Saint-Petersburg State Pediatric Medical Academy

Department of Faculty Surgery

named after Prof. A.A. Rusanov

(Head of the Dep-t - Prof. N.Y. Kokhanenko)

BENIGN ESOPHAGEAL DISEASES

Lecturer - Assistant Professor
Yuri N. Shiryaev
 1. Diverticula.
2. Esophageal achalasia.
3. Hiatal hernias.
4. Esophagitis and
esophageal ulcers.
5. Injuries and foreign bodies.
6. Benign stenoses.
Esophageal diverticulum - is a blind
pouch of the esophagus, connected
with the esophageal lumen.
It is diagnosed in radiologic
examination in 2% of human
subjects.
 Classification
А. Congenital and acquired.
Б. True and false.
В. In the way of creation: 1. Pulsion type; 2. Traction
type; 3. Mixed type.
Г. in localization: 1. Pharyngoesophageal
(Zenker’s type).
2. Properly esophageal:
- epibronchial;
- epiphrenal;
- subphrenal (abdominal).
Д. In the presence of complications:
1. Non-complicated (without and with complaints);
2. Complicated (diverticulitis, esophagitis, perforation,
bleeding, neck phlegmone, mediastinitis)
Clinical manifestations in Zenker’s
diverticula: unpleasant smell from the
mouth, feeling of compression and pain,
dysphagia, belching.
Objective symptoms - asymmetry of the neck, Cooper’s
sign (splash sounds and gurling in the neck)
Clinical manifestations:
Epibronchial (more than 2 см):
retrosternal pain, dysphagia,
eructation, low-grade fever.
Epiphrenal (asymptomatic 50%):
retrosternal or epigastric pain,
dysphagia, eructation, nausea.
Objective symptom - gurling sounds at
the auscultation.
 Instrumental diagnostics:

esophagoscopy

radiologic contrast examination (the principal

method of instrumental diagnostics)
 Treatment:

1. Conservative (in the mild

symptoms and small diverticula);
2. Surgical – inversion of the
diverticula (in the small pouch),
excision (diverticulectomy).
Esophageal achalasia (cardiospasm,
megaesophagus) is an esophageal
motility disorder characterized by
absence of esophageal peristalsis and
failure of the lower esophageal
sphincter (LES) to relax completely on
swallowing. It lead to the difficulty of
passage of food from esophagus to
stomach
 Etiology and pathogenesis
1. Congenital theory.
2. Defect of innervation.
3. Chronic mediastinitis (of tuberculosis
etiology).
4. Central neural system disorders.
5. Viral infections.
Psychoemotional trauma.
 Classification
I stage – functional, temporary spasm without
esophageal dilatation;
II – stable mild esophageal dilatation
(not more than 3 см) with enhanced motility;
III – fibrous changes with narrowing of the
esophagogastric junction and markedly
dilated esophagus (not more than 5 см);
IV – severe esophagogastric stenosis, tortously
dilated («sigmoid-like») esophagus
Complaints: dysphagia, pain,
regurgitation, weight loss,
pulmonary complications due to
aspiration.

Diagnostics: esophagogastroscopy,
esophageal manometry, radiologic
contrast assessment.
 Treatment:
1. Conservative: diet, sedative
drugs, calcium blockers.
2. Pneumatic balloon dilatation.
3. Botulinum toxin injections into the
LES
4. Surgery: esophagocardiomyotomy
(Heller’s procedure), esophagectomy.
 Hiatal hernias - condition
characterized by prolapsus of
abdominal viscera (stomach,
omentum, large bowel etc.)
through the hiatus into thoracic
cavity
«Lock function» of the physiologic cardia is
provided by:
1. Diaphragmatic crura;
2. Angle of His;
3. Mucosal valve of Goubarev.
 Classification

1. Axial hernia:
А. Esophageal, cardial, cardiofundal, subtotal gastric,
total gastric;
B. Sliding (non-fixed) and fixed
C. With the esophageal shortening and without it.
2. Paraesophageal hernia:
fundal, antral, gastrointestinal, colonic, omental.
 Clinical symptoms
1.retrosternal or epigastric pain;
pain
2. heartburn;
3. regurgitation;
4. dysphagia;
5. anemia (due to chronic bleeding from gastric
erosions).
Complications
PEH – incarceration, gastritis, ulcer, hemorrage;
SH – Barrett’s esophagus, ulcer in hernia part of
the stomach, peptic ulcer and peptic stricture
of the esophagus.

Diagnostics: endoscopy, contrast radiologic.

 Treatment
PEH – surgery only!
SH – 1. Conservative (diet, antacids,
H2-blockers, proton pump inhibitors
etc.)
2. Surgery – crurorhaphy,
gastropexy, different types of
fundoplication (Dor, Toupet, Nissen)
 Esophageal trauma:
1. wounds;
2. iatrogenous injuries;
3. spontaneus rupture (Boerhaave’s
syndrome);
4. burns – chemical, thermal,
radiation.
 Chemical burns: pathologic
changes
I stage – superficial epithelial necrosis,
erosions.
II stage – all-thickness necroses of the
mucosa.
III stage – transmural necroses with the
involvement of paraesophageal fatty
tissue and mediastinal (and sometimes
abdominal) organs.
 Chemical burns: pathologic
changes

1.Acute corrosive esophagitis (1-2 months);

2.Chronic esophagitis (2-4 months):
3.Stricture formation (3-4 weeks to 2-3 years)
4.Late complications (luminal obliteration,
suprastenotic perforation, cancer).
 Esophageal strictures:
-membranous
-ring-like (2-3 см)
-tubular (5-10 см);

-caustic (60%),
-peptic (30%),
-post-operation (10%),
-sclerodermia (very rarely).
 Esophageal strictures

Clinical manifestations:
obstructive syndrome
(dysphagia, esophageal vomiting, salivation,
weight loss, cachexia.
Subsequent pulmonary complications due to aspiration
(pneumonia, lung abscesses))

Diagnostics: endoscopy, radiologic assessment.

 Treatment: bouginage, esophagectomy .

Methods of bouginage:
1. blind (by mouth);
2. ortograde with endoscopic control;
3. retrograde through the gastrostomy with the
guided thread;
4. ortograde by the guided string.

Endoscopic dissection of the stricture with the

subsequent bouginage
Balloon dilatation (in the short strictures).
 Контрольные вопросы:
 1. Переходными называются : а) ценкеровские
дивертикулыа; б) эпифренальные дивертикулы; в) тракционные
дивертикулы; г) бифуркационные дивертикулы.
 2. Ахалазия кардии IV степени - это: а) расширение пищевода
более 7 см; б) расширение пищевода более 6 см; в) расширение
пищевода более 5 см; г) расширение пищевода более 4 см.
 3. Замыкательную функцию физиологической кардии
обеспечивают: а) острый угол Гиса; б) клапан Губарева; в)
ножки диафрагмы; г) все перечисленное верно;
 4. Абсолютным показанием к оперативному лечению является :
а) скользящая грыжа ПОД; б) параэзофагеальная грыжа; в)
кардиальная грыжа; г) фундальная грыжа.
 5. При химическом ожоге пищевода бужирование следует
начинать: а) с 1-3 суток; б) с 3-5 суток; в) с 7-15 суток; г) через
месяц.