present state of the patient
2.
to realize objective examination of patients with these diseases
3.
to estimate received data of X-ray examination and of endoscopy
4.
to create (to determine) indications for complex conservative treatment and for surgical correction of this disease.
III.
Initial level of knowledge.
Anatomo-physiological and pathogistological data about the esophagus. Different modes of surgical procedures have been studied in course of operative surgery. Students should revise this material.
IV.
Brief outline of the topic (obligatory material for acquisition).
Esophageal diverticula are classified according to their area of occurrence, wall thickness and mechanism of formation.
Esophageal diverticula occur at three distinct areas:
1.
pharyngoesophageal (Zenker’s) – at the function of the pharynx and esophagus.
2.
parabronchial (midesophageal) – near the tracheal bifurcation
3.
epiphrenic – at the distal 10sm of esophagus
According to wall thickness esophageal diverticula can be:
1.
true diverticulum containing all layers of the normal esophageal wall
2.
false diverticulum consisting primarily of mucosa and submucosa
According to mechanism of formation esophageal diverticula can be:
1.
pulsion diverticula (pharyngoesophageal and epiphrenic – are false diverticula, that arise because elevated intraluminal pressure forces the mucosa and submucosa to herniate through the esophageal musculature.
2.
traction diverticula (parabronchial) are true diverticula that result from external inflammatory reactions in adjacent mediastinal lymph modes that adhere to the esophagus and that pull the entire wall toward these lesions as they heal and contract.
Symptomatic patient with Zenker’s diverticula can complain of the following:

1.
vague sensation in the throat
2.
intermittent cough
3.
excessive salvation
4.
cervical dysphagia
5.
gurgling sounds during swallowing
6.
regurgitation of food
7.
halitosis
8.
respiration obstruction
The main complications of the Zenker’s diverticula are:
aspiration
perforation
bleeding
carcinoma
Mide-esophageal diverticula can be asymptomatic, however dysphagia, retrosternal pain, regurgitation, belching and heartburn can be noted.
Epiphrenic diverticula are occasionally asymptomatic, but patients with motility disorders and large diverticula can complain of dysphagia, regurgitation, vomiting, chest and epigastric pain, cough, halitosis or noisy swallowing. That’s why symptoms of epiphrenic diverticula are difficult to differentiate from hiatal hernia, diffuse esophageal spasm, achalasia, reflux esophagitis and carcinoma.
The main instrumental methods to define this pathology are:
1.
X-ray barium swallow examination
2.
esophagoscopy
3.
manometric tracing
Treatment
1.
esophagomyotomy and resection of the diverticulum
2.
esophagomyotomy with the following dipping of the diverticulum into mucosa and submucosa
(in case of small diverticula)
3.
diverticulopexy with cricopharyngeal myotomy
Caustic injury
Caustic ingestion almost always occur accidentally with young children, however, with adolescents and adults it usually represents a suicide attempt, with relatively large volumes of toxic substances and a greater potential for developing serious injury.
The most common chemicals are alkaline caustics, acid or acid-like corrosives and household bleaches.
The area and severity of injury depend on the character, quantity and concentration of the ingested substance. Solid lye substances tend to lodge in the oropharynx or upper esophagus.
Concentrated liquid caustics not only present an increased potential for esophageal injury, but they may also damage the stomach and distal intestinal tract.
Caustic injuries are categorized as superficial or deep. Superficial burns of the mucosa are manifested with erythema, edema, and blister appearance. Deep burns lead to circumferential ulcerations and full-thickness necrosis and perforation of the esophageal and gastric wall.
Caustic injury is manifested with the symptoms of oral pain, drooling, excessive salvation and inability or refusal to swallow or drink, substernal and back discomfort, abdominal pain.
Hoarseness, stridor and dyspnea suggest laryngeal edema or actual epiglottic and laryngeal injury.
This condition demands hospitalization and observation.
Endotracheal intubation or a tracheostomy should be performed if the airway obstruction or respiratory distress appears progressive.
After superficial injuries, re-epitheliazation of esophageal mucosa is usually complete by the sixth week, but full-thickness injury leads to scarring and contracture, which can progress for months.
Methods of the investigation:

Esophagoscopy should be performed within the first 12-24 hours and no later than the first 48 hours, to confirm the extent and severity of the burn. Exceptions for early endoscopy are cases where esophageal or gastric perforation or impending airway obstruction is suspected. Contrast Xray studies should be repeated at intervals of 3 weeks, 3 months, between 6 months and 1 year to rule out the possibility of late stricture formation.
Treatment
The treatment is started with anti-shock measures, such as:
1.
introduction of narcotic drugs for anesthesia (or pain relief)
2.
introduction of glucose solutions, electrolytes solutions and plasma
3.
introduction of corticosteroid and atropine for decrease of salvation
4.
introduction of the tube in the stomach and fulfillment of gastric lavage (irrigation, washing out) with large amount of water.
Then antibiotics, prophylactic histamine (H
2
) – blockers or therapeutic doses of antacids are recommended. Corticosteroid treatment is contraindicated in cases of severe caustic burns, which have perforated the esophagus or produced necrosis of the stomach.
In contrast, patients with signs of dyspnea, hoarseness or stridor can benefit from immediate administration of corticosteroids to relieve airway obstruction due to mucosal edema and bronchospasm.
Bougienage is used for early treatment of corrosive esophageal burns. It is performed daily for several weeks and then every other day for 2-3 weeks and finally once a week for many months.
An alternative to the bougienage technique is the placement of intraluminal silastic stents.
Surgical treatment
1.
emergency cervical esophagostomy, esophagogastrostomy, duodenostomy
2.
subtotal gastrectomy with Billroth I or II type of reconstruction (in case of pyloric stenosis)
3.
placement of a feeding jejunostomy
4.
esophageal reconstruction a) by reversed gastric tube b) left colon interposition c) substernal right colon interposition
Complications of the corrosive esophagus burns:
1.
perforation in abdominal or thoracic cavities
2.
bleeding
3.
mediastinitis
4.
stricture formation
5.
tracheoesophageal fistula
6.
malignant degeneration
Esophageal perforations can be:
1.
iatrogenic
2.
spontaneous
3.
traumatic
Causes of iatrogenic perforations:
endoscopy procedures
different endotracheal intubation
stenting, palliative intubation and laser destruction of esophageal tumors
blind dissection of abdominal esophagus for vagotomy and others.
Symptoms Signs
Vomiting
Pain
Hematemesis
Dysphagia
Dyspnea
Tachycardia
Fever
Subcutaneous emphysema
Cardiac crunch
Chest dullness

This pathology is confirmed by the plain chest X-ray examination and by contrast esophagogram, and sometimes by CT-scanning.
Treatment
1.
early primary reinforced repair with drainage of the contaminated space
2.
esophageal resection, cervical esophagostomy and enternal feeding tube with plans for late (6 months) reconstruction is used in case of late perforations
3.
jejunostomy for enteral nutrition or parenteral hyperalimentation with wide drainage of the mediastinum should be done in case of encountered late complex perforations.
4.
esophageal exclusion and later-performing a second major reconstructive procedure
5.
esophageal resection (in case of esophagus perforation above neoplastic strictures)
6.
T-tube drainage.
V. Literature
1.
Short Practice of Surgery by Charles V. Mann and all.
2.
Textbook of surgery by Sabiston
3.
Lectures
VI. Approximate actions base
1. Introduction /5 min/. Teacher short characterizes topic actuality, meets students with main aims of the study and plan.
2. Initial knowledge’s control /15 min/.
3. Individual students work with patients /30 min/. The teacher explains some more difficult and important parts of problem. The choice is realized by asking of students and their answers correction.
4. Clinical analyses of topical patients /100 min/. Students observe topical patients under teaches control. After it finishing, the students report about receiving results.
5. Work in dressing-room and operation theater. Teacher and students change the dressings of patients after different surgical procedures on esophagus.
6. Study of X-ray pictures.
7. Final knowledge control. Solution of test-questions /25 min/.
8. Conclusion /5 min/. The teacher concludes the session and gives new task for the next once.
VII.
Test-questions
1.
Mark the kinds of esophageal diverticula. a) Pharingoesophageal/ b) laryngoesophageal c) parabronchial/ d) epiphrenic/ e) cardioesophageal
2.
According to the mechanism of formation parabronchial diverticula are: a) the pulsion diverticula b) the traction diverticula/
3.
Enumerate clinical symptoms of Zenker’s diverticula: a) thoracic dysphagia b) intermittent cough/ c) excessive salvation/

d) hematomesis e) halitosis/ f) gurgling sounds during swallowing/
4.
Choose the most accurate diagnostic methods of esophageal diverticula a) esophagoscopy/ b) thoracicoscopy c) X-ray examination/ d) manometric tracing
5.
Cervical esophagomyotomy is done through: a) an oblique left cervical incision/ b) an oblique right cervical incision c) a transverse cervical incision
6.
What symptoms suggest the caustic injury of the upper respiratory airways? a) dyspnea/ b) hoarseness/ c) stridor/ d) pain in the chest
7.
How soon should the esophagoscopy be performed after the moment of caustic injury? a) no later than the first 12 hours b) no later than the first 24 hours c) no later than the first 48 hours/
8.
Clinical picture of caustic injury includes the following: a) oral pain/ b) drooling/ c) inability to swallow/ d) substernal and back discomfort/ e) abdominal pain/ f) vomiting g) hematemesis
9.
Emergency treatment of esophageal burns includes introduction of: a) narcotic drugs/ b) atropine/ c) antihistaminic drugs/ d) corticosteroids/ e) gastric lavage/ f) antacids g) histamine H
2
- blockers
10.
Esophageal perforations can be: a) iatrogenic/ b) spontaneous/ c) pneumatic d) traumatic/ e) mechanical
11.
Enumerate the main signs of esophageal perforation: a) tachycardia/ b) fever/

c) decrease of the arterial pressure d) subcutaneous emphysema/ e) chest dullness/ f) dysphagia
12.
Mark absolute indications for urgent surgical interventions in case of esophagus perforation: a) sepsis/ b) shock/ c) pneumothorax/ d) pneumoperitoneum/ e) mediastina; emphysema/ f) respiratory failure/