OESOPHAGUS

Surgical anatomy

The esophagus is a two-layered

mucosa-lined muscular tube that

journeys through the neck, chest, and

abdomen and rests unobtrusively in

the posterior mediastinum.

It commences at the base of the

pharynx at C6 and terminates in the

abdomen, where it joins the cardia of

the stomach at T11

anatomy

Anatomy

Arch of aorta makes an impression on oesophagus–radiograph & endoscopy

Symptoms of

oesophageal

disorders

Dysphagia. This term means a sensation ofobstruction

during the passage of liquid or solid through the

pharynx or oesophagus, i.e. within 15 seconds of food

leaving the mouth.

The characteristics of the

progression of dysphagia to solids can be helpful, e.g.

intermittent slow progression with a history of heartburn

suggests a benign peptic stricture;

Relentless progression over a few weeks suggests a malignant

stricture.

The slow onset of dysphagia for solids and

liquids at the same time suggests a motility disorder

Odynophagia is pain during the act

of swallowing and

is suggestive of oesophagitis.

Causes include reflux,

infection, chemical oesophagitis

Substernal discomfort, heartburn. This is a common

symptom of reflux of gastric contents into the oesophagus

usually a retrosternal burning pain thatcan spread to the neck, across the chest, and whensevere can be difficult to distinguish from the pain ofischaemic heart disease.

Chest pain-GERD;motility

disorders

Regurgitation is the effortless

reflux of oesophageal contents into

the mouth and pharynx.

it occurs frequently in patients with

gastro-oesophageal reflux disease or

organic stenosis.

reflux

Passive return of gastro duodenal

contents to mouth

Occurs in GERD

Symptoms-

1. loss of weight

2. Change of voice-irritation of vocal

cord

3. Cough or dyspnoe-tracheal

aspiration

Investigation of oesophageal

disorders Barium swallow and meal.

endoscopy

1. Oesophagoscopy.

2. Video endoscopy

Manometry

PH recording

Radiographic Evaluation

The first diagnostic test in patients

with suspected esophageal disease

should

be a barium swallow including a full

assessment of the stomach and

duodenum

radiography

Plain x-ray-foreign body

Barium swallow-motility

disorders,space occupying lesion

OESOPHAGEOGRAM

endoscopy

To view inside of oesophagus &

oesophagogastric jn

Types

1. Rigid oesophagoscope

2. Flexible video endoscope

BARRET

OESOPHAGUS

carcinoma

Oesophageal candidiasis

Oesophageal manometry

manometry is particularly necessary to

confirm the diagnosis of specific

primary

esophageal motility disorders (i.e.,

achalasia, diffuse esophageal spasm,

nutcracker esophagus, and

hypertensive LES).

24hr ph monitoring

Prolonged monitoring

of esophageal pH is performed by placing the pH probe or telemetry capsule

5 cm above the manometrically measured upper border of the distal sphincter

for 24 h.

It measures the actual time the esophagealmucosa is exposed to

gastric juice, measures the ability of the esophagus to clear refluxed acid, and

correlates esophageal acid exposure with the patient’s symptoms.

Congenital anomalies

Ectopic gastric mucosa can occur in

upper third of oesophagus

Atresia- lack of lumen formation- usually

asso-tracheo-oesophageal fistula

Fistula- aspiration & paroxysmal

suffocation from food are obvious hazards-

detected immediately after birth- aspiration

pneumonia-

O.stenosis-narrowing of lumen

Dysphagia lusoria due to vascular anomaly

Esophageal atresia and tracheooesophageal fistula

Commonest C

C.Blind upper segment,fistula between the lower segment & trachea

Clinical features-oesophageal

atresia Baby regurgitates all feeds

Saliva –continuosly from mouth

Coughing & cyanosis on feeding

As a part of;

Vertibral body segmentation

Anal atresia

Cvs-PDA

TE fistula

Renal agenesis

diagnosis

NG tube comes against an obstuction

with in 10 cm

Lateral CXR-lucent proximal pouch

that displace the trachea anteriorly

Corrective surgery – thoracotomy at

the level of 5th ics

Lower segment is divided at its

entrance in to trachea & fistula is

closed

treatment

complication

Pneumonia

Leakage from anastamosis

Foreign bodies-common

impacted material is

food

in children-coin,pin…

Foreign body

The flexible upper gastrointestinal

endoscope should be inserted under

direct visualization to avoid

inadvertently striking an object and

further impacting it or causing it to

penetrate the esophageal wall. Blunt

foreign bodies such as coins can be

securely grasped with a forceps or a

snare. A firm grasp on the foreign

body is required before withdrawal is

attempted.

COIN IN OESOPHAGUS

Button Batteries

A button battery lodged in the

esophagus is a true emergency and

immediate removal is indicated to

avoid the rapid corrosive action of

the alkaline substance on the

mucosa and subsequent

complications.

perforation Perforation of the esophagus is a surgical emergency.

Early detection and surgical repair within the first 24 hours results in 80% to 90% survival; after 24 hours, survival decreases to less than 50%.

Upon presentation, patients suspected of having a perforation based on initial history and physical exam are evaluated quickly so that surgical intervention may be initiated promptly.

Perforation from forceful vomiting (Boerhaave'ssyndrome), foreign body ingestion, or trauma accounts for 15%, 14%, and 10% of cases, respectively.

Most esophageal perforations occur after endoscopic instrumentation for a diagnostic or therapeutic procedure, including dilation, stent placement, and laser fulguration.

Other iatrogenic causes that have been noted include difficult endotracheal intubation, blind insertion of a mini-tracheostomy, and inadvertent injury during dissections in the neck, chest and abdomen.

1. Boerhaave's Syndrome-baro

trauma recurrent emesis disrupts the

normal vomiting reflex that enables

sphincter relaxation, resulting in an

increase in intrathoracic

esophageal pressure and

perforation. Postemetic rupture of

the esophagus, now known as

Boerhaave's syndrome, is only one

of many causes of esophageal

rupture.

C/F

Severe pain in chest following meal

Upper abdomen rigid

Mistaken as MI or perforated peptic

ulcer

2.Pathological perforation

Perforation of ulcers(barret ulcer or

tumours)

Causes erosion in to aorta or

ventricle-fatal

3 .Penetrating injury by knifes &

bullet-un common

4.During removal of foreign body

5.Instumental perforation

Diagnosis

Mediastinal emphysema, a strong

indicator of perforation

The diagnosis is confirmed with a

contrast esophagogram, which will

demonstrate extravasation in 90

percent of patients.

The use of a watersoluble

medium such as Gastrografin is

preferred

Treatment

The management of patients with esophagealperforation takes place in both the ICU and in the operating room.

Patients with an esophageal perforation can progress rapidly to hemodynamic instability and shock.

If perforation is suspected, appropriate resuscitation measures with the placement of large-bore peripheral IV catheters, a urinary catheter, and a secured airway are undertaken before the patient is sent for diagnostic testing.

IV fluids and broad-spectrum antibiotics are started immediately, and the patient is monitored in an ICU

Surgery is not indicated for every

patient with a perforation of the

esophagus, and management is

dependent on several variables:

stability of the patient, extent of

contamination, degree of

inflammation, underlying

esophageal disease, and location of

perforation

three criteria for the nonoperative

management

of esophageal perforation: (1) the

barium swallow must show the

perforation to be contained within the

mediastinum and drain well back into

the esophagus, (2) symptoms should

be mild, and (3) there should be

minimal

evidence of clinical sepsis.

Principles of non op mgmnt

Analgesia

Nil by mouth

Abx

IV fluids

Op management

Thoracotomy & repair of perforation

done with in few hours of perforation

Insertion of stents for treatment of

perforated cancer

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