THORACIC SURGERY: Dysphagia. Dr. Robert Zeldin Dr. John Dickie Dr. Carmine Simone. Thoracic Surgery Toronto East General Hospital

Transcription

1 THORACIC SURGERY: Dysphagia Dr. Robert Zeldin Dr. John Dickie Dr. Carmine Simone Thoracic Surgery Toronto East General Hospital

2 Objectives Definitions Common causes Investigations Treatment options

3 Anatomy Muscular tube that serves as a conduit from pharynx to stomach Layers of esophagus mucosa submucosa muscle layers inner circular outer longitudinal adventitia (serosa)

4 Dysphagia Difficulty swallowing Not Aspiration Not Painful swallowing Not Nausea and vomiting

5 Causes of dysphagia I ate/swallowed something and now I have difficulty swallowing. Over the last few months, I have had increasing difficulty swallowing. I have had heartburn for years and now I have difficulty swallowing

6 What are the 3 areas of narrowing of the esophagus? upper sphincter (cricopharyngeal muscle) left mainstem bronchus & aortic arch lower sphincter (GE sphincter) Foreign Objects

7 H & PI H & PI clarification of symptoms severity, progression, liquids vs solids, exacerbating or relieving factors generalized symptoms fever, night sweats, weight loss differential diagnosis Oropharyngeal tongue, soft palate & epiglottis

8 Assessment of esophagus Radiology Ba swallow (cineradiography) CXR/CT scan Endoscopy OGD Manometry ph Monitoring

9 Assessment of esophagus

10 Epidemiology: > 60 yo Pathophysiology: imperfect coordination of relaxation of cricopharyngeus +/- Zenker s diverticulum (M > F) Symptoms: dysphagia (solids > liquids), cough With Zenker s - regurgitation, halitosis, gurgling sounds, manual emptying, bleeding rare, respiratory Cricopharyngeal achalasia

11 Epidemiology: > 60 yo Pathophysiology: imperfect coordination of relaxation of cricopharyngeus +/- Zenker s diverticulum (M > F) Symptoms: dysphagia (solids > liquids), cough With Zenker s - regurgitation, halitosis, gurgling sounds, manual emptying, bleeding rare, respiratory Cricophayngeal achalasia

12 Cricophayngeal achalasia Investigations: *Ba swallow - prominent cricopharyngeal bar +/- diverticulum endoscopy - r/o neoplasm manometry - delayed relaxation of UES Treatment: myotomy of cricopharyngeus excise or invert diverticulum

13 Cricophayngeal achalasia Investigations: *Ba swallow - prominent cricopharyngeal bar +/- diverticulum endoscopy - r/o neoplasm manometry - delayed relaxation of UES Treatment: myotomy of cricopharyngeus excise or invert diverticulum

14 Diffuse Esophageal Spasm Investigations: Ba swallow - normal 60%, segmental spasm, corkscrew, diverticulum endoscopy - normal, r/o tumor & GERD manometry - swallowing induces repetitive nonperistaltic contractions, pressure of contractions Treatment: medical; diet alteration, drugs surgical; myotomy (resection)

15 Epidemiology: M > F, yo, most common motility disorder Pathophysiology: loss of primary peristalsis & failure of LES to relax absence or atrophy of ganglion in myenteric plexus degeneration vs infection (Chagas disease) Symptoms: dysphagia, regurgitation, respiratory wt loss & pain usually minimal Achalasia

16 Investigations: Ba swallow - dilated body into smooth cone-shaped narrowing of 3-6cm, no primary peristalsis endoscopy - dilated esophagus, scope pops thru LES, r/o malignancy (3-5% SSC) manometry - absence of primary peristalsis & failure of LES to relax, +/- increase LES pressure Treatment: medical: drugs, bo-tox, dilation surgical: heller myotomy Achalasia

17 Investigations: Ba swallow - dilated body into smooth cone-shaped narrowing of 3-6cm, no primary peristalsis endoscopy - dilated esophagus, scope pops thru LES, r/o malignancy (3-5% SSC) manometry - absence of primary peristalsis & failure of LES to relax, +/- increase LES pressure Treatment: medical: drugs, bo-tox, dilation surgical: heller myotomy Achalasia

18 Hiatus Hernia What are the types of hiatus hernias? type I; sliding type II; paraesophageal type III; mixed type IV; other intraabd organ in hernia (eg. colon) Which ones can cause dysphagia? all

19 Type I Hiatus Hernia Epidemiology: common, all ages Symptoms: pain, heartburn, worse recumbent, regurgitation, respiratory symptoms, complications of GERD (eg.bleeding, stricture, adenocarcinoma)

20 Investigations: Ba swallow - portion of stomach thru hiatus, reflux, stricture endoscopy - esophagitis, stricture, H-H, Barretts, r/ o malignancy motility - sphincter function & esophageal peristalsis Treatment: medical; diet, bed elevated, medications, dilations surgery; antireflux procedures (Nissen) Type I Hiatus Hernia

21 Type II Paraesophageal Hiatus Hernia Pathophysiology: all or part of stomach herniates into chest with GE junction in intra-abd location Symptoms: belching, discomfort, dysphagia, arrhythmias Investigations: Ba swallow & endoscopy Treatment: surgery

22 Causes of dysphagia I ate/swallowed something and now I have difficulty swallowing. Over the last few months, I have had increasing difficulty swallowing. I have had heartburn for years and now I have difficulty swallowing

23 Malignant Causes of dysphagia Primary esophageal cancer Secondary Lung cancer Symptoms: dysphagia, weight loss, pain, anemia, regurgitation, aspiration

24 Esophageal Cancer Epidemiology: 4/100,000, M>F, yo Pathophysiology: SSC; smoking, drinking, achalasia, corrosive Adeno; GERD

25 Stage 0, I and II

26 Stage 0, I and II

27 Stage 0, I and II

28 Stage III Locally advanced disease Chemotherapy Radiotherapy Surgery

29 Stage IV Disease Radiotherapy Chemotherapy

30 Esophageal Cancer Early intervention is key!!

31 Summary Importance of Hx (HPI) & DDx DDx of Dysphagia Basic Investigations of the Esophagus Common Causes of Dysphagia achalasia, diffuse esophageal spasm, hiatus hernias, tumors of esophagus

32 THANK YOU