Oesophagus Esophagus. Symptoms of esophageal disease: Surgical Anatomy.

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Oswald Lang
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1 Esophagus Surgical Anatomy. The esophagus is a muscular tube 25 cm long occupying the posterior mediastinum and extending from the cricopharyngeal sphincter to the cardia of the stomach 2 cm of this tube lies below the diaphragm. The musculature of the upper 5% is mainly striated, including upper esophageal sphincter. The middle 40% has mixed striated and smooth muscle, with the proportion of the smoothe muscle increasing distally and the distal 55% is entirely smooth muscle. There are three constrictions in this tube with distinct lesions at each level. The numbers 15, 25 and 40 represent the situations of anatomical narrowing where difficulty may be experienced in the passage of instruments and where foreign bodies may be arrested. Symptoms of esophageal disease: Dysphagia Is the term used to describe difficulty but not necessarily pain on swallowing.the type of dysphagia is important. It may be dysphagia for solids or fluids, intermittent or progressive, precise or vague in its appreciation. Odynophagia: Pain on swallowing, retrosternal discomfort within a few seconds of swallowing. Regurgitation: should strictly refer to the return of the oesophageal contents from above an obstruction in esophagus that may be functional of mechanical. Rreflux: is the passive return of the gastroduodenal contents to the mouth as part of the symptomatology of GORD. Chest pain similar to angina pectoris may be due to oesophageal spasm or motility disorder. Loss of weight, anaemia. cachexia and change of voice, due to refluxed material spilling over into the trachea through the vocal cords, are also important symptoms. 1

2 Investigations: Radiography is a most valuable investigation. 1. A plain film will show an opaque foreign body and the site of its arrest. 2. A barium swallow although it has been overshadowed by endoscopy but still it s a vey useful for demonstration of narrowing and filling defects. 3. CT scan now is an important tool in investigating esophageal tumors 4. Endoscopy is required for majority of esophageal disorders, traditionally there two types available rigid oesophagoscopy and flexible video-endoscope: I. Rigid oesophagoscopy: Most foreign bodies may be removed with a flexible gastroscope and an over-tube to protect thé oesophagus, but some may prefer to use the rigid instrument and large grasping forceps, especially for a large foreign body such as a set of dentures. II. Video-endoscopy The flexible video-gastroduodenoscope has virtually replaced the rigid instrument for diagnostic and therapeutic endoscopy because it has many advantages. General anaesthesia is not required; most examinations can be done on an out-patient basis, the quality of the magnified image is excellent, the instrument is much safer to pass and there is a greater range of therapeutic devices. III. Endoscopic ultrasonography (EUS) It gives very detailed images of the layers of the eoesophageal wall and of lymph nodes close to the oesophagus. 5. Oesophageal manometry (Oesophageal Function Test) Manometry is now widely used to diagnose oesophageal motility disorders hour ph recording Prolonged measurement of oesophageal ph is now accepted as the most accurate method for the diagnosis of gastro-oesophageal reflux. Therapeutic procedures : 1. Dilatation of strictures To restore normal swallowing, the stricture should be dilated to at least 16 mm in diameter or 50F Charrière. 2

3 2. Laser therapy Lasers may be used to core a channel through a cancer for palliation of dysphagia, and sttoping bleeding points. 3. Endoscopic banding of an esophgeal varicose vein is an important life saving procedure 4. Endoscopic stent placement for cancer palliation CONGENITAL ABNORMALITIES Atresia and tracheo-oesophageal fistula Congenital atresia of the oesophagus is usually associated with a tracheo-oesophageal fistula. In 82% of cases, it is the lower segment that communicates with the trachea. It is important to be aware of this abnormality because its recognition within 48 hours of birth, and subsequent surgical correction, is the only hope of survival. Clinical features The newborn baby regurgitates all of its first and subsequent feeds. Saliva pours almost continuously from its mouth. This is the sign of oesophageal atresia; it does not occur in any other condition. Treatment Corrective surgery is normally performed shortly after the diagnosis is made. The best approach is through a thoracotomy on the side opposite to the aortic arch, usually the right, at the level of thé fifth intercostal space. The lower segment is divided at its entrance into the nachea and the fistula is closed. It is usually possible to perform an anastomosis between the blind upper segment and the lower segment. Esophageal perforations : Perforation of the oesophagus is a serious condition that requires prompt diagnosis and treatment. 1. Borotrauma (Boerhaave syndrome) 3

4 Also called 'spontaneous' perforation of the oesophagus is usually due to severe barotrauma when a person vomits against a closed glottis. The pressure in the oesophagus rapidly increases and the oesophagus bursts at its weakest point in the lower third, sending a stream of material into the mediastinum and often the pleural cavity as well. The clinical history : is of severe pain in the chest or upper abdomen following a meal or a bout of drinking. Many cases are misdiagnosed as myocardial infarction or as a perforated peptic ulcer or pancreatitis if the pain is confined to the upper abdomen. Treatment is surgical repaire once the condition diagnosed. 2. Pathological perforation Perforation of ulcers, such as a Barrett's ulcer or tumours of the oesophagus, is unusual but does occur. Perforation may cause erosion into the aorta or ventricle, with rapidly fatal results. 3. Penetrating injury Perforation by knives and bullets is uncommon, even in war, as thé oesophagus is a relatively small target surrounded by other vital organs. 4. Foreign bodies The oesophagus may be perforated during removal of a foreign body, but, occasionally, an object that has been left in thé oesophagus for several days will erode through thé wall. 5. Instrumental perforation Instrumentation is by far the most common cause of oesophageal perforation. Perforation during diagnostic flexible endoscopy of the upper gastrointestinal tract is unusual, but occurs at a frequency of 1 in 4000 examinations. Therapeutic endoscopy increases thé risk, but thé overall risk should remain low. The oesophagus may be perforated by a guidewire or dilator above or below a stenosis. Diagnosis : Perforation of the oesophagus usually produces sevre chest pain and should be suspected if this occurs after instrumentation. Subcutaneous emphysema may be present in the neck and some-times over the upper chest as well. Emphysema is more likely to appear if the oesophagus is perforated during flexible endoscopy because of the air insufflation that is 4

5 an essential part of the procedure. Emphysema around the pericardium can sometimes be detected on auscultation as a mediastinal 'crunch' that sounds like footsteps in soft snow. Investigations : 1. A chest radiograph may show gas in the mediastinum, a pleural effusion or a pneumothorax. 2. Barium is the contrast material of choicen to obtain the exact site of the perforation. There is no evidence that the judicious use of barium suspension is clinically harmful in this setting and it is important to obtain good quality images. Complications : It will rapidly leads to a life threatening mediastinitis, dysrhythmias are common, especially atrial fibrillation Treatment: The age and general condition of the patient and whether the perforation is confined to the mediastinum dtermines the nature of the tretment. Perforations of the abdominal oesophagus are probably best managed by operative repair as is Boerhaave syndrome, in which the septic load is high. Most endoscopic perforations involve minimal contamination and are ideal for nonoperative management, particularly if the patient is a poor risk for a thoracotomy. Non operative: The aim of treatment is to limit mediastinal contamination and deal with the existing infection. MALLORY-WEISS SYNDROME Forceful vomiting may produce a mucosal tear at the cardia rather than a full perforation of the oesophagus. Vigorous vomiting produces a vertical split that is in the gastric mucosa, immediately below the squamocolumnar jujiction at the cardia in 90% of cases. In only 10% is the tear in the oesophagus. The condition presents with haematemesis and other signs of upper GIT bleeding. Usually the bleeding is not severe, but endoscopie injection therapy may be required for the occasional case with severe bleeding. Surgery is rarely required. 5

6 CORROSIVE INJURY Corrosives such as sodium hydroxide or sulphuric acid may be taken in attempted suicide. Bleach may be drunk by young children, which cause severe damage to the pharynx, larynx, oesophagus and stomach. The oesophagus is usually worst affected by sodium hydroxide. The key to management is early endoscopy by an experienced endoscopist to inspect the whole of the oesophagus and stomach, unless there is a severe necrotising lesion. Treatement : Minor injuries resolve rapidly with no late sequelae. Severe mucosal injury should be treated with steroids for 3 weeks and a programme of regular dilatations started thereafter. If full-thickness necrosis is suspected, resection should be carried out at an early stage. Oesophageal resection may be required. OESOPHAGEAL MOTILITY DISORDERS GASTRO-OESOPHAGEAL REFLUX DISEASE (GORD) Aetiology Normal competence of the gastro-oesophageal junction is maintained by the LOS. Loss of competence of the LOS (GORD). Sliding hiatus hernia has a variable association with GORD. In general, patients with the more severe stages of GORD tend to heve a hernia, but most GORD sufferers do not heve a hernia and many of those with a hernia do not heve GORD. Complications : Reflux oesophagitis is a complication of GORD that occurs in a minority of sufferers. It occurs in 40-50% of those referred to hospital, but in a much lower proportion of those who suffer from symptoms of GORD in the community as a whole. Clinical features Retrosternal burning pain (heartburn) and epigastric pain are the most common symptoms. These are usually provoked by food, particularly fatty food. As the condition becomes more severe, gastric acid may reflux to the mouth and produce an unpleasant 6

7 taste. It is in the more advanced cases that there is a history of pain and reflux when lying flat or on stooping. Some patients present with less typical symptoms such as angina-like chest pain, pulmonary or laryngeal symptoms. Dysphagia is usually a sign that a stricture has occurred, but may be caused by an associated motility disorder. Diagnosis 1. OGD is carried out mainly to exclude more serious pathology such as cancer and Barret s esophgus may be diagnosed 2. In patients with severe or persistent symptoms oesophageal manometry and 24-hour oesophageal ph recording should be performe. 3. Barium swallow and meal 4. Radiology is at best 50% accurate in the iagnosis of GORD. Management of uncomplicated GORD 1. Medical management Weight loss, cessation of smoking and alcohol intake, tea or coffee and a modest degree of head-up tilt of the bed. Tilting the bed has been shown to have an effect that is similar to taking an H.antagonist. PPIs, such as omeprazole, lansoprazole and pantoprazole, are by far the most effective drug treatment for GORD. Given an adequate dose, oesophagitis heals in the majority of cases and even most strictures respond well to one or two dilatations and long-term PPI treatment. 2. Surgery : The indication for surgery in uncomplicated GORD is essentially patient choice. But surgery mainly indicated medical therapy failed and when complications are present and whenever haital hernia present There are many operations for GORD, but essentially the choice is between total and partial fundoplication. I. Nissen total fundoplication in which the fundus of the stomach is wrapped completely around the lower oesophagus. II. The Belsey operation is a thoracic procedure in which the oesophagus is sutured to the diaphragm and to the fundus of the stomach to reduce any hiatus hernia and produce a 240 anterior fundoplication. 7

8 III. The Hill procedure is an operation in which the cardia is tightened and fixed to the preaortic fascia. Complications of GORD 1. Stricture Reflux-induced strictures are common, usually in the late middle-aged and the elderly. It is important to distinguish a benign reflux-induced stricture from a carcinoma. 2. Oesophageal shortening 8

Oesophageal Disorders

Oesophageal Disorders Anatomy Upper sphincter Oesophageal body Diaphragm Lower sphincter Gastric Cardia Symptoms Of Oesophageal Disorders Dysphagia Odynophagia Heartburn Atypical Chest Pain Regurgitation