Fiser Chaper 29. ESOPHAGUS Flashcards
Esophagus wall layers
Mucosa: squamous epithelium
Submucosa
Muscularis propria: longitudinal muscle layer
(no serosa)
Upper 1/3 and lower 2/3 esophagus
Upper 1/3: striated muscle
Lower 2/3: smooth muscle
Esophagus blood supply
Cervical: inferior thyroid artery
Thoracic esophagus: directly off aorta
Abdominal: left gastric and inferior phrenic arteries
Esophagus venous drainage
Hemi-azygous and azygous veins
Esophagus lymphatic drainage
Upper 2/3 drains cephalad
Lower 1/3 caudad
Right and left vagus nerve
Right travels on posterior portion of stomach as it exits chest; becomes celiac plexus; has criminal nerve of Grassi which can cause persistently high acid levels postop if left undivided after vagotomy
Left vagus travels on anterior portion of stomach; goes to liver and biliary tree
Thoracic duct
Travels from R to L at T4-5 as it ascends mediastinum; inserts into L subclavian vein
Where does thoracic duct enter into?
L subclavian vein
UES and LEs
UES: Cricopharyngeus (circular muscle which prevents air swallowing), 15cm from incisors, gets RLN innervation, most common site of esophageal perf (usually occurs with EGD); aspiration with brainstem stroke is due to failure of cricopharyngeus to relax
LES: anatomic zone of high pressure, NOT an anatomis sphincter; 40cm from incisors, relaxation mediated by inhibitory neurons, normal contracted at resting state (prevents reflux)
Normal UES and LES pressure
UES: 60mmHg at rest, 15mmHg with food bolus
LES: 15mmHgb at rest, 0mmHg with food bolus
Both are normally contracted between meals
Anatomic areas of esophageal narrowing (and perf)
- Cricopharyngeus muscle
- Compression by left mainstem bronchus and aortic arch
- Diaphragm
Swallowing stages
CNS initates swallow
- Primary peristalsis: food boluw and wallow initiation
- Secondary peristalsis: incomplete emptying and esophageal distension, propagating waes
- tertiary peristalsis: non-propagating, non-peristalsis (dysfunction)
Swallowing mechanism
Soft palate occludes nasopharynx
Larynx rises and airway opening is blocked by epiglottis
Cricopharyngeus relaxes
Pharyngeal contraction moves food into esophagus
LES relaxes soon after initiation of swallow (vagus mediated)
Surgical approach for different regions of esophagus
Cervical: Left
Upper 2/3 thoracic: Right (avoids aorta)
Lower 1/3 thoracic: Left
Hiccoughs causes
Gastric distension, temperature changes, EtOH, tobacco
Reflex arc: vagus, phrenic, sympathetic chain T6-12
Esophageal dysfunction primary/secondary
Primary: achalasia, DES, nutracker
Secondary: GERD (most common), scleroderma
Best test for heartburn
Endoscopy
Best test for dysphagia or odynophagia
Barium swallow (better at picking up masses)
Meat impaction dx and tx
EGD
Pharyngoesophageal disorders
trouble in transferring food from mouth to esophagus
Most commonly neuromuscular disease (MG, muscular dystrophy, stroke)
Liquids worse than solids
Plummer-Vinson syndrome
Upper esophageal web; IDA
Plummer-Vinson syndrome
Tx: dilation, Fe, need to screen for oral Ca
Upper esophageal dysphagia, choking hallitosis
Zenker’s diverticulum: caused by increased pressure during swallowing
Is a false diverticulum located posteriorly, located between pharyngeal constrictors and cricopharyngeus
Caused by failure of cricopharyngeus to relax
Dx: barium swallow, manometry, risk for perforation with EGD
Tx: Cricopharyngeal myotomy; can also resect or suspend (removal not necessary); via L cervical incision, leave drains, POD1 esophagogram
Regurgitation of undigested food, dysphagia, in some with recent inflammation/granulomatous disease/tumor
Traction diverticulum
True diverticulum, usually lies lateral and in mid-esophagus
Tx: Excision and primary closure if symptomatic, may need palliative therapy (XRT) if due to invasive ca; leave alone if symptomatic
Asymptomatic or dysphagia and regurgitation, found to have diverticulum and achalasia
Epiphrenic diverticulum
Rare, associated with esophageal motility disorders like achalasia
Most commonly in distal 10cm of esophagus
D: Esophagram and manomery
Tx: Diverticulectomy and esophageal myotomy on side OPPOSITE the diverticulectomy if symptomatic
Dysphagia, regurgitation, weight loss, respiratory symptoms
Achalasia
Caused by lack of peristalsis and failure of LES to relax after food bolus
Secondary to neuronal degeneration in muscle wall
Dx: Manometry shows increased LES pressure and incomplete LES relaxation, with NO peristalsis
Can get tortuous dilated esophagus and epiphrenic diverticula; bird’s beak appearance
Tx: Balloon dilatation of LES is effective in 80%; nitrates and CCBs; If medical tx and dilation fail, Heller myotomty (L thoracotomy, myotomy of lower esophagus ONLY, also partial Nissen)
T cruzi can produce similar symptoms
Chest pain, dysphagia, psychiatric history, manometry shows frequent strong non-peristaltic unorganized contractions and LES relaxes normally
DES
Tx: CCB, nitrates; Heller myotomy ifthose fail (myotomy of UPPER AND LOWER esophagus); surgery usually less effective than for achalasia
Chest pain and dysphagia, manometry shows high-amplitude PERISTALTIC contractions and LES relaxes normally
Nutcracker esophagus
Tx: CCB, nitrates; Heller myotomy if those fail (myotomy of UPPE AND LOWER esophagus); surgery usually less effective than for achalasia
Dysphagia and loss of LES tone with massive reflux and strictures
Scleroderma: fibrous replacement of smooth muscle
Tx: Esophagectomy usual if severe
Normal anatomic protection from GERD
Competent LES, normal esophageal body, and normal gastric reservoir
Causes of GERD
Increased acid exposure to esophagus from loss of gastroesophageal barrier
GERD symptoms
Heartburn 30-60 minutes after meals, worse with lying down
Can also have asthma symptoms (cough), choking, aspiration
GERD workup
Make sure patient does not have another cause for pain (check for unusual symptoms)
Unusual symptoms: dysphagia/odynophagia (tumors), bloating (aerophagia and delayed gastric emptying, dx GES), epigastric pain (PUD or tumor)
GERD tx
Empirically with PPI, 99% effective
Failure of PPI despite 3-4 weeks of escalating doses: need diagnostic studies
GERD dx studies
pH probe (best test), manometry (resting LES < 6 mmHg), endoscopy, histology
GERD surgical indications
Failure of medical tx, avoidance of lifetime meds, young patients
Surgical tx of GERD
Nissen fundoplication: divide short gastrics, pull esophagus into abdomen, approximate crura, 270 (partial) or 360 degree gastric fundus wrap
What is the phrenoesophageal membrane made of?
Its an extension of the transversalis fascia
Key maneuver for Nissen wrap
identification of the L crura
Complications of Nissen wrap
Injury to spleen, diaphragm, esophagus, or pneumothoraz
Belsey anti-reflux
Approach through chest
Collis gastroplasty
When not enough esophagus exists to pull down into abdomen, can staple along stomach cardia and create a neo-esophagus
MCC dysphagia after Nissen
Wrap too tight
Hiatal hernia types
I: Sliding hernia from dilation of hiatus (most common); often associated with GERD
II: Paraesophageal; hole in diaphragm alongside esophagus, normal GEJ, symptoms of chest pain, dysphagia, early satiety. Usually need repair due to high risk of incarceration; may want to avoid repair in the elderly and frail. In repair STILL NEED NISSEN as diaphragm repair can affect LES and also helps anchor stomach
III: combined
IV: entire stomach in chest plus another organ (colon, spleen)
Schatzki’s ring
Almost all have an associaed sliding hiatal hernia
Symptoms of dysphagia
Tx: dilatation of ring and PPI usually sufficent; do NOT resect
Barrett’s esophagus
Squamous metaplasia to columnar epithelium
Occurs with long-standing exposure to gastric reflux
Cancer risk is 50x higher (adenocarcinoma)
Ucomplicated Barrett’s can be treated like GERD (PPI or Nissen): surgery will decrease esophagitis and further metaplasia but will NOT prevent malignancy or cause regression of columnar lining. Need careful follow up with EGD for lifetime, even after Nissen
Severe Barrett’s dysplasia is an indication for esophagectomy
Esophageal cancer characteristics
Almost always malignant with early invasion of nodes
Spreads quickly along submucosal lymphatic channels
Symptoms are dysphagia especially to solids, and weight loss
Risk factors are EtOH, tobacco, caustic injury, nitrosamines
Dx: esophagram (best test for dysphagia)
Signs of unresectable esophageal cancer
CT chest and abdomen is the best single test for resectability
Hoarseness (RLN invasion)
Horner’s syndrome (brachial plexus invasion)
Phrenic nerve invasion
Malignant pleural effusion
Malignant fistula
Airway invasion
Vertebral invasion
Supravlavicular or celiac nodes (M1 disease; nodal disease outside area of resection)
Types of esophageal cancer
Adenocarcinoma: #1, usually in lower 1/3, liver mets most common
Squamous cell carcinoma: usually upper 2/3, lung mets most common
Chemo for esophageal cancer
Neoadjuvent CRT may downstage tumorsand make them resectable
Chemotx: 5Fu and cisplatin (for node-positive disease or preop to shrink tumors)
Esophagectomy mortality rate and cure rate
5% mortality, 20% cure rate
Primary blood supply to stomach after replacing esophagus
R gastroepiploic artery (have to divide L gastric and short gastrics)
Transhiatal approach esophagectomy
Abdominal and neck incisions; bluntly dissect intrathoracic esophagus; may hae decreased mortality from esophageal leaks with cervical anastomosis
Ivor Lewis esophagectmoy
Abdominal incision and R thoracotomy
Exposes all of the intrathoracic esophagus
Intrathoracic anastomosis
3-hole esophagectomy
Abdominal, thoracic, and cervical incisions
Esophagectomy types
Transhiatal approach
Ivor Lewis
3-Hole
Colonic interposition
Need pyloromyotomy with these procedures
Colonic interposition esophagectomy
May be choice in young patients when you want to preserve gastric function; 3 anastomosis required; blood supply depends on colon marginal vessels
Post esophagectomy care
POD7 contrast study to rule out leak
Postop strictures: most can be dilated
Most common benign esophageal tumor
Leiomyoma
Located in muscularis propria
Present as dysphagia, with mass usually in lower 2/3 of esophagus (smooth muscle cells)
Dx: esophagram, EUS, CT scan to r/o cancer, DO NOT BIOPSY (can form scar and make subsequent resection difficult)
Tx: Excise via thoractomy if > 5cm or symptomatic
Dysphagia and hematemesis, and found to have esophageal polyps
2nd most common benign tumor of esophagus
Usually in cervical esophagus
Small lesions can be resected endoscopically; larger lesions need cervical incision
Caustic esophageal injury
Alkali or acid
Primary, secondary, or tertiary burns
NO NG TUBE, DO NOT INDUCE VOMITING, NOTHING TO DRINK
Alkali and acid burns
Alkali: deep liquefaction necrosis, especially liquid (Drano), worse than acid and more likely to cause cancer
Acid: coagulation necrosis; mostly causes gastric injury
Caustic injury workup
CT chest and abdomen to look for free air and perforation
Endoscopy to assess lesion: do NOT use with suspected perforation and NOT go past a site of sevre injury
Serial exams and plain films required
Degrees of esophageal caustic injury
Primary burn: hyperemia, observe and IVF, spiting, abx, NPO 3-4 days, may need future serial dilation for strictures (usually cervial), can also get shortening of esophagus with GERD (tx PPI)
Secondary burn: ulcerations, exudates, sloughing, do prolonged observation and IVF, spitting, abx, NPO 3-4 days, future dilation if needed; indication for esophagectomy is sepsis, peritonitis, mediastinitis, free air, mediastinal or stomach wall air, crepitance, contrast extrav, pneumothorax, or large effusion
Tertiary burn: deep ulcers, charring, lumen narrowing; esophagectomy usually necessary; alimentary tract NOT restored until after patient recovers from caustic injury
CAUSTIC ESOPHAGEAL PERFORATIONS REQUIRE ESOPHAGECTOMY AND ARE NOT REPAIRED DUE TO EXTENSIVE DAMAGE
Esophageal perforations MCC
EGD
Esophageal perforations most common site
Cervical esophagus near cricopharyngeus muscle (?)
Pain, dysphagia, tachycardia
Esophageal perforation
Dx: CXR to look for free air, gastrograffin swallow followed by barium swallow
Management of esophageal perf
Contained perforation by contrast, self draining, NO systemic effects: IVF, NPO, spit, abx
Non-contained:
If <24 hr and minimal contamination: primary repair with drains (also need longitudinal myotomy to see full extent of injury and consider intercostal muscle flaps to cover repair)
If > 48 hr or extensive contamination:
- Neck: Drainage (no resection)
- Chest: Resection (esophagectomy and cervical esophagostomy) or exclusion and diversion (cervical esophagostomy, staple across distal esophagus, washout mediastinum, chest tubes - late esophagectomy at time of gastric replacement)
Indications for esophagectomy in perforation
Severe intrinsic disease (burned out esophagus from achalasia or cancer) regardless of contained or non contained
Forceful vomiting followed by chest pain
Boerhaave’s: perforation most likely to occur in L lateral wall of esophagus, 3-5 cm above GEJ
Mediastinal crunching on auscultation: Hartmann’s sign
Highest mortality of all perforations
Boerhaave’s syndrome: early diagnosis and treatment improve survival
Dx: gastrografin swallow
Tx: same as for other esophageal perforations
