ESOPHAGUS

anatomy

physiology

pathology

treatment

Anatomy of esophagus length 23-25 cm esophagus begins at the level of the sixth cervical

vertebra and it enters into the superior mediastinum through the upper thoracic outlet then it descends into the posterior mediastinum and exits the thorax through esophageal hiatus of the diaphragm and enters the abdominal cavity

there are three parts of the esophagus: cervical, thoracic and abdominal esophagus

esophagus has three physiological constrictions

Anatomy of esophagus It consists of three layers :

mucosa, submucosa muscular layer (circular and longitudinal layer)

arterial blood supply from: inferior thyroid artery descending aorta left gastric artery inferior phrenic artery

venous drainage into the superior caval vein portal vein

Anatomy of esophagus

Esophagus has an extensive lymphatic drainage into cervical, posterior mediastinal, paraesophageal and celiac axis lymph nodes

Anatomy of esophagus

Carcinoma of the esophagus most common neoplasm of the esophagus is

carcinoma

its incidence is very differentiated worldwide and

depends on geographical localization that proves

its dependency on environmental factors

90% of patients with esophageal carcinoma die

incidence of esophageal carcinoma is 8-12/100000

men per year in Europe and 6/100000 in the

United States

Carcinoma of the esophagus

risk to develop carcinoma of the esophagus

increases along with the age and is the highest

between the sixth and the seventh decade of life

more frequent in males

main risk factors: smoking, alcohol

incidence of esophageal adenocarcinoma raises

Carcinoma of the esophagus Premalignant states

Plummer-Vinson syndrome

caustic burns

achalasia

Barrett’s esophagus

leukoplakia

Carcinoma of the esophagus Screening

screening exfoliative cytology in endemic

areas

Barrett’s esophagus- endoscopic biopsy

Carcinoma of the esophagus Clinical presentation

dysphagia in 95% of cases

regurgitation

weight loss

chest pain

cough

Carcinoma of the esophagus Diagnosis

barium esophagogram

flexible fiberoptic

esophagoscopy with biopsy

Computed Tomography

endoscopic ultrasound –

diagnostic accuracy 80–

90%

Bronchoscopy

Carcinoma of the esophagus Staging

Primary tumor (size of tumor and depth of infiltration)–T

regional lymph node involvement - N

distal metastasis–M

Carcinoma of the esophagus Staging

Primary tumor - T

T1 – tumor invades lamina propria or

submucosa

T2 – tumor invades muscularis propria

T3 – tumor invades adventitia

T4 - tumor invades adjacent structures

Carcinoma of the esophagus Staging

Regional lymph nodes – N

N0 – no regional node metastasis

N1 – regional node metastasis

Distant metastasis – M

M0 – no distant metastasis

M1 – distal metastasis

Carcinoma of the esophagus Surgical management

radical – resection of a tumor with adequate

oncological margins and regional lymph

nodes

palliative - to restore oral intake of food

Carcinoma of the esophagus Most common surgical procedures

1. Thoracoabdominal Ivor–Lewis esophagectomy with high intrathoracic esophagogastric anastomosis and gastric drainage procedure

2. Thoracoabdominal McKeown esophagectomy

with esophagogastric anastomosis in the neck

3. transhiatal Orringer esophagectomy with

esophagogastric anastomosis in the neck

4. esophagectomy throuh left

thoracophrenolaparotomy

Carcinoma of the esophagus How to replace the esophagus?

stomach- the best organ to replace the

esophagus

colon- the second organ for reconstruction

small intestine (pedicle or free graft)- least

appropriate

Carcinoma of the esophagus Complications

Postoperative complications from 20 to 40%

perioperative mortality 3–10%, 20% was also

reported

Carcinoma of the esophagus Radiation therapy

patients with advanced disease patients refusing to undergo surgery irradiation with a dose of 55–60 Gy usually used as a palliative treatment,

unusually as a radical treatment has no influence on survival 5-year survival rate less than 6%

Carcinoma of the esophagus Chemotherapy

Effective for a short time

recently advocated regimen is cisplatin with

vindesine, bleomycin and 5-fluorouracil

complete and partial response rates are

reported for 25-50 %

Carcinoma of the esophagus Combination therapy

Results of monotherapy are bad

5-year survival rate after surgery alone is 10–

15 %

most patients die due to distant metastases,

hence local treatment is combined with

systemic treatment

Carcinoma of the esophagus Combination therapy - benefits

decrease in tumor size

early therapy for micrometastases

enables the assessment of response to a used

treatment and reassessment of staging after

induction therapy

surgery 3-6 weeks after induction therapy

some authors question the role of surgery in

improving survival

Carcinoma of the esophagus Palliative therapy

50% of patients have distant metastases at the

time of diagnosis

main problem reported by a patient – dysphagia

radiation therapy combined or not with

chemotherapy offers immediate clinical

improvement in dysphagia

Carcinoma of the esophagus Palliative endoscopic treatment

dilatation self-expanding stents stents laser ablation endoluminal brachytherapy photodynamic therapy

Palliative resection, bypass procedures and gastrectomy are presently not advocated

Self-expanding stents

Carcinoma of the esophagus Prevention

cessation of smoking and alcohol

consumption

treatment of Barrett’s esophagus

detection of p53 gene mutation

screening programs

Rare esophageal malignancies

Epithelial carcinoma planoepithelialae partim fusocellularae adenocarcinoma carcinoma basocellularae carcinoma microcellularae

Non-epithelial leiomyosarcoma melanoma rhabdomyosarcoma fibrosarcoma

Benign esophageal tumors Deriving from submucosa

adenoma haemangioma papilloma fibrolipoma neurofibroma

Deriving from muscular layer (intraparietal) leiomyoma lipoma fibroma

Chemical burns of the esophagus

Necrosis occurs directly after burn and is

irreversible!

Chemical burns of the esophagus

Acids - they produce coagulative necrosis that is rarely full-thickness one. Similar injury should be expected in the stomach and duodenum.

Caustic agents - they produce colliquative

full-thickness necrosis including perforation.

Classification of chemical burns of the esophagus

I. Erythema, superficial exfoliation of esophageal epithelium

II. shallow ulcerations not penetrating beyond submucosa, whitish discolorations

A. superficial erosions and ulcerations

B. deep, circumferential ulcerations

III. deep ulcerations penetrating into the muscularis propria or producing perforation

Chemical burns of the esophagus

Clinical presentation

a) severe retrosternal pain

b) dysphagia

c) shock

d) respiratory disturbances

e) subcutaneous emphysema in the neck-

sometimes

f) stridor and peritonitis- rarely

Chemical burns of the esophagus

First-aid treatment

Oral administration of small amount of water administration of antidotes, advocated in the

past, can trigger exothermic reaction and compound injury

vomits shouldn’t be induced administration of antibiotics, steroids and

analgesic agents. in a case of acute airway obstruction

tracheostomy should be performed intravenous access

Chemical burns of the esophagus

First-aid treatment

cessation of oral food intake chest x-ray examination esophagoscopy performed within 12-24 hours after

burn preceded by laryngoscopy part of surgeons is of the opinion that endoscopy

mustn’t be done and they advocate esophagogram using a water-soluble contrast medium if esophageal perforation is suspected, if not esophagoscopy can be done 2-3 days after burn and then 3 weeks after burn.

Chemical burns of the esophagus

Perforation of the esophagus occurs usually between 2 and 8 days after

burn.

Stricture of the esophagus after burn - treatment

dilatation of stricture resection of the narrowed fragment of the

esophagus and esophagoesophageal anastomosis- short strictures only

esophagectomy and reconstruction using the stomach, colon or small bowel (possible malignant degeneration)- extensive esophageal strictures

Thal or Collis gastroplasty- stenosis of gastroesophageal junction

Perforation of the esophagus

Esophageal perforation is a serious diagnostic problem.

Incidence:1case per 8000 hospitalized patients

per year and still increases due to growing

number of diagnostic and therapeutic endoscopies.

Perforation of the esophagus Etiology

Iatrogenic from inside

endoscopy dilatations variceral sclerosis esophageal intubation laser

Perforation of the esophagus Etiology

from outside mediastinoscopy intraoperative injuries (thyroid resection,

enucleation of esophageal myoma, vagotomy, pneumonectomy)

radiation therapy

Traumatic blunt trauma penetrating trauma caustic injury

Perforation of the esophagus Etiology

Spontaneous perforation

postemetic

others e.g. childbirth

Foreign body

Neoplasms

Paraesophageal infections

Perforation of the esophagus

Bacteria in saliva

Air Gastric juice

Infection Emphysema

Chemical burn

Abscess, empyema, sepsis

Tension pneumothorax

Disturbances in water and

electrolyte balance

shock

mediastinum

Perforation of the esophagus Clinical presentation

Cervical esophagus neck ache increased on swallowing hemoptysis or hematemesis subcutaneous emphysema fever local tenderness change in the timbre of voice hydropneumothorax pneumothorax neck abscess

Perforation of the esophagus Clinical presentation.

Thoracic esophagus chest pain dyspnea subcutaneous emphysema pneumo- and hydrothorax tachycardia and tachypnea cyanosis fever

Perforation of the esophagus Clinical presentation

Abdominal esophagus

peritonitis

retrosternal pain radiating to the arms

tachycardia and tachypnea

fever

Perforation of the esophagus Differential diagnosis

Chronic gastric and duodenal

ulcer disease

myocardial infarction

acute pancreatitis

dissecting aortic aneurysm

pneumonia

pneumothorax

Perforation of the esophagus Crucial aims of surgical treatment

Elimination of sources of bacterial infection

and chemical injury

drainage of infected areas

secure food intake

Perforation of the esophagus Surgical management

1. primary repair of the perforation

2. primary repair of the perforation buttressed with well-vascularized autologous tissue

3. temporary exclusion of the perforated esophagus

4. drainage procedures (T-tube drainage, washing drainage, intraesophageal drainage)

5. partial or total esophageal resection

Perforation of the esophagus Surgical management

The earlier esophageal perforation is

diagnosed the easier is a treatment.

The later it is diagnosed the more

aggressive should be a surgical

management.

Disorders of esophageal motility

Disorders of esophageal motility can result both

from its increased and decreased neuromotor

activity .

Cricopharyngeal achalasia

Clinical presentation Cervical dysphagia Barium esophagogram demonstrates hypertonicity

of the upper esophageal sphincter (narrowing of esophageal lumen)

Presence of Zenker's diverticulum in some patients

Treatment Cervical esophagomyotomy from the level of the

superior cornu of the thyroid cartilage iferiorly to 1-2 cm behind the clavicle

Neuromotor diturbances of esophageal motility

Usually myotonic

Observed in diseases such as:

miasthenia gravis,

dystrophia myotonica

Pathologies of the peripheral and central nervous

system.

Diffuse esophageal spasm

Clinical presentation Dysphagia, chest pain (retrosternal) Anxiety, signs and symptoms appear

periodically x-ray examination and esophageal

manometry demonstrate hypermotilityTreatment Nitrates, calcium channel blockers Liquid, small-volume meals Long esophagomyotomy

Achalasia

Clinical presentation dysphagia regurgitation Lack of primary esophageal peristalsis,

dilatation of the esophagus and the distal bird-beak taper of the esophagogastric junction on barium swallowing examination

Luck of primary esophageal peristatlsis on manometry

Achalasia

Alteration of the central or peripheral vagal innervation.

In many cases the lack or disintegration of

ganglion cells in the myenteric (Auerbach's)

plexus is observed.

Etiology of achalasia is unknown.

AchalasiaTreatment

Myorelaxants have weak or no therapeutic

effect

Dilatation of the lower esophageal sphincter

Esophagomyotomy (Heller procedure) – 15%

of cases

Uchyłki przełykuPodział

wrodzone nabyte prawdziwe rzekome

Typ z uwypuklenia - uwypuklenia błony śluzowej i podśluzowej przez osłabiona mięśniówkę.

Typ z pociągania - pociąganiu ściany od zewnątrz przełyku przez zapalnie lub bliznowato zmienione okołooskrzelowe i śródpiersiowe węzły chłonne.

Diverticula of the esophagusClinical presentation

Dysphagia

Regurgitation

Bad breath

Chest pain

Typical roentgenographic picture

Diverticula of the esophagus Complications

Often asymptomatic clinical course Diverticulitis Fistula Abscess Bleeding

Symptomatic patients or patients in whom

complications occured should undergo surgical

treatment.