Diseases of the esophagus

Attila Enyedi MD.

Anatomy of the oesophagus I.

• 38-40 cm lenth, (upper-middle-lower )

• Blood supply: inf.thyreoid a., direct arteries from the aorta, bronchial, gastric & phrenic arteries

• Cervical, cardial, celiac lymphnodes, Jumping metastases

• UES,LES (upper-lower oesophageal sphincter)

• No serosa

16-24 24-32 32-40

Anatomy of the oesophagus II.

Diagnosis of the oesophageal diseases

• Native X-ray, swalloving X-ray

• CT, PET

• Endoscopy, biopsy

• Endoscopic US

• Manometry, pH monitoring

Achalasia

• Symptoms (Dysphagia, regurgitation of food, weigh loss, pain)

• Complications (aspiration, ulceration)

• Radiology (absent of peristalsis, dilatation)

• Manometry

• Endoscopy, biopsy

Achalasia

Therapy

• Medical treatment• Baloon dilatation• Heller’s myotomy• Laparoscopic

myotomy

Perforation the oesophagus• Foreign body• Iatrogenic (intubation, endoscopy,

dilatation)• Accident

Complaints

• Dysphagia• Pain• Subcutaneous emphysema• Fever

– mediastinitis, empyema thoracis, peritonitis

Perforation the oesophagus

Diagnosis(in general late)

• Case history– Bone, fishbone, previous interventions

• Physical examination• Swallowing X-ray• CT (contrast enhanced)• Endoscopy????

Perforation the oesophagus

Treatment

• Conservative– AB, relieving nasogastric tube, stenting

• Surgery– Suture (in early stage) + covering of the suture– Drainage (mediastinotomy, Chest tube drainage)– Resection with cervical oesophagostomy (Thorec

operation)– Transgastric drainage

Transgastric drainage

Oesophageal diverticulum

Zenker’s diverticulum

• Dysphagia

• Pressure symptoms

• Gurgling sounds in the neck region

• Regurgitation of undigested food

• Manual emptying of the diverticulum by the patient

Oesophageal diverticulum

Diagnosis of Zenker’s diverticulum

• Typical clinical signs

• Swalloving X-ray

• CT scan

Oesophageal diverticulum

Diagnosis of Zenker’s diverticulum

Oesophageal diverticulumTherapy of Zenker’s diverticulum

Oesophago-diverticulostomy

Oesophageal diverticulum

Therapy of Zenker’s diverticulum

resection

Oesophageal diverticulum

Epiphrenic diverticulum

• Dysphagia

• Sensation of pressure in the lower oesophagus

• Intermittent vomiting

• Retrosternalsternal pain

• Regurgitation

Oesophageal diverticulum

Diagnosis of the Epiphrenic diverticulum

• Typical clinical signs

• Radiologic contour on native chest X-ray

• Swalloving X-ray

• CT scan

• Associated with hiatal hernia

Oesophageal diverticulum

Therapy of the Epiphrenic diverticulum

• Medicine therapy

• Resection of the diverticulum– Via thortacotomy– Via thoracoscopy (VATS)– Via laparotomy– Via laparoscopy

Hiatal hernia

Types of hiatal hernia

• Paraoesophageal hernia

• Sliding hernia with GERD

• Mixed form

• Upside-down stomach

Hiatal hernia

Symptoms of Paraoesophageal hiatal hernia

• Often asymptomatic• Obstruction• Pain• Dysphagia• Incarceration• Ulcer diasesae/Barret oesophagus

Hiatal hernia

Diagnosis of Paraoesophageal hiatal hernia

• Clinical signs

• Native chest X-ray

• Swalling X-ray

• Endoscopy

Hiatal hernia

Diagnosis of Paraoesophageal hiatal hernia

Hiatal hernia

Symptoms of Sliding hiatal hernia

• Chronic (80-85%)– Dysphagia– Early Satiety– Pain/Heartburn – Aspiration– Anaemia

• Acute (15-20%)– Dysphagia (sometimes

total)– Haematemesis– Obstruction– Gangrene/Perforation– Peritonitis

Hiatal hernia

Diagnosis of Sliding hiatal hernia

• Clinical signs• Native chest X-ray• Swalloving X-ray• Endoscopy with biopsy (oesophagitis)• Manometry• Ph monitoring

Hiatal hernia

Indication of surgical therapy

• Uneffective conservative treatment

• Morphologic disorders (eg. Oesophagitis, Barret oesophagus)

• Chronic aspiration (pneumonia)

• Bad complience of the patient

Hiatal hernia

Surgical therapy I.

Hiatal hernia

Surgical therapy II.

Hiatal hernia

Surgical therapy III.

Hiatal hernia

Surgical therapy IV.

Hiatal hernia

Surgical therapy IV.

Oesophageal tumours

• Benignal– Papillomas– myomas– Leiomyomas

• Malignant– Squamouscell cancer– Adenomatous cancer

Oesophageal tumours

Symptoms

• Dysphagia (solid food, than fluids)

• Weight loss

• Pain in 30%

• Coughing (oesophygotracheal fistule)

• Regurgitation

• Aspiration

Oesophageal tumours

Diagnosis

• Clinical signs

• CT

• Swalloving X ray

• Endoscopy with biopsy

• Endoscopic US

• Bronchoscopy

Treatment of benign oesphageal tumours

• Surgical treatment/resection– VATS– Thoracotomy– Laparoscopy– laparotomy

Treatment of benign oesphageal tumours

Treatment of oesophageal cancer

• Radiotherapy

• Chemotherapy

• Surgery

Protocol

• Resection than adjuvant chemo-radiotharpy

• Neoadjuvant chemo-radiotherapy than resection, than chemo-raditherapy

• Palliative treatment

Oesophageal tumours

Suegical treatment

• Transthoracal or transhiatal resection

• Subtotal resection of the oesophagus• Oesophago-gastrostomy (cervical or

intrathoracic)• Feeding and decompression

jejunostomy

Subtotal oesophagectomy I.

Subtotal oesophagectomy II.

Subtotal oesophagectomy III.

Subtotal oesophagectomy IV.

Subtotal oesophagectomy V.

Subtotal oesophagectomy VI.

Subtotal oesophagectomy VII.

Subtotal oesophagectomy VIII.

Subtotal oesophagectomy IX.

Subtotal oesophagectomy X.

Subtotal oesophagectomy XI.

Subtotal oesophagectomy XII.

Subtotal oesophagectomy XIII.

Subtotal oesophagectomy XIV.

Neooesophagus

-Stomac 91% - Colon 6%- Jejunum 3%

Subtotal oesophagectomy XV.

Subtotal oesophagectomy XVI.

Subtotal oesophagectomy XVII.

Subtotal oesophagectomy XVIII.

Contraindication of radical resection

• Distant metastasis (eg. Liver, lung)• Local spread to the surrounding organs

– Aorta– Bronchial tree (oesophago-tracheal fistula)

• Poor general condititon• Severe concomitant disease

– Cirrhosis hepatic– Ischemic heart disease– poor lung function

Palliative treatment of oesophageal cancer

• R1 resection, than adjuvans chemo-radiotharpy?

• Stenting

• Feeding gastro/jejunostomy– Via laparotomy– PEJ/PEG