Esophageal surgery

1. Esophageal surgery Dr. Mohammad Reza Lashkarizadeh

2. Anatomy

3. Arterial supply to the esophagus.

4. The Z-line.

5. Posterior view of pharynx

6. gastroesophageal junction

7. Arterial supply to the esophagus.

8. Venous drainage of the esophagus.

9. ASSESSMENT OF ESOPHAGEAL FUNCTION 1. Tests to detect structural abnormalities of the esophagus 2. Tests to detect functional abnormalities of the esophagus 3. Tests to detect increased esophageal exposure to gastric juice 4.Tests to provoke esophageal symptoms; and 5 .Tests of duodenogastric function as they relate to esophageal disease

10. Tests to Detect Structural Abnormalities The first diagnostic test in patients with suspected esophageal diseases should be a barium swallow including a full assessment of the stomach and duodenum. Hiatal hemias are best demonstrated with the patient prone The radiographic assessment of the esophagus is not completeunless the entire stomach and duodenum have been examined

11. Endoscopic Evaluation In any patient complaining of dysphagia esophagoscopy is indicated even in the face of a normal radiographic study A barium study obtained prior to esophagoscopy is helpful to the endoscopist by directing attention to locations of subtle change

12. Endoscopic Evaluation For the initial endoscopic assessment, the flexible fiberoptic esophagoscopy is the instrument of choice because o f its technical ease patient acceptance and the ability to simultaneously assess the stomach and duodenum T he rigid esophagoscopy may be an essential instrument when deeper biopsies are required or the cricopharyngeus and cervical esophagus need closer assessment

13. Tests to Detect Functional Abnormalities Stationary Manometry 2 4-Hour Ambulatory Manometry Video- and Cineradiography

14. Stationary Manometry sphincters. Manometry is indicated whenever a motor abnormality of the esophagus is suspected on the basis of complaints of dysphagia, odynophagia, or noncardiac chest pain, and the barium swallow or endoscopy does not show a clear structural abnormality

15. 2 4-Hour Ambulatory Manometry The developmen of miniaturized electronic pressure transducers and portable digital data recorders with large storage capacity has made ambulatory monitoring of esophageal motor function over an entire circadian cycle possible. Compared with standard manometry, ambulatory esophageal manometry provides a more than 100 times larger database

16. Tests to Detect increased Exposure to Gastric Juice 24-Hour Ambulatory pH Monitoring 24-HourG astricB ilirubinM onitoring

17. GASTROESOPHAGEAL REFLUX DISEASE Pathophysiology Symptoms Preoperative Evaluation Treatment

18. Pathophysiology

19. The three types of hiatal hernia.

20. Symptoms Heartburn 80 Regurgitation 54 Abdominal pain 29 Cough 27 Dysphagia for solids 23 Hoarseness 21

21. Symptoms Belching 15 Bloating 15 Aspiration 14 Wheezing 7

22. Preoperative Evaluation Endoscopy Manometry pH Monitoring Esophagogram

23. Endoscopy Endoscopy is an essential step in the evaluation of patients with GERD The value of the study is in its ability to exclude other diseases, especially a tumor,and to document the presence of peptic esophageal injury

24. Manometry

25. pH Monitoring The gold standard for diagnosing and quantifying acid reflux is the 24-hour pH test

26. Esophagogram

27. Treatment Lifestyle modifications Medical Management Surgical Therapy

28. Lifestyle modifications Cessation of smoking decreased caffeine intake and avoidance of large meals before lying Elevation of the head of the bed avoidance ofconstricting clothing

29. Medical Management H2 blockers proton pump inhibitors

30. Surgical Therapy Severe esophageal injury (ulcer, stricture, or Barrett's mucosa) Incomplete resolution of symptoms or relapses while on medical therapy

31. 360-Degree Wrap

32. mobilization of the fundus of the stomach

33. Release of peritoneal reflection at the hiatus

34. Right hiatus dissection

35. Posterior crural closure

36. Fundoplication

37. Partial fundoplication

38. Paraesophageal hernia

39. Symptomes GERD Dysphagia Anemia

40. Treatment In sliding hiatal hernia if there is reflux surgery is indicated In paraesophageal hernia in anyway surgery ins indicated.

41. NEUROMUSCULAR DISORDERS OF THE ESOPHAGUS Diverticula Achalasia Diffuse Esophageal Spasm

42. Diverticula True False

43. Diverticula location Pharyngoesophageal (Zenker's) Diverticulum Midesophageal Diverticula Epiphrenic Diverticula

44. Pharyngoesophageal (Zenker's) Diverticulum

45. Symptoms and Diagnosis Patients are often initially asymptomatic Halitosis voice changes retrosternal pain respiratory infections

46. Diagnosis is made by barium esophagram

47. Treatment Surgical or endoscopic repair of a Zenker's diverticulum

48. Midesophageal Diverticula

49. Symptoms and Diagnosis Most patients with a midesophageal diverticulum are asymptomatic Dysphagia Regurgitation Hemoptysis

50. Treatment Determining the etiology for midesophageal diverticula is critical to guiding treatment In tuberculosis or histoplasmosis, medical treatment with antituberculin or antifungal agents is indicated

51. Epiphrenic Diverticula Epiphrenic diverticula are found adjacent to the diaphragm in the distal third of the esophagus

52. Barium swallow showing mid- and distal esophageal diverticula

53. Treatment In documented motor abnormality, a long esophagomyotomy is indicated

54. Achalasia The literal meaning of achalasia is �failure to relax,� The lower esophageal sphincter remains in constant contraction Its pathogenesis is presumed to be idiopathic or infectious neurogenic degeneration The incidence is 6 per 100,000 persons per year

55. Symptoms and Diagnosis The classic triad of presenting symptoms consists of dysphagia, regurgitation, and weight loss. coughing are seen commonly The diagnosis of achalasia is usually made from an esophagram and a motility study

56. Barium swallow

57. Treatment Medical Interventional Surgical procedures

58. Medical Sublingual nitroglycerin Nitrates Calcium channel blockers

59. Interventional Dilation Injections of Botulinum toxin

60. Surgical procedures Myotomy Esophagectomy

61. Esophagectomy Esophagectomy is considered in any symptomatic patient with tortuous esophagus (megaesophagus)

62. Diffuse Esophageal Spasm DES is a hypermotility disorder of the esophagus

63. Symptoms and Diagnosis The clinical presentation of DES is typically that of chest pain and dysphagia The diagnosis of DES is made by an esophagram and manometric studies

64. Barium esophagram of diffuse esophageal spasm

65. Treatment The treatment for DES is far from ideal Today the mainstay of treatment for DES is nonsurgical evaluation for psychiatric conditions, including depression, psychosomatic complaints, and anxiety Surgery is indicated in patients with incapacitating chest pain or dysphagia who have failed medical and endoscopic therapy, diverticulum of the thoracic esophagus

66. Caustic Injury In children, ingestion of caustic materials is accidental In teenagers and adults, however, ingestion usually is deliberate during suicide Acids cause an immediate burning sensation in the mouth, whereas alkali does not. Acids cause an immediate burning sensation in the mouth, whereas alkali does not.

67. Caustic Injury There are both acute and chronic phases to caustic esophageal injuries

68. Acute phase is dependenton location of the injury the type of substance ingested (acid versus alkali) the form of the substance (liquid versus solid) The quantity and concentration of the substance ingested The amount of residual food in the stomach The duration of tissue contact

69. The chronic phase focuses on subsequent strictures and disruption of the swallowing mechanism

70. Alkali Ingestion Alkaline substances dissolve tissues by liquefactive necrosis, deeply penetrating the tissues they touch.

71. Phases of Tissue Injury From Alkali Ingestion Acute necrosis Ulceration and granulation Cicatrization and scarring

72. Acid Ingestion Ingestion of acid is difficult because it gives an immediate burning in the mouth Acid substances cause coagulative necrosis

73. Symptoms and Diagnosis During phase one, patients may complain of oral and substernal pain hypersalivation odynophagia and dysphagia hematemesis and vomiting

74. Symptoms and Diagnosis During stage two dysphagia reappear as fibrosis and scarring begin to narrow the esophagus throughout stage three.

75. physical examination Careful inspection of the lips, palate, pharynx, and larynx Auscultation of the lungs The abdomen is examined for signs of perforation

76. Diagnosis Early endoscopy is recommended 12 to 24 hours after ingestion to identify the grade of the burn A CT scan is indicated in a patient with suspicion for a perforation

77. Treatment Alkalis (including lye) are neutralized with half-strength vinegar or citrus juice. Acids are neutralized with milk, egg whites, or antacids Emetics and sodium bicarbonate need to be avoided because they can increase the chance of perforation

78. Management of esophageal caustic injury

79. Stent in esophagus

80. Esophageal Perforation Perforation of the esophagus is a surgical emergency Early detection and surgical repair within the first 24 hours results in 80% to 90% survival After 24 hours, survival decreases to less than 50%.

81. Etiology Most esophageal perforations occur after endoscopic instrumentation forceful vomiting (Boerhaave's syndrome) 15%, foreign body ingestion 14%, trauma accounts 10%

82. Boerhaave's Syndrome Postemetic rupture of the esophagus

83. Symptoms substernal, or epigastric pain Vomiting hematemesis dysphagia

84. Sings Early on, a patient may present with tachypnea, tachycardia, and a low-grade fever With increased mediastinal and pleural contamination, patients progress toward hemodynamic instability and shock

85. Diagnosis Chest x-ray contrast esophagram Chest CT

86. Chest x-ray

87. Barium esophagram

88. CT scan

89. Treatment

90. Treatment

91. Barrett's Esophagus columnar epithelium replaces the stratified squamous epithelium that normally lines the distal esophagus. Chronic gastroesophageal reflux is the factor that injures the squamous epithelium 40-fold increase in risk for developing esophageal

92. Barrett�s esophagus histology

93. Symptoms and Diagnosis Many patients are asymptomatic Most patients present with symptoms of GERD

94. Treatment In general, gastroenterologists advocate aggressive surveillance programs with high-dose acid suppression surgeons advocate antireflux surgery to correct the dysfunctional LES.

95. BENIGN TUMORS AND CYSTS constitute less than 1% of all esophageal neoplasms They can be found in the muscular wall or in the lumen of the esophagus are identified as solid tumors, cysts, or fibrovascular polyps

96. Leiomyoma Leiomyomas constitute 60% of all benign esophageal tumors They are found in men slightly more often than women present in the 4th and 5th decades Recently, they have been classified as a gastrointestinal stromal tumor (GIST).

97. Leiomyoma All leiomyomas arebenign with malignant transformation being rare.

98. Symptoms and Diagnosis Many leiomyomas are asymptomatic Dysphagia and pain are the most common symptoms

99. Barium esophagram

100. endoscopic ultrasound (EUS) Demonstrate a hypoechoic mass in the submucosa or muscularis propria.

101. Endoscopic biopsy is avoided because subsequent mucosal adherence to the mass increases the chance of a mucosal perforation during surgical resection.

102. Treatment Although observation is acceptable in patients with small (<2 cm) asymptomatic tumors In most patients, surgical resection is advocated.

103. Esophageal Cysts Esophageal cysts are the second most common benign lesion of the esophagus They can be congenital or acquired

104. Symptoms and Diagnosis Most cysts, congenital or acquired, remain asymptomatic until they are large enough to obstruct the esophageal lumen. Diagnosis is made with a barium esophagram or CT scan EUS is helpful to distinguish a cyst from a solid mass

105. Barium esophagram and CT scan of an esophageal cyst

106. Treatment Surgical resection of the cyst needs to be considered in all patients

107. Fibrovascular Polyps Fibrovascular polyps are uncommon tumors of the esophagus

108. Symptoms and Diagnosis Pedunculated polyps are usually asymptomatic until they grow large enough to cause dysphagia A barium esophagram demonstrates an irregular filling defect CT identifies the intraluminal mass

109. Barium esophagram, and CT scan , Resection

110. Treatment All fibrovascular polyps are removed with endoscope or surgery.