ESOPHAGUS

(PART-1)

By: Natnael Temesgen

PGY-2
WOLIATTA SODDO,SNNP, ETHIOPIA
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SURGICAL ANATOMY

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VASCULAR ANATOMY

Blood supply
• Inferior thyroid artery
• bronchial arteries
• esophageal branches from aorta
• left gastric artery
• Inferior phrenic arteries

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VASCULAR ANATOMY

Venous drainage
• submucosal venous plexus - periesophageal venous plexus -
esophageal veins
• inferior thyroid vein
• bronchial, azygos, or hemiazygos veins
• coronary vein

The submucosal venous networks of the esophagus and stomach are

in continuity with each other

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NERVOUS SUPPLY

• parasympathetic innervation - vagus nerves

• Muscles of the pharynx - pharyngeal plexus

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LYMPHATICS
• There are more lymph vessels than blood capillaries in the
submucosa

• Submucosal plexus runs in a longitudinal direction

• Upper two-thirds of the esophagus, the lymphatic flow is

mostly cephalad, and, in the lower third, caudad

• Cervical esophagus has more direct segmental lymph

drainage into the regional nodes

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PHYSIOLOGY
Swallowing Mechanism
• The act of alimentation requires the passage of food and drink from the mouth into
the stomach

• 1/3 - mouth and hypopharynx, and 2/3 – esophagus

• Tongue and pharynx function as a piston pump with three valves

• soft palate
• Epiglottis
• cricopharyngeus

• Body of the esophagus and cardia function as a worm-drive pump with a single
valve - LES
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CONTINUED…
• Swallowing can be started at will, or it can be reflexively elicited by the
stimulation of areas in the mouth and pharynx

• Afferent sensory nerves of the pharynx are the glossopharyngeal nerves and the
superior laryngeal branches of the vagus nerves

• Efferent discharging impulses through cranial nerves V, VII, X, XI, and XII, as
well as the motor neurons of C1 to C3

• Striated muscles of the cricopharyngeus and the upper one-third of the esophagus
are activated by efferent motor fibers distributed through the vagus nerve and its
recurrent laryngeal branches
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CONTINUED…

• Continuity of the esophageal muscle is not necessary for sequential activation if

the nerves are intact

• Afferent impulses from receptors within the esophageal wall are not essential for
progress of the coordinated wave

• Despite the powerful occlusive pressure, the propulsive force of the esophagus is
relatively feeble

• LES provides a pressure barrier between the esophagus and stomach and acts as
the valve

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• The antireflux mechanism in human beings is composed of three components:

• mechanically effective LES

• efficient esophageal clearance

• adequately functioning gastric reservoir

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PHYSIOLOGIC REFLUX
• Healthy individuals have occasional episodes of gastroesophageal reflux

• More common when awake and in the upright position than during sleep in the
supine position

• Normal subjects rapidly clear the acid gastric juice from the esophagus regardless
of their position

• Gastrin and motilin have been shown to increase LES pressure; and
cholecystokinin, estrogen, glucagon, progesterone, somatostatin, and secretin
decrease LES pressure.

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 ASSESSMENT OF ESOPHAGEAL FUNCTION

Tests to Detect Structural Abnormalities

• Endoscopic Evaluation
• Radiographic Evaluation

Tests to Detect Functional Abnormalities

• Stationary Manometry
• High-Resolution Manometry
• Esophageal Transit Scintigraphy
• Video- and Cineradiography
NORMAL MANOMETRY
DEFECTIVE LES
ESOPHAGEAL BODY PERSTALISIS
IMPENDENCE
HIATAL HERNIA
IMPENDENCE
CHICAGO CLASSIFICATION
 ASSESSMENT OF ESOPHAGEAL FUNCTION

Tests to Detect Increased Exposure to Gastric

Juice
• 24-Hour Ambulatory pH Monitoring

Tests of Duodenogastric Function

• Gastric emptying study
• 24-Hour Gastric pH Monitoring
• Cholescintigraphy
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GASTROESOPHAGEAL REFLUX DISEASE(GERD)

• Accounts for a majority of esophageal pathology in surgery

• One of the most challenging diagnostic and therapeutic problems in clinical

medicine.

• Symptoms thought to be indicative of GERD, such as heartburn or acid

regurgitation, are very common in the general population and are not specific for
gastroesophageal reflux.

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TERMINOLOGIES
Heartburn
• Is generally defined as a substernal burning type discomfort, beginning in the
epigastrium and radiating upward

• Often aggravated by meals, spicy or fatty foods, chocolate, alcohol, and coffee

• Can be worse in the supine position

• Commonly relieved by antacid or antisecretory medications

• Occurs monthly in as many as 40% to 50% of the Western population

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CONTINUED…
Regurgitation
• Is the effortless return of acid or bitter gastric contents into the chest, pharynx, or mouth

• Highly suggestive of foregut pathology

• Severe at night when supine or when bending over

• Can be secondary to either an incompetent or obstructed GEJ

• In case of obstructed GEJ, as in achalasia, the regurgitant is often bland

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CONTINUED…
Dysphagia – is difficulty swallowing
• Non specific term but most specific symptom of foregut disease

• Sensation of difficulty in the passage of food from the mouth to the stomach and can be
divided into oropharyngeal and esophageal etiologies

• Oropharyngeal dysphagia - difficulty transferring food out of the mouth into the esophagus,
nasal regurgitation, and/or aspiration

• Esophageal dysphagia refers to the sensation of food sticking in the lower chest or
epigastrium +/- odynophagia

• Can be a sign of underlying malignancy and should be aggressively investigated

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CONT
Chest pain
• Although commonly and appropriately attributed to cardiac disease, is frequently
secondary to esophageal pathology

• Exercise-induced gastroesophageal reflux is well known to occur, and may result in

exertional chest pain similar to angina.

• It can be quite difficult to distinguish between the two etiologies, particularly on clinical
grounds alone

N.B. - “Majority of people presenting to the emergency room with chest pain do not have
an underlying cardiac etiology for their symptoms”

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PATHOPHYSIOLOGY OF GASTROESOPHAGEAL
REFLUX DISEASE
• There is a high-pressure zone located at the
esophagogastric junction in humans

• Most episodes of gastroesophageal reflux

• Loss of the high-pressure zone
• Decrease in the resistance it imparts to the retrograde flow
of gastric juice into the esophageal body

• The primary cause of GERD is secondary to the

permanent attenuation of the collar sling musculature
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THE LOWER ESOPHAGEAL SPHINCTER

• There are three characteristics of the LES that work in unison to maintain its barrier
function

• resting LES pressure

• its overall length

• intra-abdominal length that is exposed to the positive pressure environment of the abdomen

• Resistance to gastroesophageal reflux is a function of both the resting LES pressure and
length over which this pressure is exerted

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CONTINUED…
• Permanently defective sphincter is defined by one or more of the following
characteristics

• LES with a mean resting pressure of less than 6 mmHg

• overall sphincter length of <2 cm

• intra-abdominal sphincter length of <1 cm

• The most common cause of a defective sphincter is an inadequate abdominal
length
• Once the sphincter is permanently defective, this condition is irreversible
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COMPLICATIONS ASSOCIATED WITH GERD

• Complications of GERD may result due to direct injurious effects of gastric fluid on the mucosa,
larynx, or respiratory epithelium

• Complications due to repetitive reflux are esophagitis, stricture, and BE; repetitive aspiration may
lead to progressive pulmonary fibrosis

• The severity of the complications is directly related to the prevalence of a structurally defective
sphincter

• Potential injurious components that reflux into the esophagus include gastric acid and pepsin, and
biliary and pancreatic secretions

• Combination of acid and pepsin is highly deleterious

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CONTINUED…
• Complications of gastroesophageal reflux such as esophagitis, stricture, and
Barrett’s metaplasia occur in the presence of two predisposing factors

• Mechanically defective LES

• Increased esophageal exposure to fluid containing duodenal content which includes

bile and pancreatic juice

• 58% of patients with GERD have increased esophageal exposure to duodenal

juice, and that this exposure occurs most commonly when the esophageal pH is
between 4 and 7

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CONTINUED…
• Antireflux operative procedures re-establish the barrier between stomach and
esophagus

• If reflux of gastric juice is allowed to persist and sustained or repetitive esophageal

injury occurs, two sequelae can result

• Luminal stricture can develop from submucosal and eventually intramural fibrosis

• Tubular esophagus may become replaced with columnar epithelium

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METAPLASTIC (BARRETT’S ESOPHAGUS) &

NEOPLASTIC (ADENOCARCINOMA) COMPLICATIONS
• Traditionally, BE was identified by the presence of columnar mucosa extending at least 3 cm
into the esophagus

• Intestinal-type epithelium found in the Barrett’s mucosa is the only tissue predisposed to
malignant degeneration

• Diagnosis of BE is presently made given any length of endoscopically identifiable columnar

mucosa that proves, on biopsy, to show IM

• Hallmark of IM is the presence of intestinal goblet cells

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CONTINUED…
• Most will require long-term PPI therapy for relief of symptoms and control of
coexistent esophageal mucosal injury

• Antireflux surgery is an excellent means of long-term control of reflux symptoms for

most patients with BE

• Typical complications in BE include

• Ulceration
• Stricture formation
• Dysplasia cancer sequence

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• About one-third of all patients with BE present with malignancy

• The long-term risk of progression to dysplasia and adenocarcinoma is a significant

concern for both patient and physician.

• Adenocarcinoma occurs at approximately 0.2% to 0.5% per year of follow-up, which

represents a risk 40 times that of the general population.
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RESPIRATORY COMPLICATIONS
• Significant proportion of patients with GERD will have associated respiratory
symptoms

• These patients may have laryngopharyngeal reflux-type symptoms, adult-onset asthma

or idiopathic pulmonary fibrosis

• These symptoms and organ injury may occur in isolation or in conjunction with typical
reflux symptoms such as heartburn and regurgitation

• 50% of patients with asthma will have endoscopically confirmed esophagitis or

abnormal distal esophageal acid exposure
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CONTINUED…
Etiology of Reflux-Induced Respiratory Symptoms

• Reflux theory suggests that these symptoms are the direct result of
laryngopharyngeal exposure and aspiration of gastric contents

• Reflex theory suggests that the vagal-mediated afferent fibers result in

bronchoconstriction during episodes of distal esophageal acidification.

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CONTINUED…
• Most difficult clinical challenge in formulating a treatment plan for reflux-
associated respiratory symptoms resides in establishing the diagnosis

• Traditionally, the diagnosis of reflux induced respiratory injury is established

using ambulatory dual probe pH monitoring

• Once the diagnosis is established, treatment may be initiated with either PPI
therapy or antireflux surgery

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MEDICAL THERAPY FOR

GASTROESOPHAGEAL REFLUX DISEASE
• When initially identified with mild symptoms of uncomplicated GERD, patients
can be placed on 12 weeks of simple antacids before diagnostic testing is initiated

• Patients should be counseled to

• Elevate the head of the bed
• Avoid tight-fitting clothing
• Eat small, frequent meals
• Avoid eating the nighttime meal immediately prior to bedtime
• Avoid alcohol, coffee, chocolate, and peppermint,

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CONTINUED…

• In patients with persistent symptoms, the mainstay of medical therapy is acid suppression
• PPIs

• Metoclopramide and domperidone

• Alginic Acid

• Once initiated, most patients with GERD will require lifelong treatment with PPIs, both to
relieve symptoms and control any coexistent esophagitis or stricture

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SUGGESTED THERAPEUTIC APPROACH

First-line therapy - antisecretory medication, usually PPI

• If fails endoscopic examination of the patient’s evaluation is recommended and

will provide the opportunity to assess the degree of mucosal injury and presence
of BE

• Treatment options for these patients entails either long term PPI use vs. antireflux
surgery

N.B. - esophageal acid exposure via 24-hour pH, status of the LES and esophageal
body function should be undertaken when patients are considered for surgery

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SURGICAL THERAPY FOR GERD

Selection of Patients for Surgery
• The key indications for antireflux surgery are
(a) Objectively proven gastroesophageal reflux disease, and
(b) Typical symptoms of GERD despite adequate medical management
(c) A younger patient unwilling to take lifelong medication
(d) Severe endoscopic esophagitis in a symptomatic patient with a structurally defective
LES
(e) Development of a stricture

• Patients with normal sphincter pressures tend to remain well controlled with
medical therapy

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CONTINUED…
Preoperative Evaluation

• Clinical symptoms should be consistent with the diagnosis of gastroesophageal reflux

• Typical symptoms which have responded, at least partly, to PPI therapy, will generally do
well following surgery

• Should also be objectively confirmed by either the presence of ulcerative esophagitis or an

abnormal 24 hour pH study

• Propulsive force of the body of the esophagus should be evaluated

• Hiatal anatomy should also be assessed

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Principles of Surgical Therapy

Basic principles when reconstructing the antireflux mechanism

• Create a flap valve which prevents regurgitation of gastric contents into the esophagus

• Place an adequate length of the distal esophageal sphincter in the positive-pressure environment
of the abdomen

• Allow the reconstructed cardia to relax on deglutition

• Do not increase the resistance of the relaxed sphincter to a level that exceeds the peristaltic
power of the body of the esophagus

• Fundoplication should be placed in the abdomen without undue tension

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CONTINUED…
• Primary goal of antireflux surgery is to safely create a new antireflux valve at the
gastroesophageal junction, while preserving the patient’s ability to swallow
normally and to belch

• To ensure relaxation of the sphincter, three factors are important:

(a) Only the fundus of the stomach should be used to buttress the sphincter
(b) The gastric wrap should be properly placed around the sphincter and not
incorporate a portion of the stomach
(c) Damage to the vagal nerves during dissection of the thoracic esophagus should be
avoided

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NISSEN FUNDOPLICATION

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POSTERIOR PARTIAL
FUNDOPLICATION

• Developed as an alternative to the Nissen procedure to minimize the risk of

postfundoplication side effects, such as dysphagia, inability to belch, and flatulence

• Commonest approach has been a posterior partial or Toupet fundoplication

• Some surgeons use this type of procedure for all patients presenting for antireflux
surgery

• Toupet posterior partial fundoplication consists of a 270° gastric fundoplication

around the distal 4 cm of esophagus
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ANTERIOR PARTIAL
FUNDOPLICATION
• An alternative approach to partial fundoplication

• construct an anterior partial fundoplication

• Division of the short gastric vessels is never needed

• Various degrees of anterior partial fundoplication have been described—90°, 120°, 180°

• Fundus and esophagus are sutured to the right side of the hiatal rim to create a flap valve at the
gastroesophageal junction, and to stabilize a 3-4 cm length of intra-abdominal esophagus

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COLLIS GASTROPLASTY

• When a shortened esophagus is encountered, many surgeons choose to add an

esophageal lengthening procedure before fundoplication

• To reduce the tension on the gastro-esophageal junction

• Divide the cardia and upper stomach, parallel to the lesser curvature of the
stomach

• Following gastroplasty a fundoplication is constructed

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OUTCOME AFTER FUNDOPLICATION

• Relieve typical reflux symptoms in more than 90% of patients at follow-up intervals
averaging 2 to 3 years and 80% to 90% of patients 5 years or more following surgery.

• Postoperative pH studies indicate that more than 90% of patients will normalize
their pH tracings

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CONTINUED

• The goal of surgical treatment for GERD is to relieve the symptoms of reflux by re-
establishing the gastroesophageal barrier

• Side effects of fundoplication

• Dysphagia

• inability to belch and vomit and increased flatulence

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GIANT DIAPHRAGMATIC (HIATAL) HERNIAS
• Relatively common abnormality and was not always accompanied by symptoms

• Three types of esophageal hiatal hernia were identified

(a) The sliding hernia, type I, characterized by an upward dislocation of the cardia in the
posterior mediastinum

(b) The rolling or PEH, type II, characterized by an upward dislocation of the gastric
fundus alongside a normally positioned cardia

(c) The combined sliding-rolling or mixed hernia, type III, characterized by an upward
dislocation of both the cardia and the gastric fundus
 CONTINUED
Incidence and Etiology
• the incidence of a sliding hiatal hernia is seven times higher than that of a PEH

• pressure gradient between the abdomen and chest enlarges the hiatal hernia

• Type II hernias are quite rare

• The median age of PEH is 61 years old; of the sliding hiatal hernias is 48 years old

• PEHs are more likely to occur in women by a ratio of 4:1

• Development of a hiatal hernia is an age-related phenomenon secondary to repetitive upward

stretching of the phrenoesophageal membrane
 CLINICAL MANIFESTATIONS
• Clinical presentation of a giant hiatal (paraesophageal) hernia differs from that of a sliding
hernia

• Dysphagia and postprandial fullness – PEHs and heartburn and regurgitation present in
sliding hiatal hernias

• Respiratory complications(dyspnea and recurrent pneumonia from aspiration) are

frequently associated with a PEH

• PEH can lead to excessive bleeding or volvulus with acute gastric obstruction or infarction

• With mild dilatation of the stomach, the gastric blood supply can be markedly reduced,
causing gastric ischemia, ulceration, perforation, and sepsis
 DIAGNOSIS
• A chest X ray with the patient in the upright position can diagnose a hiatal hernia
if it shows an air-fluid level behind the cardiac shadow

• Accuracy of the upper GI barium study in detecting a paraesophageal hiatal

hernia is greater than for a sliding hernia

• Fiber-optic esophagoscopy is useful in the diagnosis and classification of a hiatal

hernia because the scope can be retroflexed
 PATHOPHYSIOLOGY
• 24-hour esophageal pH monitoring has shown increased esophageal exposure to
acid gastric juice in 60% of the patients with a PEH and 71% incidence in patients
with a sliding hiatal hernia

• Patients with a PEH who have an incompetent cardia have

• distal esophageal sphincter with normal pressure
• shortened overall length
• Displacement outside the positive-pressure environment of the abdomen

• Esophageal peristalsis in patients with PEH is normal in 88%.

 TREATMENT
Indications and Surgical Approach
• Paraesophageal hiatal hernia traditionally been considered an indication for
surgical repair because
• bleeding, infarction, and perforation in patients being followed with known
paraesophageal herniation
• emergency repair carries a high mortality

• patients with a PEH are generally counseled to have elective repair of their hernia,
particularly if they are symptomatic.

• Watchful waiting of asymptomatic PEHs may be an acceptable option

 CONTINUED…
• The surgical approach to repair of a paraesophageal hiatal hernia may be either
transabdominal (laparoscopic or open) or transthoracic

• Each has its advantages and disadvantages

Diaphragmatic Repair
• PEH repair has a relatively high incidence of recurrence (10%–40%)
• recurrence may be reduced with the use of synthetic or biologic mesh to reinforce
the standard crural closure
 CONTINUED…

• Most outcome studies report relief of symptoms following surgical repair of PEHs in
more than 90% of patients

• Optimal results with open or laparoscopic giant hiatal hernia repair should include
options for mesh buttressing of hiatal closure and selective esophageal lengthening

• Despite high incidence of radiologic recurrence it must be reinforced that

asymptomatic recurrent hernia, like primary PEH, do not need to be repaired
 SCHATZKI’S RING
• Thin submucosal circumferential ring in the lower esophagus at the squamocolumnar
junction, often associated with a hiatal hernia

• Twenty-four-hour esophageal pH monitoring has shown that patients with a Schatzki’s

ring have a lower incidence of reflux than hiatal hernia controls

• Have better LES function

• Cause – GERD , drug-induced injury

• Symptoms of Schatzki’s ring are brief episodes of dysphagia during hurried ingestion of
solid foods

• Treatment - dilation alone to dilation with antireflux measures, antireflux procedure

alone, incision, and even excision of the ring
 SCLERODERMA
• Systemic disease accompanied by esophageal abnormalities in approximately 80% of
patients

• Small vessel inflammation appears to be an initiating event, with subsequent perivascular

deposition of normal collagen, which may lead to vascular compromise

• In the GI tract, the predominant feature is smooth muscle atrophy

• Patient can be described as having a poor esophageal pump and a poor valve

• Diagnosis of scleroderma can be made manometrically by the observation of normal

peristalsis in the proximal striated esophagus, with absent peristalsis in the distal smooth
muscle portion
 CONT
• Gastroesophageal reflux commonly occurs in patients with scleroderma,
because they have both hypotensive sphincters and poor esophageal
clearance

• Can have severe esophagitis and stricture formation

• Typical barium swallow shows a dilated, barium-filled esophagus,

stomach, and duodenum, or a hiatal hernia with distal esophageal
stricture and proximal dilatation
 CONTINUED…
• Symptoms have been treated with PPIs, antacids, elevation of the head of the bed,
and multiple dilations for strictures, with generally unsatisfactory results

• Surgical management - partial fundoplication (anterior or posterior) performed

laparoscopically is the procedure of choice

• Surgery reduces esophageal acid exposure, but does not return it to normal
 EOSINOPHILLIC ESOPHAGITIS
• A form of allergic esophagitis
• Post prandial chest pain, dysphagia commonly with solid
food
• Does not respond for PPIs
• Barium swallow and Endoscopy are modalities of diagnosis
• Ringed esophagus or feline esophagus on barium and a stack
of rings on EGD
• Biopsy-15eosinophis/hpf
• Symptomatic treatment, inhaled corticosteroids
• Dilation can be attempted for strictures
THANK YOU