الجامعة السورية الخاصة كلية الطب البشري قسم الجراحة...

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الخاصة السورية الجامعةالبشري الطب كلية

الجراحة قسمقبطان عاصم الدكتور

The esophagus1st Lecture

M.A.Kubtan

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The anatomy and physiology of the esophagus

Their relationship to disease The clinical features. Investigations . Treatment of benign and malignant disease with

particular reference to the common adult disorders

LEARNING OBJECTIVES To understand

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The esophagus is a muscular tube.

Approximately 25 cm long .

Mainly occupying the posterior mediastinum .

Extending from the upper esophageal sphincter (the cricopharyngeus muscle) in the neck to the junction with the cardia of the stomach.

Surgical anatomy

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The upper esophagus, including the upper sphincter, is striated.

This is followed by a transitional zone of both striated and smooth muscle .

There is only smooth muscle in the lower half of the esophagus .

Muscular Type

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It is lined throughout with squamous epithelium.

Histological lining

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The parasympathetic nerve supply is mediated by branches of the vagus nerve .

Has synaptic connections to the myenteric (Auerbach’s) plexus.

Meissner’s sub mucosal plexus is sparse in the esophagus.

Nerve supply

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The upper sphincter consists of powerful striated muscle.

The lower sphincter is more subtle, and is created by the asymmetrical arrangement of muscle fibers in the distal esophageal wall just above the esophagogastric junction.

Esophageal sphincters

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Remember the distances 15, 25 and 40 cm for anatomical locationduring endoscopy

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The main function of the esophagus is to transfer food from the mouth to the stomach in a coordinated fashion.

The initial movement from the mouth is voluntary.

Physiological Function

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Sequential contraction of the oropharyngeal musculature .

Closure of the nasal and respiratory passages . Cessation of breathing . Opening of the upper esophageal sphincter . Beyond this level, swallowing is involuntary. The body of the esophagus propels the bolus through a

relaxed lower esophageal sphincter (LES) .

The pharyngeal phase of swallowing

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The coordinated esophageal wave that follows a conscious swallow is called primary peristalsis.

It is under vagal control . Also there are specific neurotransmitters that control the

LES.

primary peristalsis

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The upper esophageal sphincter is normally closed at rest

Serves as a protective mechanism against regurgitation of esophageal contents into the respiratory passages.

It serves to stop air entering the esophagus other than the small amount that enters during swallowing.

Upper Esophageal Sphincters Function

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The LES is a zone of relatively high pressure that prevents gastric contents from refluxing into the lower esophagus .

It opens in response to a primary peristaltic wave . It relaxes to allow air to escape from the stomach and at

the time of vomiting.

LES Function

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Food . Gastric distension . Gastrointestinal hormones . Drugs and smoking.

Factors influence LES sphincter tone

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The arrangement of muscle fibers, their differential responses to specific neurotransmitters.

The relationship to diaphragmatic contraction. The normal LES is 3–4 cm long . LES has a pressure of 10–25 mmHg.

Factors contributing to LES Function

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Dysphagia . Odynophagia . Regurgitation and reflux . Chest pain .

Esophageal Symptoms

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Described as difficulty with swallowing. Food fails to enter the esophagus . Food stays in the mouth . Food enters the airway causing coughing or spluttering.

Dysphagia

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Oral or pharyngeal . Food fails to enter the esophagus . Stays in the mouth or enters the airway causing

coughing or spluttering. Causes are chronic neurological or muscular

diseases or inflammatory or traumatic origin.

Dysphagia in Voluntary Phase

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characterized by : A sensation of food sticking. Is often informative of the likely diagnosis.

dysphagia occurs in the involuntary phase

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Acute . Chronic . Can affect solids . Can affect fluids . Can affect solids & fluids . Can be intermittent . Can be progressive.

Mode of Dysphagia

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pain on swallowing. Patients with reflux esophagitis often feel retrosternal

discomfort . Is a feature of infective esophagitis and may be

particularly severe in chemical injury.

Odynophagia

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Regurgitation should strictly refer to the return of esophageal contents from above a functional or mechanical obstruction.

Reflux is the passive return of gastro duodenal contents to the mouth as part of the symptomatology of gastro esophageal reflux disease (GERD).

Regurgitation and reflux

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Loss of weight . Anemia . Cachexia . Change of voice . Cough or dyspnoea .

Symptoms & Signs accompany regurgitation and/or reflux.

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Similar in character to angina pectoris .

Chest pain

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Radiography . Endoscopy . Endosonography . Esophageal manometry . 24-hour pH recording .

Investigations

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Dilatation of strictures . Thermal recanalisation .

Therapeutic procedures

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Difficulty in swallowing described as food or fluid sticking (esophageal dysphagia) Must rule out malignancy .

Pain on swallowing (Odynophagia)Suggests inflammation and ulceration .

Regurgitation or reflux (heartburn) Common in gastro-esophageal reflux disease .

Chest pain Difficult to distinguish from cardiac pain

Correlation of Symptoms of esophageal disease

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The most common impacted material is food.

Usually occurs above a significant pathological lesion .

Plain radiographs are often useful for foreign bodies .

Modern denture materials are not always radiopaque .

Diagnosis made by endoscopy .

FOREIGN BODIES IN THE ESOPHAGUS

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The esophagus2nd Lecture

M.A.Kubtan

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Perforation of the esophagus is usually iatrogenic (instrumental perforations at therapeutic endoscopy) it can be managed conservatively ( not all the time ).

Barotrauma’ (spontaneous perforation). is often a life-threatening condition that regularly requires surgical intervention .

PERFORATION

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Potentially lethal complication due to mediastinitis and septic shock .

Numerous causes, but may be iatrogenic . Surgical emphysema is virtuall pathognomonic . Treatment is urgent; it may be conservative or

surgical, but requires specialised care .

Perforation of the esophagus

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Boerhaave syndrome : This occurs classically when a person vomits against a

closed glottis. The pressure in the esophagus increases rapidly, and the

esophagus bursts at its weakest point in the lower third sending a stream of material into the mediastinum and often the pleural cavity .

Boerhaave syndrome is the most serious type of perforation . This causes rapid chemical irritation in the mediastinum and pleura followed by infection if untreated.

Barotrauma (spontaneous perforation)

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Barotrauma has also been described in relation to other pressure events when the patient strains against a closed glottis (e.g.defaecation, labour, weight-lifting).

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The clinical history is usually of severe pain in the chest or upper abdomen following a meal or a bout of drinking.

Associated shortness of breath is common. There may be a surprising amount of rigidity on

examination of the upper abdomen, even in the absence of any peritoneal contamination.

The diagnosis can usually be suspected from the history and associated clinical features.

Diagnosis of spontaneous perforation

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A chest X-ray is often confirmatory with air in the mediastinum, pleura or peritoneum.

Pleural effusion occurs rapidly . A contrast swallow or CT is nearly always required to

guide management

Continue

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severe subcutaneous emphysema 33 years old woman

secondary to prolonged labor during normal vaginal delivery

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A contrast swallow

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Aero digestive fistula is most common and usually encountered in primary malignant disease of the esophagus or bronchus.

Erosion into an adjacent structure with fistula formation is more common.

Free perforation of ulcers or tumors of the esophagus into the pleural space is rare .

Coughing on eating and signs of aspiration pneumonitis may allow the problem to be recognized .

Pathological perforation

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Covering the communication with a self-expanding metal stent is the usual solution.

Erosion into a major vascular structure is invariably fatal.

Continue

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Foreign bodies : The esophagus may be perforated during removal of a foreign body .

Occasionally, an object that has been left in the esophagus for several days will erode through the wall.

Instrumental perforation : Instrumentation is by far the most common cause of perforation.

Perforation can occur in the pharynx or esophagus, usually at sites of pathology or when the endoscope is passed blindly.

Perforation may follow biopsy of a malignant tumor.

Penetrating injury

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The esophagus may be perforated by guide wires, graduated dilators or balloons, or during the placement of self-expanding stents.

The risk is considerably higher in patients with malignancy.

Continue

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Forceful vomiting may produce a mucosal tear at the cardia rather than a full perforation.

In Mallory–Weiss syndrome, vigorous vomiting produces a vertical split in the gastric mucosa.

Tear immediately below the squamocolumnar junction at the cardia in 90% of cases.

In only 10% is the tear in the esophagus .

MALLORY–WEISS SYNDROME

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Perforation of the esophagus usually leads to mediastinitis.

The aim of treatment is to limit mediastinal contamination and prevent or deal with infection.

The event causing the perforation (spontaneous vs. instrumental) .

Underlying pathology (benign or malignant) . The status of the esophagus before the perforation

(fasted and empty vs. obstructed with a stagnant residue).

Factors influencing Treatment of esophageal perforations

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attempted suicide. Accidental ingestion occurs in children and when

corrosives are stored in bottles labeled as beverages. All can cause severe damage to the mouth, pharynx,

larynx, esophagus and stomach. In general, alkalis are relatively odorless and tasteless,

making them more likely to be ingested in large volume.

CORROSIVE INJURY

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Significant stricture formation occurs in about 50% of patients with extensive mucosal damage .

Continue

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Multiple stricture of the body of esophagus

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Most congenital malformations develop during embryonic life between the third and eighth weeks of gestation.

CONGENITAL MALFORMATIONS

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A blind proximal pouch with a distal tracheo-esophageal fistula is the most common type.

Affected infants typically present Soon after birth with frothy saliva . cyanotic episodes, exacerbated by any attempt to feed. The preceding pregnancy may have been complicated

by maternal polyhydramnios.

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Esophageal atresia

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Is confirmed by failure to pass a 10 Fr oro-gastric tube into the stomach .

The tube is visible within an upper esophageal pouch on the chest radiograph.

The presence of abdominal gas signifies the tracheo-esophageal fistula.

Associated anomalies are common and include cardiac, renal and skeletal defects.

Diagnosis

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Surgical repair : The esophageal ends are anastomosed.

Division and repair of tracheo – esophageal tract .

Treatment of Esophageal Atresia

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Infants with pure esophageal atresia and no tracheo-esophageal fistula . Usually best managed by a temporary gastrostomy .

Delayed primary repair. Except for very-low-birth weight babies and those with

major congenital heart disease, most infants with repaired esophageal atresia have a good prognosis.

Continue

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Anastomotic leak . Stricture . Recurrent fistula formation . Gastro- esophageal reflux.

Potential postoperative complications

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The esophagus3rd Lecture

M.A.Kubtan

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May result from absence of an intra - abdominal length of esophagus .

The phreno-esophageal ligament is weak . The crural opening widens allowing the upper stomach

to slide up through the hiatus. Sliding hiatus hernia alone should not be viewed as the

cause of reflux. As long as the LES remains competent, pathological

GERD does not occur.

Sliding hiatus hernia

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True par esophageal hernias in which the cardia remains in its normal anatomical position are rare.

The vast majority of rolling hernias are mixed hernias in which the cardia is displaced into the chest and the greater curve of the stomach rolls into the mediastinum

PARAOESOPHAGEAL (‘ROLLING’) HIATUSHERNIA

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The symptoms are mostly due to twisting and distortion of the esophagus and stomach.

Dysphagia is common. Chest pain may occur from distension of an obstructed

stomach. Classically, the pain is relieved by a loud belch. Strangulation, gastric perforation and gangrene can

occur.

The symptoms of rolling hernia

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Chest X Ray . Barium meal study . Esophagoscopy .

Investigations

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GASTRO-ESOPHAGEAL REFLUX DISEASE ( GERD )

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Normal competence of the gastro-esophageal junction is maintained by the LES.

Is influenced by both its physiological function and its anatomical location relative to the diaphragm and the esophageal hiatus.

As long as the LES remains competent, pathological GERD does not occur.

Etiology

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Most episodes of physiological reflux occur during postprandial transient lower esophageal sphincter relaxations (TLESRs).

In the early stages of GERD, most pathological reflux occurs as a result of an increased number of TLESRs rather than a persistent fall in overall sphincter pressure.

In more severe GERD, LES pressure tends to be generally low .

loss of sphincter function seems to be made worse if there is loss of an adequate length of intra-abdominal esophagus.

Continue

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The classical triad of symptoms is : Retrosternal burning pain (heartburn) . Epigastric pain (sometimes radiating through to the back) . Regurgitation. Heartburn and regurgitation can be brought on by stooping or

exercise. Nocturnal reflux . Some patients present with less typical symptoms such as

angina-like chest pain . Dysphagia is usually a sign that a stricture has occurred .

Clinical features of GERD

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The most appropriate examination is endoscopy with biopsy.

Widespread use of proton pump inhibitor PPIs, which cause rapid healing of early mucosal lesions.

On the other hand, there is a strong correlation between worsening endoscopic appearances and the duration of esophageal acidification on pH testing.

Diagnosis

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83



The esophagus4th Lecture

M.A.Kubtan

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Benign tumors . Relatively rare. The majority of ‘benign’ tumors are not epithelial in origin Arise from other layers of the esophageal wall. Most benign esophageal tumors are small and

asymptomatic. large benign tumor may cause only mild symptoms . The most important point in their management is usually

to carry out an adequate number of biopsies to prove beyond reasonable doubt that the lesion is not malignant .

NEOPLASMS OF THE OESOPHAGUS

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Classic appearance of a large esophageal gastrointestinal

stromal tumor on barium swallow

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An intraluminal polyp that proved to be a leiomyosarcoma

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Non-epithelial primary malignancies are rare. Secondary malignancies rarely involve the esophagus . Bronchogenic carcinoma by direct invasion of either the

primary and/or contiguous lymph nodes.

Malignant tumors

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Cancer of the esophagus is the sixth most common cancer in the world.

It is a disease of mid to late adulthood . Only 5–10% of those diagnosed will survive for 5 years .

Carcinoma of the oesophagus

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Squamous cell usually affects the upper two-thirds; adenocarcinoma usually affects the lower third .

Common etiological factors are tobacco and alcohol (squamous cell) and GERD (adenocarcinoma) .

The incidence of adenocarcinoma is increasing . Lymph node involvement is a bad prognostic factor . Dysphagia is the most common presenting symptom, but

is a late feature . Accurate pretreatment staging is essential in patients

thought to be fit to undergo ’curative’ treatment . Adenocarcinoma now accounts for 60–75% of all

esophageal cancers in several countries .

Continue

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Mid-esophageal mass tuberculosis

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Endoscopy is the first-line investigation for most patients. Endoscopic ultrasound . Cytology and/or histology specimens taken via the endoscope

are crucial for accurate diagnosis . Histology and cytology increases the diagnostic accuracy to

more than 95%. Transcutaneous ultrasound . Computerised tomography CT . Magnetic resonance imaging scanning . Positron emission tomography (PET) . Bronchoscopy

Investigation

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General health and fitness for potential therapies. Indicate whether surgery alone or multimodal therapy is

most appropriate. The aim is to provide the best chance of cure while

minimising perioperative risks. Surgery alone should be reserved for patients with early

disease . Multimodal therapy should be used in patients with

locally advanced disease .

General assessment and staging

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Tis High-grade dysplasia T1 Tumor invading lamina propria or submucosa T2 Tumor invading muscularis propria T3 Tumor invading beyond muscularis propria T4 Tumor invading adjacent structures Tx Primary tumor cannot be assessed N0 No regional lymph node metastases N1 Regional lymph node metastases Nx Lymph nodes cannot be assessed M0 No distant metastases M1(a) Coeliac node involved (for distal oesophageal tumours)

Supraclavicular node involved (for proximal tumors) M1(b) Coeliac or supraclavicular node involved if not remote from tumor

site (i.e. not 1a) All other distant metastases Mx Distant metastases cannot be assessed

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TNM staging scheme for oesophageal cancer

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At the time of diagnosis, around two-thirds of all patients with esophageal cancer will already have incurable disease.

The aim of palliative treatment is to overcome debilitating or distressing symptoms while maintaining the best quality of life possible for the patient.

The principal aim of palliation is to restore adequate swallowing. Once esophageal neoplasms reach th submucosal layer of the

esophagus, the tumor has access to the lymphatic system. The proximal extent of resection should ideally be 10 cm above

the macroscopic tumor and 5 cm distal.

Treatment of malignant tumorsPrinciples

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Radical esophagectomy is the most important aspect of curative treatment

Neoadjuvant treatments before surgery may improve survival in a proportion of patients

Chemoradiotherapy alone may cure selected patients, particularly those with squamous cell cancers

Useful palliation may be achieved by chemo/radiotherapy or endoscopic treatments

Treatment of carcinoma of the oesophagus

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The esophagus5th Lecture

M.A.Kubtan

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Esophageal motility disorders : when a patient has dysphagia in the absence of a

stricture . Can be correlated with a specific abnormality on

oesophageal manometry . Pain, with or without a swallowing problem, is frequently

the dominant symptom .

MOTILITY DISORDERS AND DIVERTICULA

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Pathology and etiology : Achalasia is uncommon . It is due to loss of the ganglion cells in the myenteric

(Auerbach’s) plexus . Histology of muscle specimens generally shows a reduction in

the number of ganglion cells (and mainly inhibitory neurones) with a variable degree of chronic inflammation.

The physiological abnormalities are a non-relaxing LES and absent peristalsis in the body of the esophagus In some patients .

These uncoordinated contractions result in pain as much as a sense of food sticking.

Achalasia

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Is an achalasia-like disorder that is usually produced by adenocarcinoma of the cardia .

Pseudoachalasia

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The disease is most common in middle life . It typically presents with dysphagia . Patients often present late . Regurgitation is frequent . May be overspill into the trachea, especially at night.

Clinical features

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Achalasia may be suspected at endoscopy : By finding a tight cardia . Food residue in the esophagus. Barium radiology may show hold-up in the distal

esophagus . A tapering stricture in the distal esophagus, often

described as a ‘bird’s beak . The gastric gas bubble is usually absent. A firm diagnosis is established b esophageal manometry.

Diagnosis

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The two main methods : Forceful dilatation of the cardia (Pneumatic dilatation ) . Forceful dilatation is curative in 75–85% of cases. Heller’s myotomy , This involves cutting the muscle of

the lower esophagus and cardia . The major complication is gastro-esophageal reflux, and

most surgeons therefore add a partial anterior fundoplication .

It is successful in more than 90% of cases and may be used after failed dilatation.

Treatment

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Achalasia of the esophagus(a) Barium swallow showing the smooth outline of the stricture, which narrows to a point at its lower end

(b) Tortuosity and sigmoid appearance of the lower oesophagus.

(c) Mediastinal shadow due to a large, fluid-filled esophagus.

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Almost achalasia, but note the irregularity of the taper, which indicates carcinoma of the cardia.

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Balloon dilator for the treatment of achalasia by forceful dilatation.

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Heller’s myotomy. The incision should not go too far on to the stomach. The lateral extent must enable the mucosa to pout out, to

prevent the edges healing together.

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Diffuse esophageal spasm is a condition in which there are incoordinate contractions of the esophagus, causing dysphagia and/or chest pain.

Spastic pressures on manometry of 400–500 mmHg . marked hypertrophy of the circular muscle and a

corkscrew esophagus on barium swallow . These abnormal contractions are more common in the

distal two-thirds of the esophageal body .

Disorders of the body of the esophagus

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Corkscrew esophagus in diffuse esophageal spasm.

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Esophageal involvement is mainly seen in systemic sclerosis.

Symptoms involve : Weak peristalsis. Swallowing difficulties may be compounded by

pharyngeal problems in the disorders that primarily affect skeletal muscle .

Esophageal involvement in autoimmune disease

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Esophageal involvement is mainly seen in systemic sclerosis, may be a feature of polymyositis, dermatomyositis, systemic lupus erythematosus, polyarteritis nodosa rheumatoid disease.

Continue

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Advanced scleroderma of the esophagus. The esophagus dilates, and the lower esophageal sphincter is widely

incompetent.

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Pulsion diverticula : develop at a site of weakness as a result of chronic

pressure against an obstruction. Symptoms are mostly caused by the underlying disorder

unless the diverticulum is particularly large.Traction diverticula : much less common. Are mostly a consequence of chronic granulomatous

disease affecting the tracheobronchial lymph nodes due to tuberculosis.

Fibrotic healing of the lymph nodes exerts traction on the esophageal wall

Pharyngeal and oesophageal diverticula

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Esophageal diverticulum as it protrudes posteriorly above the cricopharyngeal sphincter through the natural weak point .

The dehiscence between the oblique and horizontal (cricopharyngeus) fibres of the inferior pharyngeal constrictor .

It involves loss of the coordination between pharyngeal contraction and opening of the upper sphincter.

When the diverticulum is small, symptoms largely reflect this incoordination with predominantly pharyngeal dysphagia.

As the pouch enlarges, it tends to fill with food on eating, and the fundus descends into the mediastinum.

Zenker’s diverticulum (pharyngeal pouch)

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Mid-esophageal diverticulum with a tracheooesophageal fistula.

Mid-esophageal traction diverticulum with the mouth facing downwards.

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a small pharyngealpouch with a prominent cricopharyngeal impression and ‘streaming’ of barium,

indicating partial obstruction;b) a large pouch extending

behind the esophagus towards the thoracic inlet.

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Vascular abnormalities affecting the oesophagus

Esophageal varices with smooth outline of the filling

defects.

الجامعة السورية الخاصة كلية الطب البشري قسم الجراحة...

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