Surgical conditions of the esophagus. Diaphragmatic hernias

1. Surgical conditions of the esophagus. Diaphragmatic hernias Emil Gavgani

2. The esophagus extends form the cricoid cartilage at the level of C6 to the gastric cardia and is 25cm long. It passes through the diaphragm at T10 and the final portion of the esophagus lie within the peritoneal cavity. • cervical, thoracic and abdominal parts

3. The esophagus has 3 anatomical constrictors • At the start of the esophagus, where the pharynx joins the esophagus, behind the cricoid cartilage • Where it is crossed on the front by the aortic arch and the left main bronchus • Where it passes through the diaphragm

4. The esophagus is lined by squamous epithelium and its wall can be divided into two layers: muscular and mucosal. • Muscular layer: longitudinal fibers outside and circular fibers inside. Upper 1/3 is striated muscle and the lower 2/3 is smooth muscle. • Submucosa is between the muscular and mucosal layer and contains: numerous mucous glands and lymphatics • Myenteric plexus – between outer longitudinal and inner circular – parasympa motor inn to smooth muscle • Submucosal plexus – between inner circular and submucosa – signals from free nerve endings to vagal afferent fibers

5. Blood supply • Arterial blood supply from the inferior thyroid artery in the cervical region, bronchial arteries and branches from the thoracic aorta in the thorax, and inferior phrenic and left gastric arteries in the abdominal region. • Venous drainage is to the inferior thyroid veins in the neck, hemi-azygous and azygous veins in the thorax, and the left gastric vein in the abdomen. • The connection between these veins is important in the development of varices in patients with portal hypertension.

6. Esophageal peristalsis is initiated by swallowing when the bolus is pushed back towards receptors in the pharynx (primary peristalsis) or by luminal distention (secondary peristalsis) and progresses distally by coordinated contraction and relaxation of esophageal muscle. • The upper esophageal sphincter opens by the swallowing reflex. The lower sphincter relaxes momentarily before the peristaltic wave arrives • Pressures of 80mmHg are generated in the esophageal body.

7. Achalasia • An esophageal motility disorder, unknown cause. • Failure of the LES to relax, increased LES tone or absent peristalsis of the esophagus • Dysphagia, heartburn, chestpain and regurgitation • Barium swallow reveals characteristic ”bird beak” on fluoroscopy imaging, esophageal manometry reveals higher pressure especially at the level of LES. • Treatment: lifestyle changes – chew slowly, plenty of fluids with meal. • nitrates for smooth muscle relaxation, Ca channel blockers, botulinum toxin injection during endoscopy and pneumatic dilatation are only temporary treatments and are recommended for elderly or people that doesnt qualify for surgery. • Laparoscopic Heller myotomy is the procedure of choice but complications include GERD so a partial fundoplication or ”wrap” is generally added to prevent excessive reflux.

9. Diffuse esophageal spasm • Complaints are of intermittent dysphagia and retrosternal pain, can mimic angina. The symptoms are caused by repetitive irregular peristalsis of the esophagus. • Can be precipitated by GERD so should be excluded by 24h esophageal pH study. • Diagnosis by esophageal manometry • Same pharmacologic treatment as for achalasia + PPI. • Surgical long myotomy treatment has unpredictable results so most patients are treated medically.

10. GERD • usually caused by changes in the junction between the stomach and the esophagus, including abnormal relaxation of the LES and hiatal hernia. Increased intraabdominal pressure in obese people and pregnancy. • Patients complain of heartburn, regurgitation of acid, nausea, hypersalivation, epigastric pain. Other symptoms include hoarseness, dental erosions, cough.

11. Diagnosed by history, endoscopy and esophageal pH study. • Patients should be advised about lifestyle changes including stopping smoking, eating less fatty and spicy food, drinking less caffeine and alcohol. • Definitive treatment is provided by a course of PPIs. Metoclopramide may also help by improving LES tone and promote gastric emptying. • Indications for surgery include those whose symptoms cannot be controlled by medical therapy, those with recurrent strictures despite treatment and young people that wish not to continue acid suppression therapy for decades.

12. Nissen fundoplication • For GERD and hiatal hernia

13. Barrets esophagus • Barrets esophagus is a histological diagnosis made after endoscopic biopsies. GERD can cause esophagitis and this might lead to metaplastic changes in the mucosa from squamous to columnar epithelium. • During endoscopy the mucosa has salmon pink appearance • Intestinal cells with goblet cells is characteristic on histology. • If further becoming dysplastic it can turn into esophageal adenocarcinoma.

14. BE treatment • Metaplasia: PPIs for reflux symptoms, may not guarantee control of acid reflux.Fundoplication surgery may reverse the cells to normal squamous epithelium. • Dysplasia: high dose PPIs for 2months and repeat endoscopy with multiple biopsies. If LGD – fundoplication with ablation of dysplastic epithelium and endoscopy every 6-12months because the patient is at a higher risk group of adenocarcinomaIf HGD – patient enrols in an endoscopic surveillance program (every 3rd month). If unwilling or carcinoma -> esophagectomy

16. Diverticula • Protrusions of mucosa though a weak area in the muscle wall. Incoordination of swallowing and failure of relaxation of the cricopharyngeus muscle cause the herniation. • Zenker diverticulum above UES • Epiphrenic diverticulum above LES

17. Most patients are elderly and males are more commonly affected. • Symptoms include regurgitation of food, halitosis, dysphagia being the main complaint, gurgling sounds in the neck, aspiration into tracheobronchial tree – pneumonia • Diagnosis made by barium swallow. (Endocopy can confirm diagnosis also but should be done by care to avoid perforation) • Treatment by endoscopic stapling: A special linear stapling device is placed perorally under direct vision with one limb of the stapler in the esophageal lumen and the other limb in the pouch’s before the stapler is closed and fired. This creates a common lumen between the pouch and the esophagus and divides the cricopharyngeal sphincter at the same time.

19. Hiatal hernia • An abnormal protrusion of the stomach through the esophageal diaphragmatic hiatus into the thorax. • Caused by weakness of the muscles around the hiatus. • W>M • Tend to occur in middle-aged and elderly patients • Higher incidence in obese

20. Sliding hernia • Occurs when the stomach slides through the diaphragmatic hiatus so that the gastroesophageal junction lies in the chest cavity. • It is covered anteriorly by peritoneum, posterior is extraperitoneal

21. Rolling/para-esophageal hernia • Formed when the stomach rolls up anteriorly through the hiatus, cardia is in its normal position so cardioesophageal junction and sphincter is intact.

22. Heartburn and regurgitation, esophagitis from persistent reflux, epigastric pain, symptoms of increased intrathoracic pressure • Complications of hernia: volvulus of stomach, vomiting from gastric outflow obstruction. • Obstruction – abdominal pain, vomiting and distention and • Strangulation – compression of vasculature leads to venous congestion, swollen red area, local peritonitis, gangrene and sepsis Treatment: Fundoplication, if presented with obstructed hiatus the hernia should be decompressed by nasogastric tube or endoscopically.

23. Congenital diaphragmatic hernias • Congenital diaphragmatic hernia (CDH) is a birth defect of the diaphragm. Malformation allows the abdominal organs to push into the chest cavity, hindering proper lung formation • CDH is a life-threatening pathology in infants and a major cause of death due to two complications: pulmonary hypoplasia andpulmonary hypertension • A failure of the diaphragm to completely close during development • Herniation of the abdominal contents into the chest • Pulmonary hypoplasia

24. The Bochdalek hernia, is the most common one. • the diaphragm abnormality is characterized by a hole in the postero-lateral corner of the diaphragm which allows passage of the abdominal viscera into the chest cavity. • Mostly left sided herniation

25. Morgagni hernia • it is characterized by herniation through the foramina of Morgagni which are located immediately adjacent and posterior to the xiphoid process

26. Diaphragm eventration • The diagnosis of congenital diaphragmatic eventration is used when there is abnormal displacement (i.e. elevation) of part or all of an otherwise intact diaphragm into the chest cavity. This rare type of CDH occurs because in the region of eventration the diaphragm is thinner, allowing the abdominal viscera to protrude upwards.

27. Tumors • Esophageal leiomyoma is the most common benign tumor. Often asymtomatic but may bleed or cause dysphagia • Local enucleation

28. carcinomas • Risk factors for adenocarcinoma: reflux and obesity • Most important risk factors of squamous cell carcinomas: alcohol, smoking leucoplakia, achalasia, plummer vinson syndrome • Progressive dysphagia to solids is the most common presentation. If presented with metastatic disease – hepatomegaly, anemia anorexia, hoarseness.

29. Diagnosed with endoscopy w biopsy then TNM staging is made by • Endoscopic ultrasonography for tumor stage T and nodal spread N • CT , PET scan or laparoscopy are best used for assessing metastases M • The aim of treatment is to offer radical treatment to those with potentially curable disease and improve quality of life.

30. If considered curable we use perioperative chemotherapy and surgery. • If not we may implant an esophageal stent to improve quality of life.´+ palliative care • Ca 70% are presentedlate and arent operable

31. Ivor Lewis esophagectomy: laparotomy during which the stomach is fully mobilised with the lower esophagus. A right thoracotomy is done to resect the esophagus, and the mobilised stomach is moved up and anastomosed to the proximal esophagus. • Surgery of choice for mid-low tumorsin the esophagus

32. Thank You • Principles & practise of surgery • Google • Current diaagnosis and treatment in surgery • Wiki for congential diaphragmatic hernias