- Only organ navigating through three different body cavity
- “The history of esophageal surgery is the tale of men repeatedly losing to a stronger adversary yet persisting in this unequal struggle until the nature of the problems became apparent and the war [is] won.”
- Dobromysslow performed the first intrathoracic segmental esophageal resection and primary anastomosis
- Franz Torek, Oshava, Ivor Lewis, McKewon, Orringer and Sloan, Dor, Heller, Toupet, Belsey, Nissen - few surgeons
- Boerhaave, Zenker, and Barrett-physicians
--- Content provided by FirstRanker.com ---
EMBRYOLOGY
--- Content provided by FirstRanker.com ---
- Esophagus begins in week 3 of gestation and, by the 14th week, the fetus takes its first swallow
- Develops from the foregut
SURGICAL ANATOMY
- 25 cm long
- Starts at C6
- UES upper esophageal sphincter
- Cricopharyngeus muscle
- Upper part striated muscle
- Transitional zone
- Lower part only smooth muscle
- Vagus, Auerbach's plexus, Meissner's plexus
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
- Midline, left(trachea), right(carina) and left(esophageal hiatus)
- Enters abdomen at T11
- Pharyngeal, cervical, thoracic and abdominal parts
- Only mucosa and muscularis propria
- No serosa
- Lining throughout squamous
- Z-line distal transitional zone ( 1 to 2 cm )– columnar
- The collar of Helvetius – transitional zone between circular and oblique muscle fibres
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
- Three anatomical narrowing
- Cricopharygeal (15 cm )---14mm
- Aortic and bronchial (25 cm )---16mm
- Diaphragmatic (40cm)—18mm
--- Content provided by FirstRanker.com ---
- Normal diameter 25mm
- GEJ/LES for identifying land marks two external and two endoscopic
- Internally Z Line and transition from smooth to rugal fold
- Externally collar of Helvetius and gastroesophageal fat pad
--- Content provided by FirstRanker.com ---
- Arteries and veins
- Sup thyroid, inf thyroid, esophageal branches, intercostal, right and left bronchial arteries, inferior phrenic, left gastric
--- Content provided by FirstRanker.com ---
SYMPTOMS OF ESOPHAGEAL DISEASES
- Esophageal dysphagia – Malignancy
- Occurs in involuntary phase
- Food sticking
- Solid and /fluid
--- Content provided by FirstRanker.com ---
- Odynophagia – inflammation/ ulcer/chemical injury
- Reflux-GERD
- Passive return of gastroduodenal contents
- Loss of weight, anemia, cachexia, voice change, cough, dyspnea
--- Content provided by FirstRanker.com ---
- Chest pain ? Cardiac
INVETSIGATIONS
- Radiography
- Plain x ray – foreign body
- Barium swallow – narrowing, lesions, anatomical distortions, motility disorder
- CT scan
--- Content provided by FirstRanker.com ---
- Endoscopy
- View, biopsy/cytology, removal of FB, stricture dilatation
- Rigid/flexible
- GA/local
- Flexible – along with OGDScopy
--- Content provided by FirstRanker.com ---
- Endosonography
- Manometry – for motility disorders
- 24 hr p H monitoring –GERD ---Johnson-Demeester scoring
--- Content provided by FirstRanker.com ---
FOREIGN BODIES
- Food most common
- Associated pathological lesions may be seen
- Plain radiograph
- Flexible endoscopy
- Button / batteries dangerous --- should not be pushed to stomach
- Over-tube used for sharp objects
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
PERFORATION
- Iatrogenic / barotrauma
- Iatrogenic – most common, usually conservative
- 1 in 4000
- Pharynx/esophagus/at the site of pathology
- Contributed by osteophytes, pharyngeal pouch,
- Biopsy
- More with therapeutic endoscopy
- Pain/hoarseness/surgical emphysema/pnemo/hydropneumothorax
--- Content provided by FirstRanker.com ---
- Spontaneous – Boerhaave syndrome
- Vomiting against closed glottis
- Lower third – weakest
- Mediastinitis
- d/d MI/ peptic ulcer perforation / pancreatitis
- Xray – pnemomediastinum / pleural effusion
- Surgical intervention
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
- Aim of treatment to limit infection
- Surgery depends on site, event, underlying pathology, status of esophagus
- Cervical/spontaneous/benign/empty esophagus – conservative
- Antibiotics, diversion, nasogastric aspiration,
- Surgery - direct repair/external fistula creation/resection and late repair
--- Content provided by FirstRanker.com ---
MALLORY WEISS SYNDROME
- Vigorous vomiting – vertical split in lower esophagus – below Z line(90%)/in esophagus(10%) producing hematemesis
- Endoscopic injection therapy may be required
- Usually self subsiding
- Resolve in 7 – 10 days
--- Content provided by FirstRanker.com ---
CORROSIVE INJURIES
--- Content provided by FirstRanker.com ---
- Acid/ alkali
- Suicidal
- Type/concentration and volume decides the damage
- Alkali – more of esophagus – liquifaction, saponification, thrombosis of blood vessels fibrous scarring
- Acid – stomach also affected, coagulation necrosis and eschar formation
- Early endoscopy by experts
- Conservative management to feeding jejunostomy, resection and replacement of esophagus(late)
- Dilatation --- controversial
--- Content provided by FirstRanker.com ---
GORD
--- Content provided by FirstRanker.com ---
- Most common disease of esophagus
- Loss of competence of LOS
- What is TLOSRS ? (Transient Lower Oesophageal Sphincter Relaxations)
- Associated with hiatus hernia – sliding
- Triad of symptoms – heartburn, epigastric pain and regurgitation
- Diagnosis – suspicion, endoscopy, 24hr pHmonitoring is the gold standard
- Esophageal manometry – TLOSRS
- Dysphagia – late and sign of stricture
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
- Treatment
- Medical
- PPI, (8wks)
- Lifestyle modification
--- Content provided by FirstRanker.com ---
- Endoscopic dilatation
- Surgery
- Endoscopic procedures – plication, radio-frequency ablation, injection of polymers
- Surgery – antireflux surgeries
- Create intra abdominal esophagus
- Fundoplication (partial or full)
- Crural repair
- Wrapping of stomach
--- Content provided by FirstRanker.com ---
- Medical
--- Content provided by FirstRanker.com ---
FUNDOPLICATION
- Nissen -full
- Short term dysphagia but better long term control
- Gas blot syndrome – no belching – solution by floppy technique
- Toupet / Dor / Watson - partial
- Less complication but no long term control
- Some times two surgeries or revisional surgeries may be required
- Hill's procedure
- Belsey's Mark IV
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
COMPLICATIONS OF GORD
--- Content provided by FirstRanker.com ---
- Stricture
- Differentiate from malignancy
- PPI long term
- Dilatation
- Surgery – standard antireflux surgery
- Esophageal shortening
- Inflammation, fibrosis, shortening
- Collis gastroplasty
- Collis- Nissen Operation
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
BARRETTS ESOPHAGUS
- Columnar lined lower esophagus
- In response to chronic GORD
- Intestinal metaplasia – contains goblet cells
- Distinguish from sliding hernia (gastric mucosal folds )
- Stricture can develop
- Malignancy – adenocarcinoma esophagus – 25 fold increase
- Regular endoscopy
- Length determines the incidence of ca
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
- Classic Barrett's (3 cm or more columnar epithelium);
- Short -segment Barrett's (less than 3 cm of columnar epithelium);
- Cardia metaplasia (intestinal metaplasia at the oesophagogastric junction without any macroscopic change at endoscopy)
- Treatment
- PPI
- Dilatation endoscopic ablation with Laser, photodynamic therapy, argon-beam plasma coagulation and endoscopic mucosal resection (EMR)?
- Surveillance
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
ROLLING HERNIA
- Para-esophageal hiatus hernia
- Mixed type
- Cardia displaced into chest with greater curvature rolls into mediastinum
- Colon or small bowel may be there
- Volvulus may be associated
- Elderly
- Dysphagia, chest pain ( relieved by loud belch)
- Strangulation, gastric perforation, gangrene
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
- X ray typical – fluid level behind heart or gas bubble in chest
- Barium meal
- Endoscopy confusing
- Surgery required – emergency or elective
- Fundoplication ?
- Laparoscopic approach getting popular as elective procedure
--- Content provided by FirstRanker.com ---
NEOPLASAMS OF ESOPHAGUS
- Benign
- Rare
- Papillomas, adenomas, hyperplastic polyps
- GIST, lipomas, granular cell tumor – arise from outer wall
- Small and asymptomatic
- Adequately biopsied to rule out malignancy
--- Content provided by FirstRanker.com ---
- Malignant
- Primary
- Secondary – from bronchogenic crcinoma
- Non epithelial malignancy – malignant melanomas
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
BENIGN
CARCINOMA ESOPHAGUS
- 6th most common cancer
- Mid to late adulthood
- 5-10% five year survival
- SCC upper 2/3rd adenocarcinoma lower 1/3rd
- Commonest SCC
- Geographical variation
- Asian belt SCC, western adeno
- Fungal contamination of food, nutritional deficiency, tobacco, alcohol
- Obesity – GORD – barrett's esophagus
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
- Symptomatic when advanced
- Direct, lymphatic and blood spread
- Trans-peritoneal for intra-abdominal oesophagus
- Dysphagia –for solid food, weight loss, odynophagia, regurgitation, vomiting
- Recurrent laryngeal palsy, horner's syndrome, spinal pain, diaphragmatic palsy
- Cutaneous mets, cervical LN
- Endoscopy – gold standard -biopsy
- Barium swallow
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
- Blood inv- general assessment – HB LFT etc
- USS – abdomen mainly
- CT – contrast -- Lymph nodes minimum size 5mm
- MRI
- Bronchoscopy
- Laparoscopy
- EUS – depth of tumor penetration and lymph node status
- PET
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
STAGING
TREATMENT
TREATMENT
--- Content provided by FirstRanker.com ---
- Definitive
- Surgery - esophagectomy/esophago-gastrectomy
- Possible in 1/3rd of cases
- Clearance 10 cm proximally and 5 cm distally
- Phototheraopy – intramucosal tumors
- Surgery alone in T1/T2 NO lesions
- Others multimodal approach – radio/chemo
- Neoadjuvant
- Chemo radiation alone for SCC
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
- SURGERY
- Thoraco abdominal approach – single incision towards left thorax
- Two stage (Ivor Lewis – abdominal and right thoracotomy)
- McKeown three incisions
- Trans-hiatal Orringer
- Neoadjuvant
- Non surgical
- Palliative
- Intubation
- Endoscopic laser
- Brachytherapy
- Feeding jejunostomy or gastrostomy
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
ACHALASIA CARDIA
- “Failure to relax"
- Loss of ganglion in myenteric plexus
- Similarity with chaga's disease
- Dysphagia ( rule out carcinoma )
- Few ganglion in dilated esophagus ( in comparison to hirschsprung)
- Non relaxing LOS with absent peristalsis
- Absent gas bubble in stomach
- Mega-esophagus
- Retention esophagitis – predispose to carcinoma
- Peudo-achalasia – cardia tumor
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
- Middle life, dysphagia, pain, regurgitation, pneumonia
- Endoscopy – tight cardia and food residue in esophagus
- Barium swallow – bird beak appearance
- Absent gastric bubble
- Esophageal manometry – final conclusion
- Treatment
- Pneumatic dilatation – plummer – may cause perforation
- Hellers myotomy - laparoscopic
- Heller-Dor's operation – additional fundoplication
- Botulinum toxin injection to LOS
- Drugs – calcium channel blockers
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
DIFFUSE ESOPHAGEAL SPASM
--- Content provided by FirstRanker.com ---
- Incoordinate contractions
- Dysphagia and chest pain
- Corkscrew esophagus on barium
- Manometry – 400-500mm of hg
- Ca channel blockers, vasodilators, endoscopic dilatation – transient role
- Extended esophageal myotomy
- Nutcracker esophagus is condition where peristaltic pressure more than 180 mm of Hg
--- Content provided by FirstRanker.com ---
--- Content provided by FirstRanker.com ---
This download link is referred from the post: MBBS Lecture Notes for all subjects (updated for 2021 syllabus) - All universities