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The benign disorders of the
esophagus
Paszt Attila
ESOPHAGEAL DIVERTICULUM
• PULSION TYPE: the protrusion of
mucosa and submucosa through a
weakness or defect in the musculature
• TRACTION TYPE: The pulling
outward of the esophageal wall from
inflamed and scarred peribronchial
mediastinal lymph nodes
PHARYNGOESOPHAGEAL
(ZENKER’S) DIVERTICULUM
GENERAL CONSIDERATIONS
• Most common of the esophageal
diverticula
• Pulsion type
• More frequent in men
• Most patients are over 60
PHARYNGOESOPHAGEAL
(ZENKERS’S) DIVERTICULUM
CLINICAL FINDINGS
• Dysphagia, pressure symptoms, gurgling
sounds in the neck
• Regurgitation of undigested food
• Manual emptying of the diverticulum by the
patients
• Swelling of the neck, a sour metallic taste in
the mouth
PHARYNGOESOPHAGEAL
(ZENKER’S) DIVERTICULUM
COMPLICATIONS
• Regurgitation, aspiration, pulmonary infection
• Perforation, mediastinitis, paraoesophageal abscess
• Bleeding, fistula formation
PHARYNGOESOPHAGEAL
(ZENKERS’S) DIVERTICULUM
Diagnostic tests
• Barium swallow, fluoroscopic examination
(a smoothly rounded outpouching arising
posteriorly in the midline of the neck)
• Esophagoscopy
• Manometry
Surgical treatment for Zenker
diverticulum
Conventional surgery: crycopharyngeal myotomy +
diverticulectomy or diverticulum suspension
Endoscopic approach (Mosher, 1917)
diathermic/laser dissection (Dohlman, Mattsson
1960)
Endoscopic stapling diverticulostomy (Collard,
1993)
• Light and short general anaesthesia
• Short operation time and hospital stay
• Low risk of perforation of diverticular pouch
• No injury of reccurent nerve
• Early resumption of oral feeding
• Complete relief of dysphagia
• No scar in neck
Advantages of endoscopic stapling
diverticulostomy
Endoscopic stapling
diverticulostomy
Operative technique
• General anaesthesia
• Surgical equipments:
– Rigid, fixable, double –lipped laryngoscope
(Weerda, Karl Stortz)
– Endostapler (Endopath ETS, Ethicon)
– 5 mm rigid telescope
Midesophageal Diverticulum
• Traction type (associated mediastinal
granulomatous disease)
• Pulsion type (with or without
motility disorders)
Midesophageal Diverticulum
Diagnostic tests
• Barium swallow, fluoroscopic
examination (a smoothly rounded
outpouching arising posteriorly in the
midline of the neck)
• Esophagoscopy
• Manometry
Barium swallow
Midesophageal Diverticulum
Treatment
• Diverticulectomy with or without
myotomy
• Thoracotomy/thoracoscopy
Surgical technique I.
Thoracoscopic diverticulectomy
• Lateral decubitus position
• Selective intubation
• CO2 insufflation was not required
• Endoluminal endoscopic controll
Surgical technique
II.
Port sites
Thoracoscopic diverticulectomy
Barium swallow after surgery
Epiphrenic Diverticulum
• Rare condition
• Pulsion type
• Commonly associated esophageal motor
abnormalities (achalasia, hypertensive
LES etc.)
Epiphrenic Diverticulum
Diagnostic tests
• Barium swallow
• Esophagoscopy
• Manometry
Epiphrenic Diverticulum
Treatment
• Diverticulectomy with myotomy• Myotomy alone
• Traditional technique (laparotomy, thorcotomy)
• Minimal invasive technique (laparoscopy/thoracoscopy)
Barium swallow before/after
surgery
Hiatal hernias
PARAESOPHAGEAL HIATAL
HERNIA
All or part of the stomach herniates
into the thorax immediately adjacent
and to the left of an undisplaced
gastroesophageal junction
Less than 10% of hernias of the
esophageal hiatus
PARAESOPHAGEAL HIATAL
HERNIA
SYMPTOMS AND SIGNS• Often asymptomatic• Gaseous eructations• Sense of pressure• Palpitation due to cardiac dysrhythmias
COMPLICATIONS• Ulceration – bleeding• Obstruction• Strangulation, incarceration
PARAESOPHAGEAL HIATAL
HERNIA
TREATMENT
SURGERY
SLIDING HIATAL HERNIA
GENERAL CONSIDERATION
• 90% of hernias at the esophageal hiatus
• The upper stomach, along with the cardioesophageal junction, is displaced upward into the posterior mediastinum
SLIDING HIATAL HERNIA - GERD
Confusing pathogenic relationship
• Most patients (>80%) with clinically significant reflux have a hiatal hernia
• The converse is not true – the majority of the patients with sliding hiatal hernia do not have esophagitis (GERD)
• The LES pressure is the deciding factor• Reflux is more likely to occur at given LES pressure
in patients with hernias• Reflux is unlikely in the presence of higher LES
pressure regardless of hernia status
SLIDING HIATAL HERNIA
SYMPTOMS AND SIGNS
Typical
• Heartburn
• Acid regurgitation
• Hypersalivation
• Odynophagia
• Unobstructive
dysphagia
Atypical
• Angina like chest pain
• Cough
• Nonallergic asthma
• Chronic bronchitis
• Pneumonia
• Hoarsness
SLIDING HIATAL HERNIA
DIAGNOSIS
• 24-hour pH monitoring• Manometry of LES• Endoscopy with biopsy• Barium esophagogram• Prolonged motility monitoring• Acid perfusion test (Bernstein test)• Radionuclide studies
SLIDING HIATAL HERNIA
COMPLICATIONS
• Esophagitis
GR. 1. Redness without erosions
GR. 2. Linear erosions
GR. 3. Erosions coalesce
GR. 4. Stricture, ulcer
• Stricture (10%)
• Barrett’s esophagus
SLIDING HIATAL HERNIATREATMENT
1. Lifestyle changes
• Modify diet if symptoms are related to diet
• Lose weight if overweight (is always
beneficial)
• Reduce smoking and alcohol intake (is
always beneficial)
• Avoid supine position after meals
• Avoid certain drugs if they related to
symptoms
SLIDING HIATAL HERNIA
TREATMENT
II. Pharmacologic management
• Antacids
• Sucralfate
• Prokinetic drugs
• H2 receptor antagonists
• Acid pump inhibitors
SLIDING HIATAL HERNIA
TREATMENT
SurgeryIndications• Persistant or recurrent symptoms despite
good medical therapy• Recurrent esophageal stricture• Esophagotracheal aspiration resulting
recurrent pneumonia, asthma or laryngitis
• Barrett esophagus, linear gastric erosions
SLIDING HIATAL HERNIA
TREATMENT
Surgery
Laparoscopic or open antireflux procedure
• Nissen fundoplication (wrapping part of the
fundus completely around the lower 4-6 cm of
the esophagus)
• Belsey-Mark IV fundoplication
• Collis procedure (acquiered short esophagus)
SLIDING HIATAL HERNIA
STRICTURES
• Endoscopic dilatations
• Esophagus resection with jejunum or
colon interposition
ACHALASIA
DEFINITION
• Achalasia „lack of relaxation”
• Achalasia is an esophageal motility disorder
characterized by abscence of esophageal
peristalsis and failure of the lower
esophageal sphincter (LES) to relax
completely on swallowing
ACHALASIA
GENERAL CONSIDERATIONS
• Neuromuscular disorders• Etiology• Abscence, atrophy or desintegration of the
ganglion cells Auerbach’s myenteric plexuses• Infectious cause – Chagas’ disease
(trypanosoma cruzi) • Incidence:
0.5 per 100 000no sex predilectionpeak years are 30-60
ACHALASIACLINICAL FINDINGS
• SymptomsDysphagiaRegurgitation, aspirationHeartburnWeight loss (variable)
• ComplicationsUlceration – haemorrhage (occult)Aspiration – pneumonitis, pulmonary abscessMalnutritionCarcinoma (5% of all cases)
ACHALASIA
DIAGNOSIS
• X-ray findings/barium esophagogram- narrowing at the cardia- dilated body of the esophagus
• Manometry- absent peristalsis of the distal segment of the esophagus- elevated LES pressure- incomplete sphincter relaxation
• Endoscopy
ACHALASIA
DIFFERENTIAL DIAGNOSIS
• Benign strictures
• Infiltrating intramural carcinoma
• Scleroderma
ACHALASIATREATMENT
• Drug therapynitrates, calcium channel blockers, nifedipine
• Pneumatic dilatationsuccessful in 75% of casescomplications (bleeding, perforation)
• Surgery(1) extramucous cardiomyotomy (Heller
operation)Laparoscopic – traditional technique(2) esophagus resection
INSTRUMENTAL PERFORATION
OF THE ESOPHAGUS
GENERAL CONSIDERATIONS
• Occur during diagnostic esophagoscopy,
gastroscopy, gastroesophageal balloon
tamponade, esophageal dilation
• Most common at natural site of narrowing (at
the level of cricoid cartilage, the left main stem
bronchus and the diaphragmatic hiatus)
INSTRUMENTAL PERFORATION
OF THE ESOPHAGUS
CLINICAL FINDINGS
• Pain in the neck or chest
• Dysphagia, change of voice into bass-like tone
• Crepitus in the neck owing to extravasation of air
• Subcutaneous emphysema (mainly in the cervical region)
• Cervical tenderness
• Fever, leukocytosis
• Shock (develops earlier in thoracic perforation)
INSTRUMENTAL PERFORATION
OF THE ESOPHAGUS
CLINICAL FINDINGS / X-RAY
FINDINGS
• Demonstrating the perforation
• Locating the exact site of the injury
INSTRUMENTAL PERFORATION
OF THE ESOPHAGUS
PERFORATION OF THE CERVICAL
ESOPHAGUS
• Air in the soft tissues (along the cervical
spine)
• Trachea may be displaced anteriorly by air
and fluid in the space behind the esophagus
• Widening of the superior mediastinum
INSTRUMENTAL PERFORATION
OF THE ESOPHAGUS
PERFORATION OF BODY OF THE
ESOPHAGUS
• Mediastinal widening
• Emphysema
• Pleural effusion with or without
pneumothorax
• Localization of the injury by fluoroscopic
studies with water-soluble opaque media
COMPLICATIONS OF
INSTRUMENTAL PERFORATION
OF THE ESOPHAGUS
• Fulminant mediastinitis,
bronchopneumonia, pericarditis,
severe sepsis, septic shock
• Abscess formation, empyema
TREATMENT OF INSTRUMENTAL
PERFORATION OF THE
ESOPHAGUS
• Immediate operation
• Closure of the perforation, external
drainage
• Total parenteral nutrition, nasogastric
decompression or gastrostomy
• Massive doses of antibiotics
TREATMENT OF INSTRUMENTAL
PERFORATION OF THE
ESOPHAGUS
LATE DIAGNOSIS
• Transhiatal esophagectomy, cervical
esophagectomy, gastrostomy,
mediastinal drainage
SPONTANEOUS (POSTEMETIC)
PERFORATION OF THE ESOPHAGUS
GENERAL CONSIDERATION I
• Described by Herman Boerhaave in 1724
• Usually in males
• History of alcoholic debauch, excessive
food intake or both
SPONTANEOUS (POSTEMETIC)
PERFORATION OF THE ESOPHAGUS
GENERAL CONSIDERATION II
• No preexisting esophageal disease
• Rupture involves all layers of the esophageal
wall
• Most common site of perforation
• The left posterolateral aspect 3-5 cm above the
gastroesophageal junction
SPONTANEOUS (POSTEMETIC)
PERFORATION OF THE ESOPHAGUS
SYMPTOMS AND SIGNS
• Violent vomiting or retching followed by agonizing pain in the epigastrium and lower anterior thorax
• Rigid abdomen• Crepitus in the neck• Hematemesis may occur• Fever, shock
SPONTANEOUS (POSTEMETIC)
PERFORATION OF THE ESOPHAGUS
X-RAY FINDINGS
• Mediastinal widening
• Emphysema
• Pleural effusion with or without
pneumothorax in the left chest
• Localization of the injury by
esophagogram
using water-soluble contrast media
SPONTANEOUS (POSTEMETIC)
PERFORATION OF THE ESOPHAGUS
SPECIAL STUDIES
• Thoracocentesis
Cloudy or purulent pleural fluid,
elevated amylase concentration,
low pH
SPONTANEOUS (POSTEMETIC)
PERFORATION OF THE ESOPHAGUS
DIFFERENTIAL DIAGNOSIS
• Myocardial infarction
• Pulmonary embolus
• Ruptured intraabdominal viscus
• Pancreatitis
SPONTANEOUS (POSTEMETIC)
PERFORATION OF THE ESOPHAGUS
TREATMENT
• Immediate operation• Closure of the perforation, external drainage• The repair reinforced with a flap of nearby
healthy tissue (pleura, pericardium, diaphragm)
• Total parenteral nutrition, nasogastric decompression or gastrostomy
• Massive doses of antibiotics
SPONTANEOUS (POSTEMETIC)
PERFORATION OF THE ESOPHAGUS
LATE DIAGNOSIS
• Transhiatal esophagectomy, cervical
esophagectomy, gastrostomy,
mediastinal drainage
Prognosis: overall death rate: 50%
FOREIGN BODIES IN THE
ESOPHAGUS
• Children, mentally disturbed patients
• History of recent ingestion of food or foreign material
FOREIGN BODIES IN THE
ESOPHAGUS
CLINICAL FINDINGS
• Pain in the midline of the thorax or neck
• Dysphagia (varying from mild distress to
complete obstruction)
• Occassionally, respiratory distress
Radiographic discovery of foreign matter
or of esophageal obstruction
Esophagoscopy
FOREIGN BODIES IN THE
ESOPHAGUS
DIAGNOSTIC INVESTIGATIONS
Radiographic discovery of foreign matter
or of esophageal obstruction
• Esophagoscopy
FOREIGN BODIES IN THE
ESOPHAGUS
COMPLICATIONS
• Esophageal inflammation
• Esophageal perforation
• Mediastinitis, hemorrhage
• Abscess formation
• Tracheoesophageal fistula
• Late strictures
FOREIGN BODIES IN THE
ESOPHAGUS
TREATMENT
• Esophagoscopy/extraction
• Surgery
CORROSIVE ESOPHAGITIS
• Ingestion of strong solutions of acid or
alkali or of solid substances
• Concentration, duration of exposition
CORROSIVE ESOPHAGITIS
CLINICAL FINDINGS
• Burns of the lips, mouth and tongue
pain and dysphagia
• Edema, inflammation of the submucosa,
thrombosis of the esophageal vessels,
infection, perforation, mediastinitis
• Respiratory distress, tracheobronchitis
CORROSIVE ESOPHAGITIS
TREATMENT
• Emergency treatment• Broad-spectrum antibiotics• Corticosteroids• Esophagoscopy and dilatations• Surgical treatment
esophago-gastrectomy (Thorek procedure)feeding gastrostomy, late reconstructiongastric resection
Benign tumours of the esophagus
I. Leiomyoma
II. Cyst /enterogenic, bronchogenic/
III. Polyp
0,5 – 1 %
Symptoms
Many lesions are discovered
incidentally
• Dysphagia
• Epigastric or substernal pain
• Odynophagia
• Dyspnoe
BENIGN TUMORS OF THE
ESOPHAGUS
COMPLICATIONS
• Hemorrhage
• Progressive dysphagia
• Laryngeal obstruction
BENIGN TUMORS OF THE
ESOPHAGUS
DIAGNOSIS
• Radiographic demonstration of intra- or
extraluminal mass, snooth in outline
ESOPHAGOSCOPY
• Intramural lesions should not be
biopsied, because (1) there is a risk of
haemorrhage and (2) an adhesion
develops
Diagnostic tests
• Barium swallow
• Esophagoscopy
• Endoscopic UH
• Chest CT
Diagnostic tests
• Barium swallow
• Esophagoscopy
• Endoscopic UH
• Chest CT
Diagnostic tests
• Barium swallow
• Oesophagoscopy
• Endoscopic UH
• Chest CT
Diagnostic tests
• Barium swallow
• Esophagoscopy
• Endoscopic UH
• Chest CT
Surgical treatment of benign
esophageal tumours
Traditional surgical
technique
Via thoracotomy
Minimal invasiv surgical
technique
Videothoracoscopy
EXCISION
Surgical technique I.
• Lateral decubitus position
• Selective intubation
• CO2 insufflation was not required
• Endoluminal endoscopic controll
Surgical technique
II.
Port sites
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