Download MBBS (Bachelor of Medicine and Bachelor of Surgery) 4th Year (Final Year) Surgery Oesophagus Notes Handwritten Notes
? 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
EMBRYOLOGY
? 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 , Aeurbach's plexus , Meissner's plexus
? 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
? Three anatomical narrowing
? Cricopharygeal (15 cm )---14mm
? Aortic and bronchial (25 cm )---16mm
? Diaphragmatic (40cm)--18mm
? 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
? Arteries and veins
? Sup thyroid, inf thyroid , esophageal branches, intercostal, right and left
bronchial arteries, inferior phrenic , left gastric
SYMPTOMS OF ESOPHAGEAL
DISEASES
? Esophageal dysphagia ? Malignancy
? Occurs in involuntary phase
? Food sticking
? Solid and /fluid
? Odynophagia ? inflammation/ ulcer/chemical injury
? Reflux ?GERD
? Passive return of gastroduodenal contents
? Loss of weight, anemia , cachexia, voice change, cough, dyspnea
? Chest pain ? Cardiac
INVETSIGATIONS
? Radiography
? Plain x ray ? foreign body
? Barium swallow ? narrowing, lesions, anatomical distortions, motility disorder
? CT scan
? Endoscopy
? View , biopsy/cytology, removal of FB, stricture dilatation
? Rigid/flexible
? GA/local
? Flexible ? along with OGDScopy
? Endosonography
? Manometry ? for motility disorders
? 24 hr p H monitoring ?GERD ---Johnson-Demeester scoring
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
PERFORATION
? Iatrogenic / barotrauma
? Iatrogenic ? most common , usually conservative
? 1 in 4000
? Pharynx/esophagus/at the site of pathology
? Contributed by osteophytes, pharyngeal pouch,
? Biospy
? More with therapeutic endoscopy
? Pain/hoarseness/surgical emphysema/pnemo/hydropneumothorax
? Spontaneous ? Boerhaave syndrome
? Vomiting against closed glottis
? Lower third ? weekest
? Mediastinitis
? d/d MI/ peptic ulcer perforation / pancreatitis
? Xray ? pnemomediastinum / pleural effusion
? Surgical intervention
? 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
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
CORROSIVE INJURIES
? 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
GORD
? 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
? Treatment
? Medical
? PPI, (8wks)
? Lifestyle modification
? 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
FUNDOPLICATION
? Nissen ?full
? Short term dyphagia 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
COMPLICATIONS OF GORD
? Stricture
? Differentiate from malignancy
? PPI long term
? Dilatation
? Surgery ? standard antireflux surgery
? Esophageal shortening
? Inflammation , fibrosis , shortening
? Collis gastroplasty
? Collis- Nissen Operation
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
? 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
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
? 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
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
? Malignant
? Primary
? Secondary ? from bronchogenic crcinoma
? Non epithelial malignancy ? malignant melanomas
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
? 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 -
? 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
STAGING
TREATMENT
TREATMENT
? 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 N0 lesions
? Others multimodal approach ? radio/chemo
? Neoadjuvant
? Chemo radiation alone for SCC
? 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
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
? 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
DIFFUSE ESOPHAGEAL SPASM
? Incordinate 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
This post was last modified on 11 August 2021