Esophagus and Diaphragmatic Hernia

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Esophagus and Diaphragmatic Hernia

• Hashmi

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Surgical Anatomy

• The esophagus lies in the midline
• left in the lower portion of the neck and upper
  portion of the thorax
• midline in the midportion of the thorax near the
  bifurcation of the tracheaI
• lower portion of the thorax, the esophagus again
  deviates to the left and anteriorly to pass
  through the diaphragmatic hiatus
• Three normal areas of esophageal narrowing
• uppermost narrowing is at the entrance into the
  esophagus and is caused by the cricopharyngeal
  muscle
• middle narrowing is due to crossing of the left
  main stem bronchus and aortic arch
• lowermost narrowing is at the hiatus of the
  diaphragm and is caused by the gastroesophageal
  sphincter mechanism

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Surgical Anatomy
                           
 
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Physiology
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Assessment of Esophageal Function

• Tests to Detect Structural Abnormalities
• Radiographic Evaluation
• Barium Swallow
• Endoscopic Evaluation
• Tests to Detect Functional Abnormalities
• Stationary Manometry
• 24-Hour Ambulatory Manometry
• Esophageal Impedance
• Esophageal Transit Scintigraphy
• Video- and Cineradiography

• Tests to Detect Increased Exposure to Gastric
  Juice
• 24-Hour Ambulatory pH Monitoring
• 24-Hour Ambulatory Bile Monitoring
• Radiographic Detection of Gastroesophageal Reflux
  
• Tests of Duodenogastric Function
• Gastric Emptying
• Gastric Acid Analysis
• Cholescintigraphy
• 24-Hour Gastric pH Monitoring
• 24-Hour Gastric Bilirubin Monitoring

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Gastroesophageal Reflux Disease

• gastric distention
• shortening of sphincter length
• loss of LES resistance
• increased esophageal acid exposure
• complications
• Esophagitis
• Erosions
• Ulceration
• Fibrosis
• Strictures
• Columnar metaplasia
• Barrett's metaplasia ? Adeno Ca 1 per year

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Gastroesophageal Reflux Disease

• Medical Therapy
• 8 to 12 weeks of simple antacids
• hydrogen potassium proton pump inhibitors
• gastric emptying meds
• metoclopramide, domperidone, or cisapride
• elevate the head of the bed
• avoid tight clothing
• eat small, frequent meals
• avoid eating before bed
• lose weight
• avoid alcohol, coffee, chocolate, and peppermint
• Consider Surgery
• continued reflux
• poor esophageal contractility
• erosive esophagitis
• columnar-lined esophagus at initial presentation

• Surgical Therapy Five Basic Principles
• restore the pressure of the distal esophageal
  sphincter to a level twice resting gastric
  pressure
• length of the distal esophageal sphincter in the
  positive-pressure environment of the abdomen
• 3cm length with of 1.5-2cm of abdominal esophagus
  
• reconstructed cardia to relax on deglutition
• use only the fundus of the stomach
• wrap around the sphincter only
• avoid vagal nerves
• not increase the resistance of the sphincter
• constructed over a 60F bougie
• tension free, and approximating the crura

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Procedures

• Nissen Fundoplication - 360
• Abdominal
• Thoracic
• Laparoscopic
• Toupet Fundoplications - 270
• Transabdominal
• Belsey Mark IV Fundoplications - 270
• Transthoracic
• Collis Gastroplasty
• Lesser Curvature

• Transhiatal
• Abdominal Left Neck
• neck anastamosis
• Ivor Lewis
• Abdominal Right Thoracotomy
• Intrathoracic anastamosis
• 3-Field
• Abdominal, Thoracic, Neck
• Surgical Approaches
• Cervical Esophagus
• Left
• Upper Thoracic
• Right
• Lower Thoracic
• Left

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Barrett's Esophagus

• Norman Barrett in 1950
• Esophagus is lined with columnar epithelium
  rather than squamous epithelium
• 7 to 10 of patients with GERD
• Intestinal metaplasia is the presence of
  intestinal goblet cells
• Ulcer, stricture, dysplasia
• Low/Intermediate dysplasia
• GERD treatment
• High Grade dysplasia
• Esophagectomy
• Adenocarcinoma 1 per year

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Motility Disorders of the Pharynx

• Zenker's Diverticulum
• decreased compliance of the skeletal portion of
  the cervical esophagus
• barium swallow
• false diverticulum
• pharyngo-cricoesophageal myotomy
• diverticulopexy
• diverticulectomy

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Motility Disorders of the Esophagus

• Achalasia
• Incomplete lower esophageal sphincter (LES)
  relaxation (lt75 relaxation)
• Aperistalsis in the esophageal body
• Elevated LES pressure but lt26mmHg
• Increased intraesophageal baseline pressures
  relative to gastric baseline
• Degenerative changes have been shown in the vagus
  nerve and in the ganglia in the Auerbach plexus
  of the esophagus
• Birds Beak

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Motility Disorders of the Esophagus

• Diffuse Esophageal Spasm (DES)
• Simultaneous, nonperistaltic contractions
• Repetitive and multi-peaked contractions
• Spontaneous contractions
• Intermittent normal peristalsis
• Contractions may be of increased amplitude and
  duration
• rapid wave progression down the esophagus
  secondary to an abnormality in the latency period
• Hypertrophy of the muscular layer
• epiphrenic or midesophageal diverticulum
• corkscrew esophagus or pseudodiverticulosis

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Motility Disorders of the Esophagus

• Nutcracker Esophagus
• Mean peristaltic amplitude in distal esophagus
  gt180mmHg
• Increased mean duration of contractions (gt7.0s)
• Normal peristaltic sequence
• supersqueezer, hypertensive peristalsis" or
  "high-amplitude peristaltic contractions"

• Hypertensive Lower Esophageal Sphincter
• Elevated LES pressure gt26mmHg
• Normal LES relaxation
• Normal peristalsis in the esophageal body

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DIVERTICULA OF THE ESOPHAGEAL BODY

• Epiphrenic diverticula
• terminal third of the thoracic esophagus
• pulsion diverticula
• Midesophageal
• traction diverticula
• true diverticulum
• Treatment
• diverticulopexy
• diverticulectomy
• myotomy

• Myotomy
• Left VATS / Thoracotomy
• performed through all muscle layers
• extending distally 4-5cm
• may need to extend 1-2 cm below the
  gastroesophageal junction
• proximally 4-5cm over the abnormality

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Carcinoma of the Esophagus

• Most common worldwide ? Squamous (upper
  two-third)
• smoking alcohol
• Most common in US/UK ? Adenocarcinoma (lower
  third)
• Barretts esophagus
• EUS, Thoracoscopic and Laparoscopic staging, PET,
  CT
• Curative resection
• tumor has not penetrated the esophageal wall
• fewer than five positive lymph nodes
• Regional lymph nodes N1 disease
• Celiac, Cervical, Supra-clavicular lymph nodes
  M1 disease

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Carcinoma of the Esophagus
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Sarcoma of the Esophagus

• Sarcomas and carcinosarcomas are rare neoplasms
• 0.1-1.5 of all esophageal tumors
• Smooth, large polypoid intraluminal esophageal
  mass

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Benign Tumors and Cysts

• Leiomyoma
• 90 are located in the lower two thirds of the
  esophagus smooth muscle
• smooth, semilunar, or crescent-shaped filling
  defect
• moves with swallowing
• sharply demarcated, and is covered by normal
  mucosa
• not be biopsied because of an increased chance of
  mucosal perforation or scarring
• Esophageal Cyst
• Congenital cysts embryologic origin
• columnar ciliated epithelium of the respiratory
  type
• glandular epithelium of the gastric type
• squamous epithelium
• transitional epithelium
• Acquired retention cysts
• result of obstruction of the excretory ducts of
  the esophageal glands

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Esophageal Perforation

• Causes
• Diagnostic or therapeutic procedures
• Boerhaave's syndrome - 15
• Hartmanns Sign (mediastinal crepitus)
• Longitudinal myotomy to see extent
• Foreign bodies - 14
• Trauma - 10.
• Location
• Left side 66
• Right side 25
• Bilateral 10
• Diagnosis
• Contrast esophagogram
• water-soluble medium such as Gastrografin
• Mediastinal emphysema
• Mediastinal widening
• secondary to edema

• Management
• Within 24 hours
• Resulting in 80 to 90 survival
• Edges of the injury are trimmed and closed using
  a Gambee stitch
• The closure is reinforced by the use of a pleural
  patch, intercostal muscle flap, pericardial fat
• After 24 hours
• Survival decreases to less than 50
• Resection with cervical esophagostomy
• Mediastinum is drained
• Feeding jejunostomy tube is inserted
• Delayed reconstruction

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Caustic Injury

• Alkalies gt Acids, because strong acids cause an
  immediate burning pain in the mouth
• Alkalies dissolve tissue, penetrate more deeply
• Acids coagulative necrosis that limits their
  penetration
• Progression
• Necrosis (1-4 days)
• coagulation of intracellular proteins results in
  cell necrosis, and the living tissue surrounding
  the area of necrosis develops an intense
  inflammatory reaction
• Ulceration and Granulation phase (3-15 days)
• superficial necrotic tissue sloughs, leaving an
  ulcerated base, and granulation tissue fills the
  defect
• Scarring (14-21 days)
• connective tissue begins to contract, resulting
  in narrowing
• adhesions between granulating areas results in
  pockets and bands
• Immediate Treatment
• Lye or other alkali
• neutralized with half-strength vinegar, lemon
  juice, or orange juice
• Acid
• neutralized with milk, egg white, or antacids
• sodium bicarbonate is not used because it
  generates CO2, which might increase the danger of
  perforation

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Caustic Injury

• Endoscopy
• to lessen the chance of perforation, the scope
  should not be introduced beyond the proximal
  esophageal lesion
• Endoscopy Grading
• First degree Mucosal hyperemia and edema
• Second degree Limited hemorrhage, exudate
  ulceration, and pseudomembrane formation
• Third degree Sloughing of mucosa, deep ulcers,
  massive hemorrhage, complete obstruction of lumen
  by edema, charring, and perforation
• Surgical Intervention
• complete stenosis in which all attempts have
  failed to establish a lumen
• marked irregularity and pocketing on barium
  swallow
• development of a severe periesophageal reaction
  or mediastinitis with dilatation
• fistula
• inability to dilate or maintain the lumen above a
  40F bougie
• a patient who is unwilling or unable to undergo
  prolonged periods of dilation
• Esophageal Substitute
• Colon
• Stomach

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Diaphragmatic Hernias

• Type I
• sliding hernia
• upward dislocation of the cardia in the posterior
  mediastinum
• Type II
• rolling or paraesophageal hernia
• upward dislocation of the gastric fundus
  alongside a normal cardia
• Type III
• sliding-rolling or mixed hernia
• upward dislocation of both the cardia and the
  gastric fundus
• Type IV
• Intra-abdominal content in hernia

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Diaphragmatic Hernias

• Deterioration of the phrenoesophageal membrane
• Thinning of the upper fascial layer of the
  phrenoesophageal membrane
• supradiaphragmatic continuation of the
  endothoracic fascia
• Loss of elasticity in the lower fascial layer
• infradiaphragmatic continuation of the
  transversalis fascia
• Phrenoesophageal membrane yields to stretching in
  the cranial direction
• persistent intra-abdominal pressure
• esophageal shortening on swallowing

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Miscellaneous Lesions

• Plummer-Vinson Syndrome
• dysphagia plus atrophic oral mucosa, spoon-shaped
  fingers with brittle nails, iron-deficiency
  anemia, and esophageal web
• malignant lesions of the oral mucosa,
  hypopharynx, and esophagus have occured in 100
  of patients
• Mallory-Weiss Syndrome
• longitudinal mucosal tears at the
  gastroesophageal junction
• acute upper gastrointestinal bleeding following
  repeated vomiting
• bleeding will stop spontaneously
• laparotomy and high gastrotomy with oversewing of
  the linear tear
• Fistula
• close contact with the membranous portion of the
  trachea and left bronchus
• acquired vs. traumatic fistulas
• onset of cough immediately after swallowing
  suggests aspiration, whereas a brief delay (30 to
  60 seconds) suggests a fistula
• treatment
• resection with pleural flap
• occluding stent
• diversion with feeding jejunostomy

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Miscellaneous Lesions

• Schatzki's Ring
• thin submucosal circumferential ring in the lower
  esophagus at the squamocolumnar junction
• Treatment
• dilation alone
• dilation with antireflux measures
• antireflux procedure alone
• incision
• excision

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Miscellaneous Lesions

• Scleroderma
• smooth muscle atrophy and collagen deposition
  
• normal peristalsis in the proximal striated
  esophagus
• absent peristalsis in the distal smooth muscle
  portion