01/26/2010 GENERAL SURGERY ABSITE ANATOMY ANATOMY. Yvonne M. Carter, MD Georgetown University Medical Center. Layers. mucosa. squamous epithelium

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1 GENERAL SURGERY ABSITE REVIEW: ESOPHAGUS Yvonne M. Carter, MD Georgetown University Medical Center ANATOMY Layers mucosa muscle squamous epithelium columnar epithelium (distal 2cm) inner = circular outer = longitudinal no serosal layer!!!! ANATOMY cervical left side posterior to trachea thorax behind membranous trachea crosses over to the right in subcarinal region back to left side at T7 level 1

2 ANATOMY Arterial blood supply segmental aorta, intercostals Venous blood supply submucosal venous plexus --> hemiazygous, azygous, left gastric v. Lymphatic drainage +/- longitudinal extension regional LNs ANATOMY thoracic duct phrenic nerves plexus on muscle left = anterior trunk right = posterior trunk GE junction crura phrenoesophageal ligament continuation of transversalis fascia MANOMETRY High pressure zones cricopharyngeus muscle - tonic contractions lower esophageal sphincter Peristaltic waves Primary - propels foodstuffs into stomach Secondary - lower 2/3 smooth muscle, propel foodstuffs Tertiary- nonperistaltic 2

3 ACID REFLUX LES - inadequate length and/or pressure Diagnostic tests EGD small HH is common anatomic damage ph study documented log of symptomatic episodes decreased accuracy with 0.1% HCl instillation manometry suspect motility disorder REFLUX: LES Pressure/Tone INCREASE cholinergic agents anticholineserases alpha - adrenergics gastric alkalinization gastric distension DECREASE anticholinergics alpha - adrenergic antagonists beta - adrenergics foods - EtOH, chocolate, fatty meals REFLUX: Complications Barrett s esophagitis anemia aspiration PNA, bronchiectasis, abscess disturbed motility spasm, disordered peristalsis Schatzki s ring stricture esophageal shortening 3

4 Barrett s esophagus columnar metaplasia of normal squamous epithelium complications stenosis, ulceration, dysplasia, malignant transformation treatment PPIs, H2Bs antireflux surgery relieve esophagitis prvent further metaplaia REFLUX: Surgery ANTI - REFLUX PROCEDURES approach, degree, description Hill abdominal, degree crura to crura, GEJ to median arcuate ligament Dor thoracic, degree 2 layer (fundus, esophagus, crura) REFLUX: Surgery Belsey - Mark IV thoracic, 280-degree 2 layer (fundus, esophagus, crura) Nissen abdominal, degree (fundus) Toupe abdominal, degree 4

5 HIATAL HERNIAS I = SLIDING intrathoracic gastric cardia intact phrenoesophageal ligament II = PARAESOPHAGEAL III = I + II defective phrenoesophageal mb intrathoracic stomach peritoneal - lined hernia sac GEJ may be in normal position IV = other intrathoracic viscera Motility Disorders: Achalasia hypertrophic inner circular muscle Auerbach s plexus is absent or degenerative c/o dysphagia, regurgitation, weight loss manometry = aperistalsis incomplete relaxation of LES esophagram = bird s beak, +/- dilation tx = CCBs, endoscopic balloon dilation, Heller myotomy Motility Disorders: DES c/o chest pain, dysphagia manometry high amplitude contractions normal LES relaxation esophagram: corkscrew tx: antispasmodics, counseling,etc... NO SURGERY!!! 5

6 DIVERTICULA True (traction) complete wall of mucosa, submucosa, muscle midesophagus inflammation of mediastinal LNs False no muscle layer pharyngoesophageal (Zenker s) and epiphrenic functional/mechanical obstruction Zenker s is posterior, while all others are lateral UPPER GI BLEED Ulcer Reflux gastric or duodenal Mallory - Weiss tear h/o repeated emesis linear, esophagogastric mucosa dx +/- tx via EGD ESOPHAGEAL CANCER Risk factors Types EtOH, tobacco, GERD, corrosive injury, achalasia, tylosis, celiac sprue, pickled vegetables, cured meats adenocarcinoma squamous cell carcinoma Metastasis lymph nodes liver lung 6

7 ESOPHAGEAL CANCER: Surgery Transhiateal (THE) blind left neck + abdominal incisions cervical anastomosis all locations Ivor - Lewis (ILE) abdominal + right thoracotomy incisions mid - esophageal tumors intrathoracic anastomosis ESOPHAGEAL CANCER: Surgery McKeown (3 hole) left neck + right thoracotomy + abdominal incisions cervical anastomosis Left thoracoabominal distal tumors ESOPHAGEAL CANCER: Surgery Conduits stomach reliable blood supply (left gastric) 1 anastomosis jejunum peristaltic no reflux colon long length preserves gastric reservoir tenuous blood supply redundant limited length redundant 7

8 CORROSIVE INJURY: Management ABC s Alkaline vs acidic Chest X-ray cervical subq emphysema pneumomediastinum Endoscopy perform early NOT in case of perforation, potential airway obstruction determine extent of injury NOT PAST the proximal extent of injury CORROSIVE INJURY: Management No emetics, neutralizing agents Tracheostomy laryngeal/epiglottic edema delays EGD EGD Antibiotics +/- steroids + NPO +... resume po s in 5-7 days PEG esophagram in 1 week, repeat 2-3 weeks (?stricture) dilation diversion CORROSIVE INJURY: Surgery Emergent Thoracotomy mediastinitis/perforation chest pain tachycardia cervical subq emphysema pneumomediastinum wide mediastinum pleural effusion PTX 8

9 CORROSIVE INJURY: Surgery Emergent Laparotomy free air interstitial air in gastric wall signs of perforation (clinical or radiologic) aspiration of alkalotic NG contents from stomach thoracoabdominal incision when dealing with both the esophagus and stomach CORROSIVE INJURY: Complications LATE stricture multiple, cervical region tx = dilation GERD shortened esophagus malignancy 40+ year lag time squamous cell 9