Ministry of Science and High Education of Russian Federation

Federal State Autonomous Educational Institution of High Education

"V.I. Vernadsky Crimean Federal University"
Institute "S.I. Georgievsky Medical Academy"
Department of Topographical Anatomy and Operative Surgery

STUDENT NAME : DHONTHIREDDY RAJA JOSEPH REDDY

LA4-CO-218(2)

NAME OF THE ABSTRACT- 7. The

contribution of the Russian and Crimean
surgeons to the development of surgical
treatment of diseases of the esophagus.
CONTENTS:-

o Esophagus
o Esophageal Disorders
o What are the risk factors for esophageal disorders?
o What are the symptoms of esophageal disorders?
o Esophagectomy
o How are esophageal disorders treated?
o How can I reduce my risk of getting an esophageal disorder?
o What are the complications of esophageal disorders?
o A note from Cleveland Clinic
o History of surgery of the esophagus
o The Russian military surgeon Nikolai Korotkov
o When is surgical treatment indicated in patients with
gastroesophageal reflux disease?
o What are the current options for surgical treatment of
gastroesophageal reflux disease?
o Are there any data on the long-term efficacy of these
procedures?
o How do these surgeries compare in terms of adverse effects?
o How does a physician determine which procedure to perform in
a patient with gastroesophageal reflux disease?
o Are repeat procedures or supplemental therapies usually needed
with surgical treatment for gastroesophageal reflux disease?
o Have there been any head-to-head studies comparing any of the
surgical treatments with nonsurgical treatments for
gastroesophageal reflux disease?
o How difficult are these procedures to perform? Are there
significant learning curves?
o Is antireflux surgery being performed as frequently as it was in
the past?
 o What are the next steps in research in this area?

Esophagus
The esophagus, historically also spelled oesophagus, is a tubular, elongated organ of the digestive
system which connects the pharynx to the stomach. The esophagus is the organ that food travels
through to reach the stomach for further digestion. It follows a path that travels behind the trachea
and heart, in front of the spinal column, and through the diaphragm before entering the stomach.The
esophagus is subdivided into three anatomical segments: cervical, thoracic, and abdominal. The
cervical segment begins at the cricopharyngeus and terminates at the suprasternal notch. This
segment lies just behind the trachea, to which it is joined via loose connective tissues. Posteriorly,
prevertebral fascia connects the esophagus to the bodies of sixth through eighth cervical vertebra.
The thoracic duct can be found on the left side of the sixth cervical vertebra. The carotid sheath and
the lower poles of the lateral thyroid gland can be found lateral to the esophagus in the lower part of
the neck. The thoracic segment lies between the vertebral column and the trachea in the superior
mediastinum, extending from the suprasternal notch to the diaphragm. As the esophagus is followed
distally, it passes behind the aortic arch at the level of the T4 through T5 intervertebral discs and
enters the posterior mediastinum. The final segment, the abdominal segment, runs from the
diaphragm to the fundus of the stomach. This segment descends and passes through the right crus of
the diaphragm at the level of the tenth thoracic vertebra and into the cardia of the stomach at the
eleventh thoracic vertebra level.

The organ is typically about nine to ten inches (23 to 25 cm) long in fully grown adults, with
sphincters located at each of its proximal and distal extremities, a mucosa-lined lumen and
connective tissue, and smooth muscle outer composition. The sphincter located anteriorly, the upper
esophageal sphincter, allows for the single direction passage of food into the esophagus, and
anteriorly, the lower esophageal sphincter allows for the single direction passage of food into the
stomach.

Structure and Function

The primary function of the esophagus is to transport food entering the mouth through the throat
and into the stomach. This function begins at the very beginning of the esophagus, following some
taste buds located on the organ, at the upper esophageal sphincter (UES). The UES, also termed the
pharyngoesophageal sphincter, is a circular bundle of muscle tissue which normally remains closed
in a contracted position. During swallowing, the muscles relax temporarily and allow the passage of
materials or bolus in the form of food, drink, mucus, and saliva into the esophagus.

Next, the bolus travels into the esophageal body. Peristaltic movement propels the bolus down the
esophagus via primary and secondary peristalsis.
The first irreversible step in swallowing, the pharyngeal stage, occurs next and is categorized by a
rapid phase of muscle contraction to propel the bolus through the upper esophageal sphincter and
into the esophagus. This stage starts when the consumed bolus makes its way to the palatoglossal
arch.

During the pharyngeal stage of swallowing, the muscular walls of the pharynx contract providing a
strong initial peristaltic motion of the bolus and sending the bolus through the UES with kinetic
energy. This peristaltic wave continues into the esophagus and constitutes the primary peristalsis. If
the primary peristalsis is not sufficient to carry the bolus to the stomach, realized by the body as
continued distention of the esophagus following primary peristalsis, secondary peristalsis initiates
and continues until the bolus is successfully moved to the stomach.

Thus,the tongue seals the oropharynx. The soft palate and proximal pharyngeal wall seal off the
nasopharynx. The vocal cords and arytenoids close off the laryngeal opening and the epiglottis
swings down to cover the laryngeal vestibule. These actions seal the airway from the pharyngeal
cavity
The lower esophageal sphincter (LES), also termed the cardiac sphincter
and cardioesophageal sphincter, is located slightly more than an inch (about 3 cm) proximally from
where the esophagus meets the stomach. Similar to the UES, the LES is normally contracted and
closed, primarily preventing stomach contents from entering the esophagus body.

The LES is controlled involuntarily and is triggered to open during esophageal peristalsis, thereby
allowing the propelled bolus to enter the stomach and completing the primary function of the
esophagus.

While the primary function of the esophagus is to allow for the passage of material from the mouth
and throat to the stomach, it is also a means by which material may be expelled from the body from
the stomach and out the mouth in cases of vomiting, eructation, and at times when the gag reflex is
initiated. However, this function is typically not desirable as food being expelled via this route may
result in malnutrition and possible damage to the esophagus from gastric acid.

The esophagus functions to transport masticated and swallowed material (a bolus) through
the mediastinum from the pharynx to the stomach. In both species, the esophagus has upper and
lower esophageal sphincters at the proximal and distal ends, which prevent retrograde movement of
food by contracting and closing the lumen of the esophagus. During swallowing, these sphincters
relax to allow forward passage of food. Mice, unlike humans, cannot vomit.

In mice, the esophagus is a straight tube that lies dorsal to the larynx in the cervical region, traverses
the thorax to the left of the trachea, and passes through the esophageal hiatus in the diaphragm
slightly left of midline. The esophagus enters the midpoint of the mouse stomach at the lesser
curvature near the limiting ridge (margo plicates), the region where the
nonglandular forestomach meets the glandular mucosa, elevated by thickened forestomach lamina
propria. In humans, the esophagus begins at the cricoid cartilage, traverses the thoracic cavity in the
posterior mediastinum, and penetrates through the diaphragm for several centimeters before
entering the stomach. At the gastroesophageal junction (GEJ), the nonkeratinizing esophageal
squamous mucosa abruptly transitions to compact glandular secretory gastric mucosa. This
transition is seen macroscopically as a sharply demarcated line of contrast called the Z-line.

Embryology
During the fourth week of human development, the embryo elongates and the yolk sac is divided
into intra-embryonic and extraembryonic regions. The origin of the digestive tube occurs in the
intra-embryonic region, with the regression and disappearance of the extraembryonic portion
occurring around week 12, at which time the digestive system divides into the foregut, midgut, and
hindgut. The continued development of the foregut gives rise to the esophagus.

Blood Supply and Lymphatics

Lymph channels and lymph nodes together provide the esophagus with lymphatic drainage. The
channels begin endothelial or as blind sacculations which are also endothelial. They then collect
into larger lymph channels running the length of the esophagus (orthogonally to the transverse
plane). Flow direction is dictated by paired semilunar valves in these channels. These channels then
combine in different areas to enter into respective regional lymph nodes. Drainage occurs in three
sections of the esophagus, broken into thirds, with significant interconnections existing between
each segment.
Drainage into the thoracic duct from the deep cervical lymph nodes is achieved by the drainage of
the proximal third segment of the esophagus. Drainage into the superior and posterior mediastinal
node is achieved by the lymphatics of the third middle section of the esophagus. Finally, the
lymphatics of the distal third-most section of the esophagus ultimately drain into the gastric and
celiac lymph nodes.

Nerves

The innervation of the esophagus involves the sympathetic and parasympathetic nervous systems,
with primary innervation being sourced from the vagus nerve and spinal nerves (from segments T1
to T10) via the thoracic and cervical sympathetic trunk. The vagus nerve is primarily responsible for
the parasympathetic motor functions of the esophageal muscles and glands.

The thoracic and cervical chain nerves primarily constitute the sympathetic innervation and serve to
assist in the constriction of blood vessels, contractions of the UES and LES, muscle wall relaxation,
along with gland and peristaltic activity increases. Both nerves allow for sensation, with the vagus
nerve detecting pressure which can translate to pain and the sympathetic trunk more directly sensing
pain.

Muscles

The upper third of the esophagus is composed of striated (voluntary) muscle. The middle third is a
mixture of striated and smooth (involuntary) muscle, and the lower third consists only of smooth
muscle. The esophagus has two sphincters, circular muscles that act like drawstrings in closing
channels.
Approximately the proximal third of the esophagus is primarily composed of skeletal muscle while
the distal two-thirds are smooth muscle. The muscle fibers of the esophagus are bi-directional, with
the external layer running longitudinally and the internal layer comprising of circular fibers. The
internal muscle layer allows for the peristaltic contractions that move boluses down the esophagus
and is thicker than the external layer.The thickening and overlapping of the internal muscles at the
point of the esophagus below the diaphragm before the stomach comprise the form and function of
the LES. Proximally, the cricopharyngeus, thyropharyngeus, and craniocervical muscles comprise
the form and function of the UES with the opposing orientations of their respective muscle fibers.
Physiologic Variants

There are not many natural physiological variations amongst esophagus. Variations which are most
common are related to size and length. However, there does exist a variety of congenital
abnormalities of the esophagus including the following:

A) Esophageal atresia (EA) and tracheoesophageal fistula (TEF) - rare conditions that
develop before birth. They often occur together and affect the development of the
esophagus, trachea or both. These conditions can be life-threatening and must be treated
shortly after birth.

B) Esophageal stenosis- a clinical condition defined as a fixed narrowing of the esophagus.

This condition can be congenital or acquired. Congenital esophageal stenosis (CES) is
manifested as an intrinsic narrowing of the esophagus present at birth.
C) Esophageal duplication and duplication cyst- rare inherited lesions usually diagnosed in
early childhood. Most of them are found in the mediastinum and manifest themselves as
separate masses along or in continuity with the native esophagus. Their prevalence remains
unknown and they are treated either surgically or endoscopically.

D) Esophageal rings and webs - thin structures that partially occlude the esophageal lumen.
Patients with esophageal rings or webs are usually asymptomatic. Symptomatic patients
typically present with intermittent dysphagia to solids.

Esophageal ring
 Esophageal web

Surgical Considerations

Certain conditions of the esophagus may warrant surgery. Amongst these issues are esophageal
cancer, achalasia, tearing, and esophageal varices. Where applicable and possible, laparoscopic
surgery is recommended to allow for a minimally invasive approach to the esophagus and faster
patient recovery.

Clinical Significance

Understanding the esophagus and treating diseases related to the esophagus is of great clinical
significance. Most issues of the esophagus, when detected early, can be treated to prevent further
damage and even death of the patient. The esophagus is a primary delivery route of food to the
stomach, and issues related to this route may affect the nutrition of a patient by not allowing him or
her to receive these vital nutrients via this route.
Heartburn and gastroesophageal reflux disease are very common issues of the esophagus which can
affect patients and is highly independent of many factors such as sex, race, and age to name a few.
How do you treat heartburn in the esophagus?
The options include:
1. Antacids, which help neutralize stomach acid. Antacids may provide quick relief. ...
2. H2 blockers, which can reduce stomach acid. H2 blockers don't act as quickly as antacids,
but they may provide longer relief. ...
3. Proton pump inhibitors, which also can reduce stomach acid.
Understanding the function and role the LES has on this issue is of great clinical significance for
this reason. These simple, yet common, issues may lead to further esophageal issues such as
esophagitis, esophageal cancer, esophageal ulcers, achalasia, and tears of the esophagus.
Esophageal Disorders

Esophageal disorders affect your esophagus, the tube that carries food from your mouth to your
stomach.

The most common type is GERD. Disorders like GERD, achalasia and Barrett’s esophagus cause
heartburn or swallowing problems and increase your risk for esophageal cancer. Medications, along
with dietary and lifestyle changes, can help.
What are esophageal disorders?

Esophageal disorders are a collection of conditions that affect how the esophagus works. Your
esophagus — or the food pipe — is the part of the digestive system that helps food travel from your
mouth to your stomach.

Different diseases can affect the esophagus, causing dysphagia or difficulty swallowing. The most
common esophageal disorder is gastrointestinal reflux disease (GERD). GERD is the condition in
which excessive stomach acid moves back into the esophagus (acid reflux), causing inflammation.

What are the types of esophageal disorders?

Types of esophageal disorders include:

A) GERD: The most common esophageal disorder occurs when the lower esophageal sphincter
doesn’t close properly. As a result, stomach acid and contents flow backward into
esophagus.
B) Achalasia: The lower esophageal sphincter doesn’t open or relax, preventing food from
going into the stomach. Experts believe achalasia may be an autoimmune disease, but the
exact cause is unknown. Something damages the nerves that control the muscles in the
esophagus.

C) Barrett’s esophagus: For people with chronic, untreated acid reflux, the lining of the
bottom part of their esophagus starts looking like stomach lining, and the cells start to
resemble intestinal cells. These changes take place where the esophagus and stomach meet.
This condition is associated with a higher risk of esophageal cancer.
D) Eosinophilic esophagitis: White blood cells called eosinophils become overabundant in the
esophagus. The result is inflammation or swelling of the esophageal lining (esophagitis).
This condition is more common in patients with multiple allergies.

E) Esophageal cancer: There are two types of esophageal cancer: squamous cell carcinoma,
and adenocarcinoma. Generally speaking, smoking, radiation and HPV infection increases
the risk of esophageal squamous cell carcinoma, while smoking and acid reflux increase
risks of adenocarcinoma.

F) Esophageal diverticulum: An outpouching occurs in a weak spot in the esophagus. People

with achalasia are more prone to developing diverticula.
G) Esophageal spasms: Abnormal muscle spasms (contractions) occur in the esophagus. This
rare, painful condition keeps food from reaching the stomach.

H) Esophageal strictures: The esophagus becomes too narrow. Foods and liquids pass through
slowly to the stomach.

I) Hiatal hernias: The upper part of the stomach protrudes above an opening in the
diaphragm, and sits in the chest. This condition leads to more acid reflux.
SYMPTOMS AND CAUSES
What are the risk factors for esophageal disorders?

Factors that increase the chances of developing an esophageal disorder include:

Alcohol use.

Extra weight due to obesity or pregnancy.

Medications, including certain antibiotics, antidepressants and pain relievers.

Radiation therapy to your neck or chest.

Smoking, including exposure to secondhand smoke.

What are the symptoms of esophageal disorders?

Symptoms vary depending on the type of esophageal disorder. You may experience:

Abdominal pain, chest pain or back pain.

Chronic cough or sore throat.

Difficulty swallowing or feeling like food is stuck in your throat.

Heartburn (burning feeling in your chest).

Hoarseness or wheezing.

Indigestion (burning feeling in your stomach).

Regurgitation (stomach acid or contents coming back up your esophagus to your mouth)
or vomiting.

Unexplained weight loss.

DIAGNOSIS AND TESTS

How are esophageal disorders diagnosed?

The healthcare provider will evaluate your symptoms and perform a physical exam. They may feel
your neck while you swallow.

Diagnostic tests for esophageal disorders include:

Upper endoscopy examines the upper part of the digestive tract using a long, thin scope. Your
provider may also take tissue samples to biopsy and look for signs of inflammation, cancer and
other diseases.

Gastrointestinal X-rays (barium swallow) use imaging to see how a liquid barium solution flows
through the esophagus and digestive tract.
Esophageal manometry measures how well the muscles in your esophagus and lower esophageal
sphincter work as you swallow a liquid.

Esophageal pH test measures the amount of stomach acid (pH levels) in your esophagus.

Esophagectomy

An esophagectomy is the surgical removal of the esophagus. The esophagus is a hollow tube that
moves food and liquid from the throat to the stomach. The esophagus was is composed of several
layers of tissue, including mucous membrane, muscle, and connective tissue.

An esophagectomy is performed to treat the following conditions:

Advanced cases of Barrett's esophagus, a pre-cancerous condition. Since most patients with
Barrett's do not develop esophageal cancer and the operation carries significant risk of
complication, esophagectomy is only considered for cases of high-grade dysplasia, a late stage of
the condition.

Esophageal cancer that has not spread (metastasized) to other organs in good surgical candidates,
healthy enough for the surgery, which is complex and lengthy.

In patients with high-grade dysplasia, the goal of the surgery is remove all of the abnormal Barrett's
lining to eliminate the risk of developing esophageal adenocarcinoma and to find and remove
unsuspected cancer that may be present in the Barrett's tissue .

In patients with esophageal cancer without metastatic disease, and good performance status, surgery
is performed with the intention to cure and to permit patients to swallow.
Esophagectomy at High Volume Centers-

Large well-designed studies have shown that patient outcomes in esophagectomy are highly
dependent on the number of such procedures performed at the institution where the surgeon
operates. Esophagectomy is a technically difficult surgery and the surgeon should regularly perform
the procedure in a medical center with experience in the care of these patients.At high volume
medical centers, the mortality rate from esophagectomy is approximately 3-8%. By contrast, the
surgical mortality at low volume hospitals is 16-23%. Therefore, patients undergoing
esophagectomy should do so only in the hands of an experience esophageal surgeon who regularly
performs these procedures in a center of excellence.

UCSF serves as major regional referral center for the multidisciplinary treatment of Barrett's
and esophageal cancer. Thoracic and general surgeons work in tandem to perform
esophagectomies in high volume with very low peri-operative mortality, each handling one aspect
of the surgery, part of a multidisciplinary team of gastroenterologists, medical oncologists and
radiation oncologists experienced in the management of patients with esophageal disease.

Surgical Techniques

The two most commonly performed surgeries for are the transhiatal esophagectomy (THE) and
the transthoracic esophagectomy (TTE), also known as the Ivor-Lewis Procedure. In both
procedures, the patient's diseased esophagus and proximal (top part) stomach is removed. A
segment of the stomach is then pulled up into the chest and connected to the remaining normal
esophagus, forming a new esophagus.

These surgeries have similar cure and complication rates, each with its own advantages and
disadvantages. The type of surgery performed depends on the following factors

 Age and health of the patient

 Size and location of the tumor
 Whether the tumor has invaded other structures in the chest, such as the lungs or
large blood vessels
 Minimally Invasive Esophagectomy

UCSF is one of a select group of specialty centers performing minimally invasive esophagectomies.
This procedure uses tiny incisions and a small scope, through which miniature surgical instruments
are passed, connected to a video camera. The camera sends a magnified image from inside the body
to a monitor, giving the surgeon a close-up view of the anatomy.
The advantages of minimally invasive esophagectomy include:

 Less post-operative pain

 Faster recovery from surgery
 Shorter hospital stay
 A more rapid return to work and normal activities

MANAGEMENT AND TREATMENT

How are esophageal disorders treated?

Treatments vary depending on the condition. They may include:

Antacids, proton pump inhibitors and histamine receptor (H2) blockers to reduce stomach
acid.

Endoscopic dilation to open a narrowed esophagus or relax a sphincter muscle.

Botulinum toxin (Botox®) injections to temporarily stop esophageal spasms or relax the sphincter
muscle.

Esophagectomy surgery to remove part or all of a diseased esophagus.

Laparoscopic antireflux surgery (Nissen fundoplication) to treat GERD or a hiatal hernia by

reinforcing the lower esophageal sphincter.

Heller myotomy and peroral endoscopic myotomy (POEM) treat achalasia and esophageal
spasms.

PREVENTION

How can I reduce my risk of getting an esophageal disorder?

GERD, or acid reflux, can lead to other, more serious esophageal disorders. You can take these
steps to prevent or reduce GERD and esophageal problems:

Avoid eating late at night and allow at least three hours between eating and lying down.
Cut back on spicy, fatty, tomato-based or citrus foods, as well as caffeinated and carbonated drinks.

Eat smaller meals throughout the day, take your time when eating and stop eating a few hours
before sleep.

Limit alcohol consumption and seek help to quit smoking or stop using tobacco products.

Raise the head of your bed or elevate your head on a pillow when sleeping.

Stay physically active and maintain a healthy weight.

OUTLOOK / PROGNOSIS
What are the complications of esophageal disorders?

Without proper treatment, certain esophageal disorders like GERD and achalasia can increase your
risk of esophageal cancer.

Regurgitation may cause food to go into your trachea (windpipe) and lungs. This problem (called
aspiration) can lead to pneumonia and lung infections. Swallowing problems also make you more
prone to malnutrition and dehydration.

What is the outlook for people with esophageal disorders?

Many people with esophageal disorders get symptom relief with over-the-counter or prescription
medications. Certain conditions, like esophageal cancer or achalasia, may require surgery.
Treatments combined with dietary and lifestyle changes can keep symptoms in check.

You may want to ask your healthcare provider:

 What type of esophageal disorder do I have?

 What caused this esophageal disorder?
 What is the best treatment for this type of esophageal disorder?
 What are the treatment risks and side effects?
 Am I at risk for other esophageal disorders?
 What dietary or lifestyle changes can I make to protect my health?
 Should I look out for complications?
A note from Cleveland Clinic

Esophageal Conditions & Treatments

 Achalasia.
 Asthma associated with GERD.
 Barrett's esophagus.
 Diffuse esophageal spasm.
 Dysphagia.
 Esophageal atresia.
 Esophageal cancer.
 Esophageal diverticula.

Esophageal disorders can be uncomfortable or painful. The most common type, GERD, causes
heartburn. If not treated, GERD and some other esophageal disorders can put you at risk for
esophageal cancer. Medications often improve symptoms and keep these diseases in check. More
serious esophageal disorders like cancer and achalasia may require surgery. Your healthcare
provider can recommend dietary and lifestyle changes to reduce your risk of discomfort and serious
complications.
History of surgery of the esophagus-

The progress of esophageal surgery from the beginning of medical history through five historical
eras, up to the second half of the 20th century, is reviewed. Progress was slow from the first
surgical repair of the esophagus in ancient Egypt in 2500 B.C. until the end of the 19th century,
when scientific discoveries made possible the solid beginnings of abdominal surgery.Thoracic
surgery followed in the 20th century, with rapid strides in World War II. These wartime advances
stimulated an interest in esophageal surgery in the postwar era, when operative techniques became
well standardized and surgery of the esophagus was placed on a par with that of other parts of the
gastrointestinal tract.

Because of the limitations of time and space, much important material has had to be left out. Yet it
is hoped that this brief historical overview will put in perspective the important advances of the
second half of this century, which will be presented by our distinguished speakers. It has been a
privilege for me to have had a part in the development of this type of surgery and to share these
ideas with you.
The Russian military surgeons-

A)Nikolai Korotkov-

He is known worldwide, mainly among internists and cardiovascular specialists, as the discoverer
of the auscultatory method of measuring arterial blood pressure in 1905. He is one of the first
military vascular surgeons to carefully investigate, analyze, and register cases of vascular injury
during his voluntarily trips to the Russian Far East in 1900 to 1901 and the Russo-Japanese War of
1904 to 1905. Examining 44 patients with extremity arterial and arterial-venous pseudoaneurysms
following war-related injury, he routinely performed a measure termed the "arterial pressure index"
using "Korotkov sounds."

This pioneering approach to assessing extremity perfusion was the precursor to the modern-day
ankle-brachial and injured extremity indices, and it initiated the quantitative assessment of the
compensatory ability of the vascular system to restore circulation following axial artery ligation.
Because of high thrombosis rates following direct vessel repair during his day, he proposed use of
pharmacologic substances such as digitalis and amyl nitrite to improve extremity perfusion.

As evidence of his innovative nature, Korotkov even proposed the use of "oxygenated nutrient
solutions" in the future to improve extremity circulation. More than 100 years after his work, as
continuous wave Doppler ultrasound, contrast angiography, and computed tomography are
ubiquitous as diagnostic tools, the practice of surgery would be well served to recall Korotkov's
foundational work and the rule of thumb for any physician: examine the patient.
B) Nikolay Ivanovich Pirogov-

Nikolay Ivanovich Pirogov, one of the greatest Russian surgeons of the 19th Century, was
convinced of the importance of deploying nurses to care for the casualties of war. With the support
of Grand Duchess Elena Pavlovna, sister-in-law of Tsar Nikolas I, Pirogov realised the idea during
the Crimean war when Russia became the first country to send female nurses to the battle front.
Later in the 19th century, large numbers of Russian women trained as nurses under the auspices of
the Russian Red Cross, founded in 1867. In peacetime, their expertise was extremely valuable.

In the mid-18th century in Russia, a limited role developed for women in the general care of
patients in civilian hospitals. In the Pavlov Hospital in Moscow and the Mariinsky Hospital in Saint
Petersburg, wives of sick soldiers and soldier’s widows worked as ward orderlies but were also
allowed to admit patients, examine sick women and administer simple treatments.
Under the influence of Nikolay Ivanovich Pirogov and the Grand Duchess Elena Pavlovna, several
women’s Communities were formed whose members cared for the poor and sick. During the
Crimean War, Russia became the first country to send well-trained female nurses to the battle front.
After the Crimean and later the Russo-Turkish Wars (1877–1878), large numbers of women
throughout Russia trained as nurses under the auspices of the Russian Red Cross and the number of
women involved in medical care increased substantially.
Case presentation:
During the period from October to December 2019, a successful surgical treatment of 2 patients (1
male and 1 female) with enterogenous and duplication cysts of esophagus was performed at the
Clinic of Faculty Surgery at Sechenov University. In both cases thoracic tumors were incidental
findings during routine health investigation.

Clinical discussion:

Clinical manifestations of ECs are caused by compression or displacement of the adjacent

anatomical structures, therefore, most often patients complain of dysphagia, vomiting, pain in the
chest, which may be constant or occur during an act of breathing.
There are also observations of neurological symptoms due to compression of the radicular nerves
The method of choice in the treatment of ECs is their surgical removal.

FIG. Endoscopic photo. Esophagus cyst. The malformation almost completely covers the lumen of
the esophagus, passable for the endoscope.

Fig. Intraoperative photo. Esophageal cyst (indicated by arrows

Fig. CT scan. Esophageal cyst (indicated by arrow)

 Fig. Intraoperative photo. Esophagus cyst (taken by clamp)

Defects of Development of the Digestive Organs- In the esophagus atresia is observed, which is
usually accompanied with the formation of trachea-esophageal fistula. The following defects may
develop:
a) two segments, which blindly come to an end;
b) one segment, that comes to an end blindly, and the second,which opens into the trachea;
c) two segments, which open into the trachea;
d) anastomosis between the trachea and esophagus. These defects are accompanied by aspiration
pneumonia. In the stomach stenosis of the pylorus (pylorostenosis) is observed more often. In the
intestines stenosis and atresia, single or multiple, form. More often they locate in the duodenum and
at the place of transition from the ileum into the cecum, as well as at the distal areas of the rectum.
Full or partial doubling of the intestines both the small and large, and doubling of the appendix are
occasionally observed.
Dolichosigma is a congenital prolongation of the intestine without its expansion. The sigmoid
colon, as a rule, forms 2–3 additional folds and more. Megasigmoid is a frequent defect
(Hirschsprung’s disease). This expansion and hypertrophy of a part of the colon, generally the
sigmoid, is connected to its peristalsis infringement. Treatment is surgical, consists in removal of
the aganglionic zones and pathological changed expanded sites located above the site. Two defects
of development of the intestines are connected with the preservation of the embryonic structures. It
is hernia of the umbilical cord and fistula at the navel area. With partial preservation of passage,
Meckel’s diverticulum forms. It is similar to a glove’s finger and exits from the ilea at a distance of
25 cm and more from the Bauhin’s valve. Congenital defects of development of the biliary tracts
consist of an unusual position of the gallbladder and its size, occurrence of cysts of the common
biliary tract and atresia or stenosis of one of the biliary tracts. The latter is connected with
intrauterine hepatitis there-fore biliary cirrhosis of the liver takes place. Anorectal anomalies are
observed in 0.25–0.66% of the cases, twice as often in girls than in boys. The following anorectal
anomalies are distinguished:
1. Ectopia of the anus (perineal and vestibular).
2. Congenital fistulae in the sexual and urinary systems or in the perineum in the case of normally
developed anus.
3. Congenital narrowing of the anus, rectum, anus and rectum at the same time; occurs more often
in boys.
4. Atresia:
a) simple;
b) with fistulae in the sexual or urinary system;
c) casuistics (congenital cloaca, atresia and doubling of the rectum).

C) Christian Albert Theodor Billroth (1829–1894)-

He is a pupil of Bernhard Rudolph van Langenbeck (1810–1887), professor of surgery in Vienna

and one of the most outstanding surgeons in history, diagnosed a 36-year-old religion teacher with
laryngeal carcinoma located under the vocal cords, on one side of the thyroid cartilage. The
condition was confirmed by Carl S. Stoerck (1832–1896) – one of the founders of world
rhinolaryngology. At the end of November 1873, Billroth, having introduced a cannula with a
sealing inflatable Trendelenburg balloon into the trachea, performed a tracheotomy under general
chloroform anaesthesia. A week after the tracheotomy Billroth performed a laryngofissure. After
the tumour was removed, the surface from which it originated was scraped out with a sharp curette.
Because of the recurrence of the disease process Billroth had to intervene further. Initially, he
intended to perform a laryngofissure again and “vigorously scrape out the tumour”. However,
because of the considerable expansion of the tumour he changed his decision. Having obtained the
patient's consent, on the 31st of December of the same year (1873) he performed a total
laryngectomy – the first in the history of medicine. He did not remove the neck lymph nodes and
reduced the resulting throat loss with three sutures [5]. After the operation, accompanied by
considerable bleeding, the patient was fed through a stomach tube. Two months after the operation,
the patient, equipped with an artificial larynx designed by Gussenbauer, was presented at a meeting
of the Viennese Medical Society and on the 3rd of March he left the clinic. Carl Gussenbauer (1842–
1903), a pupil of Billroth, when performing a laryngoscopy on the patient indicated a suspicion of
the beginning of a recurrence. A few months later as a result of cancer relapse the patient passed
away

When is surgical treatment indicated in patients with gastroesophageal reflux disease?

Antireflux surgery is indicated when a patient has moderate-to-severe gastroesophageal reflux

disease that can be objectively documented (usually via a positive 48-hour pH study). In addition,
the patient usually has persistent symptoms of heartburn and regurgitation despite undergoing
proton pump inhibitor therapy.

What are the current options for surgical treatment of gastroesophageal reflux disease?

Gastroesophageal reflux disease (GERD) occurs when stomach acid repeatedly flows back into
the tube connecting your mouth and stomach (esophagus). This backwash (acid reflux) can
irritate the lining of your esophagus. Many people experience acid reflux from time to time
Nissen fundoplication is the most well-established and efficacious surgical treatment for
gastroesophageal reflux disease. This operation involves repairing the hiatal hernia, which is often
associated with gastroesophageal reflux disease, followed by fashioning the fundus of the stomach
around the lower esophagus to form an external buttress. Although the operation has been used in
clinical practice since the 1950s, Nissen fundoplication is currently almost always performed using
minimally invasive surgery. This treatment has a very well-documented short- and long-term track
record of between 80% and 90% relief of gastroesophageal reflux disease symptoms in dozens of
well-done prospective studies.

Another surgical option for gastroesophageal reflux disease is the recently developed esophageal
sphincter device (Linx Reflux Management System, Torax Medical, Inc). This device is essentially
an artificial sphincter consisting of a ring of 12 to 14 magnets (approximately the size of the
average ankle or wrist bracelet). The attraction of these magnets restores competency to the
gastroesophageal junction by making it less compliant.

When a patient is eating, the food forces the magnets apart; once eating is finished, the magnets
reattract, restoring competency to the gastroesopha-geal junction. This device has a reasonably
well-documented short-term efficacy of approximately 75% to 80% and is an acceptable alternative
to Nissen fundoplication in patients with mild-to-moderate gastroesophageal reflux disease.

Transoral incisionless fundoplication (EsophyX, EndoGastric Solutions, Inc), which has been
around for approximately 5 or 6 years, is an endoscopic intraluminal procedure that is performed in
the operating room but does not require entry into the abdominal cavity. However, this procedure
has demonstrated mixed success and is not widely practiced in the clinical setting.Finally, there is a
promising surgical antireflux procedure in development, lower esophageal sphincter stimulation
therapy (EndoStim), which involves an implantable neuro-stimulator similar to a pacemaker.
However, most of the research on this procedure comes from animal studies; there is not yet much
research on the use of this therapy in humans.
Are there any data on the long-term efficacy of these procedures?

Three- to 5-year data are available for the esophageal sphincter device. The Linx pivotal trial
showed relief of heartburn and regurgitation in over 85% of patients, normalization of pH studies at
1 year in 58% of patients, and satisfaction with the outcome at 3-year follow-up in 94% of patients.
Nissen fundoplication is the only surgical antireflux procedure that has 10- and 20-year data. Relief
of gastro-esophageal reflux disease symptoms is long-lasting in 75% to 80% of patients, depending
on the indication.

How do these surgeries compare in terms of adverse effects?

The Nissen operation is arguably the most complex. It has a low mortality rate, a complication rate
of 3% to 7%, and an adverse effect rate of 10% to 15% (most commonly involving difficulty
swallowing and flatulence). The esophageal sphincter device also has a low mortality rate in
addition to a complication rate of less than 5% and, at least to date, an adverse effect rate that is
lower than that of Nissen fundoplication. Transoral incisionless fundoplication and lower
esophageal sphincter stimulation therapy appear to have morbidity rates similar to the one
associated with the esophageal sphincter device.
How does a physician determine which procedure to perform in a patient with
gastroesophageal reflux disease?

Right now, by and large, the decision comes down to Nissen fundoplication or the esophageal
sphincter device, with occasional use of transoral incisionless fundoplica-tion and hardly any use
yet of lower esophageal sphincter stimulation therapy.

The first branch point is the severity of the patient’s gastroesophageal reflux disease, as represented
by the size of the hiatal hernia and the degree of endoscopic esophageal damage, esophagitis, or
Barrett esophagus. Nissen fundoplication can treat gastroesopha-geal reflux disease of all degrees of
severity, whereas the esophageal sphincter device and transoral incisionless fundoplication are
generally used only in patients with mild-to-moderate gastroesophageal reflux disease.

Are repeat procedures or supplemental therapies usually needed with surgical treatment for
gastroesophageal reflux disease?
These operations are redone between 3% and 5% of the time; however, as many as 30% to 35% of
patients end up back on gastroesophageal reflux disease medications, a number that is higher than
would be indicated by any objective measure of recurrent reflux.

Have there been any head-to-head studies comparing any of the surgical treatments with
nonsurgical treatments for gastroesophageal reflux disease?

There have been at least 5 prospective randomized trials of Nissen fundoplication vs medical
therapy for gastroesophageal reflux disease, all of which have shown superiority of the surgical
treatment. There have been no comparative studies of the other surgical therapies.

How difficult are these procedures to perform? Are there significant learning curves?
Yes, there are significant learning curves for all of these procedures. I would say that the procedures
are of moderate difficulty for a well-trained general surgeon.

Is antireflux surgery being performed as frequently as it was in the past?

It is performed more frequently than it was in the 1970s and 1980s but less frequently than it was in
the 1990s. Although patients are generally receptive of anti-reflux surgery in the right
circumstances nowadays, there is often a mistaken or misplaced reticence in the gastroen-terology
community to use antireflux surgery; it is often thought that Nissen fundoplication is a poorer
operation than it really is, particularly in good hands, both in terms of complication rates and long-
term adverse effects. There is also a general misconception about the longevity of these procedures;
they are generally more long-lasting than is recognized.

What are the next steps in research in this area?

We need to refine the outcomes of Nissen fundo-plication and of the esophageal sphincter device,
which means improving patient selection as well as improving the widespread technical capabilities
of these procedures. A technological evolution is needed in terms of the instrumentation and
longevity of transoral incisionless fundo-plication. Finally, lower esophageal sphincter stimulation
therapy needs further research so that it can be brought into clinical practice.

REFERENCES:-
1. https://www.macmillan.org.uk/cancer-information-and-support/oesophageal-
cancer/the-
oesophagus#:~:text=The%20oesophagus%20is%20a%20muscular,behind%20th
e%20windpipe%20(trachea)
2. https://teachmeanatomy.info/abdomen/gi-tract/oesophagus/
3. https://my.clevelandclinic.org/locations
4. https://www.googleadservices.com/pagead/aclk?sa=L&ai=DChcSEwii6_LutuL6
AhVTRpEFHRFyATwYABAAGgJscg&ohost=www.google.com&cid=CAESb
OD2lZQVV0fsg3X6yVX-BEFSxpf2rEo8IXQa7zHddw7gcdrbSym-HkevZu4-
PoiOQbxiS8UULPprMIZ5-rYO6W5ZtbZdKofD9j0MFG1h-
yorMhCAEcab1Al2s1rnDRDSEagU8L9aLysCsnvvqA&sig=AOD64_0sEtyy9Z
mlHpUtj6gJcRwp4x8jpA&q&adurl&ved=2ahUKEwiu-
ezutuL6AhWUAxAIHSjTA1YQ0Qx6BAgHEAE
5. https://www.nature.com/articles/s41598-021-86503-9
6. https://thoracickey.com/embryology-of-the-esophagus/
7. https://aboutgerd.org/treatment/surgery/surgical-treatments/
8. https://www.nature.com/articles/s41536-021-00200-9
9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7317451/
10. https://aboutgerd.org/treatment/surgery/surgical-treatments/
11. https://sgsmn.com/condition/esophageal-disease/
12. Netter’s Atlas for Human Anatomy