dr. henk k-the esophagus

7/27/2019 Dr. Henk K-The Esophagus

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THE ESOPHAGUS

Dr. Henk Kartadinata, SpB, SpBD, FICSBagian Ilmu Bedah

Fakultas KedokteranUkrida


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Two major 20 th centurydevelopments

1. Introduction of techniques permittingoperations on the intrathoracic position of esophagus

2. Perfection and clinical application of sophisticated technique of measuringnormal and abnormal esophagialfunction


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Historical aspects

Before trans thoracic operation onlycervical esophagus could be treatedsurgically

Earliest operations were limited to cervicalesophagotomy for removal of foreign body

Billgoth and Czerny (latter part of 19 th

century) :Surgical ablation for malignant lesions of cervical esophagus


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1886 : Resection of pharyngo esophageldiverticulum

Early 1900 :-Transabdominal procedures for the relief of esophagial achalasia

-Staged reconstructive operations for corrosive strictures and amlignant lesions

Historical aspects


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Ohsawa (1933) : ones stage transpleuralesophagus resection andesophagogastrotomy for carsinoma

After world war II :Through the efforts of code cs andIngelfinger, the heretofore poorly

understood physiology of this importantorgan was carefully detailed and theinformation disseminated

Historical aspects


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Anatomy

Esophagus is a long muscular tube extendingdownward from pharynx above the level of C-VIto reach the stomach within the abdomen.

Begins at level of the cricopharyngeal muscles. The cricopharyngeal muscles runs transverselyacross the posterion wall of the esophagus,connecting the two lateral borders of cricoid

cartilago inferiorly benda to the circular andlongitudinal muscle fibers of the upper esophagus. It reaches the abdomen through theesophageal liatus.


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A noose of diaphragmatic muscle mostoften made up actively of the rightdiaphragmatic crus.

An esophageal segment of variable lengthlies within the abdomen where it join thestomach.

Anatomy


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The muscular wall

The muscular wall of the esophagus iscomposed of an inner circular layer and anouter longitudinal layer without a

surrounding serosal covering. Striated muscle fibers make a

considerable contribution to the outer longitudinal coat in the upper portion of theesophagus, where as smooth musclepredominates in the lower third


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A prominent sub mucosa contain :1. Mucous glands

2. Blood vessels3. Meissner plexus of nerves4. A rich network of lymphatic vessels


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Mucosa

The mucosal lining to characteristicallymade up of squamos


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Epithelium

The distal an 2 cm is lined by columnar epithelium


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Artery

The cervical esophagus :-Inferior thyroid arteries

The thoracic esophagus :-Branches of aorta-Esophageal branches of the Bronchialarteries-Supplemented by vessels descendingfrom the neck and ascending from arterieson the abdominal side of diaphragm


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Artery

The abdominal onaph :-A phreinca inferior

-A gastrica sinistra


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Vein

Subepithelial and submucous venous channelscourse longitudinally to empty above and belowinto hypopharyngeal and gastric veins.

The drainage from the cervical esophagusempty into inferior thyroid and vertebral veins

From the thocaic portion into the azygos andhemiazygos veins

From the abdominal portion mostly into the leftgastric veins.


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Lympatic vessels

Tend to run longitudinally in the wave of the esophagus before penetrating themuscle layers to reach regional mode-Tracheal-Tracheobronchial

-Posterior mediastinal-Diaphragmatic


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Nerve supply

From both the vagus and the symphateticchain

The recurrent nerves supply the upper portion of the esophagus which alsorecives branches from N IX, N X, cranialroot N XI and symphatetic nerves

Along most of the esophagus, the vagusnerves lie on either side, forming a plexusabout it.


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As the hiatus is approached the two major trunks emerge, the left one coming to lieanteriorly and the right one posteriorly

Nerve supply


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Physiology Function as channel through which ingested

material is conveyed from the pharyns to thestomach.

At either end of the tube are regulator mechanism, permitting one way passage only,except under unusual circumstances.

At the upper end of the esophagus is a 3 cmzone of increased pressure which relaxes

promptly with swallowing and constacts thereafter as a wave high pressure passes through it.This is the upper esophageal sphincter, which iscomposed of the cricopharyngeal muscles and afew cm of the upper cervical esophagus


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Physiology

Contraction of the sphincter are inperistaltic sequence with those of thepharynx above and the esophagus below.

The peristaltic pressure sweeps in anorderly fashion down the entire body of esophagus.

Pressure reach an intensity of 50-100 cmof water and are slightly more forceful inthe lower esophagus


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Resting pressures in the body of the esophagusare less than athmospheric pressure

There is a zone of increased pressure at the

lower end of the esophagus 3-5 cm. It is locatedin the region of the hiatus. In response to aswallowing effort relaxation of this zone can beidentified, followed by sphinteric contraction.This constitutes the inferior esophagealsphincter

Physiology


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The important factors which maintaingastro esophageal competence :- Diaphragm-The valve flap mechanism-The gastric sling fibers

-The oblique angle of entry-The mucosal rosette

Physiology


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It is likely that in most humans themusculature of the intrinsic sphincter incombination with prominent folds of gastric

mucosa at the esophago gastric junctioncontributes to the reflux barrier. The sphincter functions better when in its

normal position than when displaced andso the supporting structures must becredited with some ancillary function.

Physiology


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Innervation

Cervical esophagus :-Part by the recurrent nerves-Cricopharyngeal function is probably dependent

on the nerve derived from the pharyngealbranch of the vague through the pharyngealplexus.

Body of the esophagus :

-Under vagal controle, because division of thenerves produce low simultaneous pressure after diglutition


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Inferior esophageal sphincter -May continue to relax on swallowing evenafter lower thoracic vagotomy andsymphatetic denervation. So it mustpossess a high autonomy-There is a rise in sphincteric pressure inresponse to injection of gastrin

Innervation


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Disorders of the Upper Sphincter

Cause of abnormalities of pharyngoesophageal function:

1. Central nervous systems-Bulbar poliomyelitis-C V A

-Multiple sclerosis Abnormalities of sphincteric relaxationare said to characterize such lesions


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2. Diseases that directly affect muscular activity-Muscular dyshophy-Myasthenia gravis-Dermato myositis-Myopathy of thyrotoxicocisIn such patients, failure to developeffective pharyngeal peristalsis seems tobe the most common cause of

swallowing difficulties.



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3. After extensive operations on theoropharyngeal regionSpasm of the cricopharyngeal musclehas been considered contributory to theswallowing difficulties.Cricopharyngeal myotomy is advisablewhen extensive resections of this sortare performed



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Achalasia

Synonym : Cardiospasm Ethiology :

-Unknown-Characterized by absence of the inferior esophageal sphincter to relax in responseof swallowing

-First prescribed by Thomas Willis (1674)-There is a general agreement that is hasa neurogenic basis


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Pathology :-Disintegration or absence of ganglioncells of Auerbacks plexus in theesophagus, demonstrable at all levels of the thoracic esophagus although moreprominent in the body.

-It is not known whether they represent aprimary or secondary manifestation of thedisease

Achalasia


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Pathology :In Brazil and other South Americancountries where there leishmaniacal formsof Trypanozoma cruzi exist, Chagasdisease appears to have an esophagealcondition indistinguishable from achalasia

Incidence : An annual incidence rate of 0.6 per 100.000

Achalasia


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Sex :Equal frequency in both sexes

Age :Is may occurs at any age, but is seemmost often between 30-50 years

Achalasia


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Natural history :-The earliest and most constant symptomis obstruction to swallowing or dysphasia.

At first intermittent but becomes moreconstant as the disease progresses-The patient experience more difficulty

with cold than with warm food-Solid foods are said to pass more easilyat first than liquids

Achalasia


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Natural history :-Pain is relatively infrequent, more likely tooccurs in the early stage of the diseaseand becomes less noticeable as theesophagus dilates

Achalasia


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Regurgitation :-Particularly noticeable at night when thepatient is declining-10% pulmonary complications in the formof aspiration pneumonitis.-An increased susceptibility to trhedevelopment of Ca of the esophagus.

Achalasia


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Rontgenologis signs :-The esophagus is dilated-The lower portion of the lumen appearsconical and narrowed for a short distancewith a beak like extension directed intonarrowed segment

Esophagoscopy-Is essential to distinguish early achalasiafrom Ca or from benign esophagealstricture

Achalasia


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Esophageal motility studies:-Slight elevation of pressures-Lack of peristalsis in the body of esophagus after diglutation-Swallowing effort is accompanied byfeeble elevation in pressyre that are

stimultaneous throughout the body of theesophagus-The inferior esophageal sphincter fails torelax in response to swallowing efforts

Achalasia


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Treatment :-Cannot be restored to normal andeffective therapy must be directed to relief

the distal esophageal obstruction-Forceful dilatation of the esophago gastric

junction

Hydrostatic Pneumatic MechanicalComplication : Perforation

Achalasia


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Treatment :-Surgical therapy : esophagomyotomy

This stems historically from the doublecardio-myotomy first carried out by Heller (1913), Incidence of reflux esophagitis isminimal.

Achalasia


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Differential DiagnosisSymtoms of sign Achalasia Diffuse

spasmVigorousAchalasia

Pain Uncommon Almost always FrequentObstruction Always Sometimes Nearly

alwaysRegurgitation Common Rare FrequentRetention Frequent Never FrequentNervousness Uncommon Almost always Occasionaly

Radiologic Findings-Diffuse dilatation-Segmentalspasm

Common Never OccasionalyUncommon Frequent Common


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Diverticula

Classification :1. Location :

-Pharyngoesophageal-Midthoracic-Epiphrenic or subdiagprahmatic

2. Mode of development-Underlying esophagus mobilitydisturbance-Traction, pulse


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Classification :3. Status

-True : include all layers of theesophageal wall

-False : Consist of esophageal mucosaand submucosa

Diverticula


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Pharyngo esophageal diverticulum

Pharyngo esophageal diverticulum :-Most common diverticulum of theesophagus

-Arises between the oblique fibers of theinferior consicter muscle of the pahrynxand the transverse fibers of thecricopharyngeal muscle-Usually occurs in elderly patients


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-Clearly represent in acquired abnormality,although a congenital weakness or deficiency in the supporting musculare of the area has been postulated as a

possible cause-Motility study :an incoordination in the swallowing

mechanism, pharyngeal contraction,occurs after closure of the cricopharyngealmuscle. This may well prove to be thecause of the pharyngeal pouch



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-Incidens of coexisting hiatal hernia hasbeen high and the reslutinggastroesophageal reflux has beenassociated with high pressure in the uppr sphincter



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Symptoms:-Dysphagia-Regurgitation

-Noisy deglutition-Pulmonary manifestation teomastiratedregurgitation

The diverticulum enlarge, if untreated, totalesophageal obstruction occurs

Diagnosis :Is made rontgenograpically



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Treatment :-Single stage resection

*The sac is dissected up to its neck, dividedand removed*The pharyngeal mucosa is closed withinterenpted suture, this knods within theesophageal lumen* The edge of the muscle layers areapproximated* Recurrence is rare

-Cricopharyngeal myotomy, particularly for thesmall pharyngeal pouch



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Mid thoracic diverticula

Seldom develop Rarely produce symptomsSymptoms usually caused by granulomatousinfections of the mediastrinal lymph nodes,

particularly the sub carinal and parabronchialregion Rarely give rise to significant complication

The most serious is a tracheo bronchialesophageal fistula. Excision and closure of the communication with inter position of normal tissue are usually succesful inpreventing recurrence


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Epiphrenic diverticulum

Less common than the upper pharyngealpouches

Less likely to produces symptoms

Pathologic anatomy :Very similar to that of upper pharyngeal pouches

Frequently associated with underlying motility

disturbances, usually achalasia or diffuse spasm Ro : charateristic


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Operation is indicated when symptoms areprogressive and severe :Resection of the diverticulum accompanised

by a long extra mucosal esophagomyotomy*Recurrent is rare*Result are usually excellent

Epiphrenic diverticulum


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Hiatus Hernia

In its downward course through the thorax. The esophagus traverres the

diaphragmathrong a defect.

Pressure within the thorax is less thanatmospheric whereas intraabdominalpressure is above atmospheric. This isone of the important factors that tend topromote passage of a portion of thestomach upward through the hiatus : anesophageal hiatal hernia


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Types:1. Para esophageal hiatus hernia2. Sliding hiatus hernia

Anatomy The wall of esophageal hiatus is formed in the

entirely of the skeleted muscle composing thediaphragm

Hiatus Hernia


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Anatomy : There is a separation in the anterior posterior

plane of muscle fibers composing the right crus of the diaphragm. Thuis seperation forms a slinganterior to the esophagus. But, there is a lessdefinite reunion of the muscle fibers posteriorly,leaving a V shaped, tapered defect

The hiatus is normally just large enough tocomfortably permit passage of the esophagus:more or less 2.5 cm in diameter.

The esophagus passes through the crural turnedobliquely : Directly anterior to the aorta just above the

hiatus To the left of the aorta just below the hiatus

Hiatus Hernia


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Anatomy :- Both diaphragmatic crura arise from the lateralaspects of L I L IV- The esophagus hiatus contracts :

*with inspiration*stimulation of the phrenic nerve

- With inspiration the diaphragm and hiatus descend,

increasing the angulation of the esophagus at thehaitus-The acute angle between the left border of theabdomen esophagus and the medial border of thegastric fundus is known as the angle of His

Hiatus Hernia

Hiatus Hernia


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Anatomy :- The lower esophagus and esophagus-gastric

junction are held loosely in the esophageal hiatusby a tethering device known as the phrenic-esophageal ligament or membrane- Arise circumferentially around the hiatal margin- A fibro elastic membrane- Is a continuation of the transversal fascia in the abdomen

and the endothoracic fascia in the thorax

- Insert circumferentially around the diaphragmatic esophagusclose to the squamocolumnar junction, the upper leaf 3cm above the squamocolumnar junction, the lower leaf 1.5 cm below the squamocolumnar junction

This insertion becomes continuous with the fibroelastictissue of the intermuscular fascia of the esophagus

Hiatus Hernia


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Physiology of The Esophagogastric JunctionPhysiologic studies have demonstrated this sphincter

mechanism even more convincingly (Code cs andIngelfinger cs)

Careful study of the pressure indicated :- A High pressure zone 3.5 cm at the level of the diaphragm-The diaphragm is located by the pressure inversion point (PIP)

: below the diaphragm inspiration cause a rise in pressure,above the diaphragm inspiration cause a fakk

-In the junctional zone the intraluminal pressure in theesophagus is almost higher than that either stomach or esophagus above. This is true in all stages of the respiratorycycle and in any position of the body.

-Deglutition initiated a peristaltic wave. As the peristaltic wavepassed downward the pressure in the high pressure zone fellsharply

Hiatus Hernia


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Paraesophageal Hiatus Hernia 5% of hiatal hernia Esophagogastric junction remains below the

diaphragm Competence of the lower esophagealsphincter is preserve

Hernial defect with sharply defined, firm

borders Develops to the left of the esophagus The defect varies widely in the site and mey

be as large as 10-12 cm in diameter.

Hiatus Hernia


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Paraesophageal Hiatus Hernia Has a well defined hernial sac compose of

thickened and fibrosis diaphragmatic peritoneum.

The greater curvature of the stomach rolls upwardas the defect and the hernial sac become largerolling hernias

Almost the entire stomach may rotated upward intothe hernial sac to that only the pylorus and antrumremain below the diaphragm and are closer together

50% has a thoracic scoliosis

Hiatus Hernia


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Paraesophageal Hiatus HerniaClinical manifestation :

Pain : epigastric and retrosternal

Ingestion of a meal will provide a bolus thatenters the thoracic stomach and distends it. Thepain is closely associated with eating that thepatient restrict intake

Severe weight lossRespiratory distressPeptic ulcer in the thoracic stomach and usuallyis not influenced by antiacid medication

Hiatus Hernia


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Paraesophageal Hiatus HerniaClinical manifestation

Acute and occult bleeding of the upper GIT

ObstructionIncarcerationPressure necrosis

PerforationStrangulationVolvulus (organo-axial)

Hiatus Hernia


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Paraesophageal Hiatus HerniaDiagnosis :

Radiologic examination:*The thoracic stomach retains enough gas to show a

radioluscent pocket within the usual cardiac silhouette . Twoor three air fluid levels, 1 below and 1 or 2 about thediaphragm

*Barium study to ascertain the location of the esophagogastric junction and to determine the presence and level of the

obstructionEsophagoscopy Usually only in the negative :*Subdiaphragmatic location of the esophagogastric

junction

*Absence of the esophagus

Hiatus Hernia


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Paraesophageal Hiatus HerniaDiagnosis :

Gastric secretory analysisDuodenal ulcer diathesis is seldompresentMeasuremen of pH

No gastroesophageal refluxManometryNormal esophagogastric sphincter

Hiatus Hernia

Hi t s Herni


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Paraesophageal Hiatus HerniaPathogenesis :

The etiology is completely unknownIt appears to be an acquired lesion since it is rare before latemiddle life and is most frequently seen in the elderly

Therapy :Exclusively surgicalThe optimal approach is through the abdomen :*Repositioning of the hernial content*Repair of the defect by approximately the crux of thediaphragm in front or behind the esophagus *Reconstruction (suture) the angle of His*Fixation of the fundus to the diaphragm*Fixation of the antrum wall to the posterior right rectum sheathThe result are extremely good and recurrent quite rare

Hiatus Hernia


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Sliding Hiatus HerniaPathologic anatomy-It is essence a failure of the normal tethering device, the

phrenoesophageal ligament to retain the esophagogastric junction within the esophageal hiatus

-Unfavorable pressure relationship permit the cardiac portion of the stomech to herniate upward in concentric fashion throughthe esophageal hiatus

-The phrenoesophageal ligament becomes lengthened andthinned out; whether it is primary or secondary is unclear.-The esophageal hiatus becomes dilated to a variable degree-The esophagogastric junction slides back and forth readily,

depending in body posture, abdominal distention, gastric filling,etc


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Sliding Hiatus HerniaPathologic anatomy-When the hernia is reduced it may be difficult for the

radiologist to visualize it.

-The diaphragmatic peritoneum reduces readily alongwith the cardia-Well develop hernial sac is present only in large hernias-Inflammation and scarring secondary to severe and

longstanding reflux esophagitis may remove thesliding feature of concentric hiatus hernias

-Fixation and contraction of scar tissue may produceacquired shortening of the esophagus and fixation of esophagogastric junction well above the diaphragm


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Sliding Hiatus HerniaClinical manifestation

A sliding hiatus hernia in and of itself is

totally asymptomaticIt is only when a lesion is associated withgastroesophageal reflux and refluxesophagitis that symptoms supervene

The classic symptoms of esophagitis areeasily recognized but unfortunately areso common

dr. henk k-the esophagus

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