Esophageal Diseases ABSITE Lecture Series Faiz Bhora, MD Attending Thoracic Surgeon St. Luke’s Roosevelt Medical Center, NY,

Esophageal Esophageal DiseasesDiseases

ABSITE Lecture SeriesABSITE Lecture SeriesFaiz Bhora, MDFaiz Bhora, MD

Attending Thoracic SurgeonAttending Thoracic Surgeon

St. Luke’s Roosevelt Medical St. Luke’s Roosevelt Medical Center, NY, Center, NY,

Esophagus Lecture Part 1Esophagus Lecture Part 1

Essential Esophageal Essential Esophageal AnatomyAnatomy

The esophagus is 25 cm in length. The lower 5-7 The esophagus is 25 cm in length. The lower 5-7 cm are below the diaphragmcm are below the diaphragm

Average distance from incisors to GE junction is Average distance from incisors to GE junction is 38-40 cm in men. The distance from the incisors 38-40 cm in men. The distance from the incisors to the cricopharyngeus is 15 cmto the cricopharyngeus is 15 cm

Topographically, the esophagus begins at the Topographically, the esophagus begins at the lower border of C6. The diaphragmatic hiatus is lower border of C6. The diaphragmatic hiatus is at T10at T10

The upper 1/3 esophagus is slightly to the left of The upper 1/3 esophagus is slightly to the left of midline, the middle 1/3 slightly to the right, and midline, the middle 1/3 slightly to the right, and the lower 1/3 slightly to the leftthe lower 1/3 slightly to the left

Essential Esophageal Essential Esophageal AnatomyAnatomy The upper 1/3 is composed of striated muscle and is The upper 1/3 is composed of striated muscle and is

innervated by the vagus and its recurrent branch. The lower innervated by the vagus and its recurrent branch. The lower 2/3 is composed of smooth muscle and is supplied by the 2/3 is composed of smooth muscle and is supplied by the vagus and the intrinsic autonomic nerve plexusvagus and the intrinsic autonomic nerve plexus

The arterial blood supply is segmental. These include the The arterial blood supply is segmental. These include the inferior thyroid artery, bronchial arteries and aortic branches, inferior thyroid artery, bronchial arteries and aortic branches, and branches of the left gastric and inferior phrenicand branches of the left gastric and inferior phrenic

The venous drainage likewise is via the azygous, hemiazygous, The venous drainage likewise is via the azygous, hemiazygous, intercostals, and left gastric veinsintercostals, and left gastric veins

The lymphatic drainage of the upper 1/3 is to the internal The lymphatic drainage of the upper 1/3 is to the internal jugular, deep cervical and para tracheal nodes. The middle jugular, deep cervical and para tracheal nodes. The middle 1/3 drains into the subcarinal and inf pulmonary ligament 1/3 drains into the subcarinal and inf pulmonary ligament nodes. The lower 1/3 drains into the paraesophageal and nodes. The lower 1/3 drains into the paraesophageal and celiac nodes. celiac nodes.

Esophageal Spasm Esophageal Spasm SyndromesSyndromes

Inadequate LES relaxationInadequate LES relaxation

Achalasia, epiphrenic diverticulumAchalasia, epiphrenic diverticulum Uncoordinated esophageal contractionUncoordinated esophageal contraction

Diffuse esophageal spasm (DES)Diffuse esophageal spasm (DES) HypercontractionHypercontraction

High-amplitude peristaltic contraction (HAPC, High-amplitude peristaltic contraction (HAPC, “nutcracker esophagus”), Hypertensive lower “nutcracker esophagus”), Hypertensive lower esophageal sphincter (HLES)esophageal sphincter (HLES)

HypocontarctionHypocontarction

Ineffective esophageal motility (IEM)Ineffective esophageal motility (IEM)


Pain is the Predominant SymptomPain is the Predominant Symptom

1.1. DESDES Patients present with cardiac like chest painPatients present with cardiac like chest pain Dysphagia to both solids and liquidsDysphagia to both solids and liquids Corkscrew esophagus on contrast esophagogramCorkscrew esophagus on contrast esophagogram Manometry shows > 10% of a series of wet swallows Manometry shows > 10% of a series of wet swallows

associated with simultaneous contractions and with associated with simultaneous contractions and with mean amplitudes of > 30 mmHg. LES is normalmean amplitudes of > 30 mmHg. LES is normal

Treatment includes medications, pneumatic dilatation, Treatment includes medications, pneumatic dilatation, botulinum toxin injections. Operative intervention when botulinum toxin injections. Operative intervention when conservative measures have failedconservative measures have failed


Pain is the Predominant SymptomPain is the Predominant Symptom

2.2. HAPC (Nutcracker esophagus)HAPC (Nutcracker esophagus) Patient’s present with sharp, episodic chest painPatient’s present with sharp, episodic chest pain Dysphagia uncommonDysphagia uncommon Contrast esophagogram of low yieldContrast esophagogram of low yield Manometry shows high amplitude, coordinated, Manometry shows high amplitude, coordinated,

peristaltic contractionsperistaltic contractions Treatment with diltiazem has been shown to be helpful. Treatment with diltiazem has been shown to be helpful.

Long esophageal myotomy and partial fundoplication if Long esophageal myotomy and partial fundoplication if medical therapy failsmedical therapy fails


Pain is the Not the Predominant SymptomPain is the Not the Predominant Symptom

1.1. AchalasiaAchalasia

AchalasiaAchalasia

Achalasia is best confirmed by:Achalasia is best confirmed by:

1.1. A birds beak appearance on barium A birds beak appearance on barium esophagogramesophagogram

2.2. Aperistalsis of the cervical esophagusAperistalsis of the cervical esophagus

3.3. Failure of the LES to relax on swallowingFailure of the LES to relax on swallowing

4.4. LES pressure < 5 mmHgLES pressure < 5 mmHg

5.5. Biopsy proven esophagitis on flexible Biopsy proven esophagitis on flexible endososcopyendososcopy

AchalasiaAchalasia Achalasia is a primary motor disorder of the Achalasia is a primary motor disorder of the

esophagus characterized by failure of relaxation esophagus characterized by failure of relaxation of the LES and loss of peristaltic waveform in the of the LES and loss of peristaltic waveform in the bodybody

The cause is believed to be neuronal degeneration The cause is believed to be neuronal degeneration in the myenteric plexus (Auerbach’s plexus)in the myenteric plexus (Auerbach’s plexus)

Symptoms include dysphagia, regurgitation, Symptoms include dysphagia, regurgitation, weight loss, chest pain, pneumoniaweight loss, chest pain, pneumonia

Achalasia is a premalignant condition, with Achalasia is a premalignant condition, with carcinoma developing in 1-10% of patients over carcinoma developing in 1-10% of patients over 15-25 years15-25 years

Characteristics of Characteristics of AchalasiaAchalasia

ManometryManometry1.1. Incomplete LES relaxation on swallowingIncomplete LES relaxation on swallowing2.2. Aperistalsis of the bodyAperistalsis of the body3.3. Elevated LES pressure (>35 mmHg)Elevated LES pressure (>35 mmHg)4.4. Increased resting esophageal pressureIncreased resting esophageal pressure

EsophagogramEsophagogram1.1. Esophageal dilationEsophageal dilation2.2. Air/Fluid levelAir/Fluid level3.3. Bird’s beak or Sigmoid esophagusBird’s beak or Sigmoid esophagus

EndoscopyEndoscopy1.1. Esophageal dilationEsophageal dilation2.2. Retained foodRetained food3.3. Frequently normalFrequently normal

Treatment of AchalasiaTreatment of Achalasia Traditionally, the primary therapeutic approach for Traditionally, the primary therapeutic approach for

achalasia involves pharmacological agents, achalasia involves pharmacological agents, endoscopic botulinum toxin into the LES and endoscopic botulinum toxin into the LES and pneumatic dilatation of the LESpneumatic dilatation of the LES

Pharmacologic AgentsPharmacologic Agents

1.1. Calcium channel blockers and long acting Nitrates Calcium channel blockers and long acting Nitrates both decrease LES resting pressure. Usually poor, both decrease LES resting pressure. Usually poor, short-lived response, side effects limit their short-lived response, side effects limit their effectivenesseffectiveness

2.2. Endoscopic botulinum toxin is successful in 80% of Endoscopic botulinum toxin is successful in 80% of patients in relieving dysphagia. However, symptoms patients in relieving dysphagia. However, symptoms return in 50% in 6 months. Retreatment is return in 50% in 6 months. Retreatment is successful in 50% of original responderssuccessful in 50% of original responders

Treatment of AchalasiaTreatment of Achalasia Pneumatic DilatationPneumatic Dilatation

Disrupts LES muscle fibers and produces relief Disrupts LES muscle fibers and produces relief of symptoms in 50-85% of patients. However, of symptoms in 50-85% of patients. However, most patients require multiple dilatations, most patients require multiple dilatations, increasing the risk of perforation (up to 8%). increasing the risk of perforation (up to 8%). Long term relief of symptoms in 40-65%Long term relief of symptoms in 40-65%

Pneumatic Dilation vs Surgical MyotomyPneumatic Dilation vs Surgical Myotomy

Only one randomized controlled trial with long Only one randomized controlled trial with long term follow-up (dysphagia relieved in 91% vs term follow-up (dysphagia relieved in 91% vs 65%)65%)

Treatment of AchalasiaTreatment of Achalasia

Surgical MyotomySurgical Myotomy Transabdominal vs TransthoracicTransabdominal vs Transthoracic Dysphagia relief about 90% at 2 yearsDysphagia relief about 90% at 2 years Recurrent dysphagia within 2 months likely due Recurrent dysphagia within 2 months likely due

to incomplete myotomy, torsion of the repair or to incomplete myotomy, torsion of the repair or scarring of the mucosa from cauteryscarring of the mucosa from cautery

Late-onset dysphagia due to mucosal stricture Late-onset dysphagia due to mucosal stricture from reflux, or the latent effects of delayed from reflux, or the latent effects of delayed gastric emptying. These patients ultimately need gastric emptying. These patients ultimately need gastric or esophageal resectiongastric or esophageal resection

Treatment of AchalasiaTreatment of Achalasia

Surgical MyotomySurgical Myotomy A resting LES > 36 mm Hg is associated with a A resting LES > 36 mm Hg is associated with a

good surgical outcomegood surgical outcome Patients with esophageal dilation > 6 cm or with Patients with esophageal dilation > 6 cm or with

loss of the esophageal axis (i.e. sigmoid, tortuous loss of the esophageal axis (i.e. sigmoid, tortuous or convoluted esophagus) will need an or convoluted esophagus) will need an esophagectomyesophagectomy

Addition of an Anti-Reflux Procedure?Addition of an Anti-Reflux Procedure? Reflux symptoms occur in up to 30% of patients. A Reflux symptoms occur in up to 30% of patients. A

partial fundoplication should be added. partial fundoplication should be added. No difference between a 180-degree Dor or a 270-No difference between a 180-degree Dor or a 270-

degree Toupet partial fundoplicationdegree Toupet partial fundoplication


Pain is the Not the Predominant SymptomPain is the Not the Predominant Symptom

2.2. Hypertensive Lower Esophageal Sphincter Hypertensive Lower Esophageal Sphincter (HLES)(HLES)

Most patients present with dysphagiaMost patients present with dysphagia Manometry shows elevated basal LES pressure, Manometry shows elevated basal LES pressure,

normal peristalsis and normal LES relaxationnormal peristalsis and normal LES relaxation Treatment options include medication, Treatment options include medication,

pneumatic dilatation or myotomypneumatic dilatation or myotomy


Pain is the Not the Predominant SymptomPain is the Not the Predominant Symptom3.3. Ineffective Esophageal Motility (IEM)Ineffective Esophageal Motility (IEM) Most often seen in scleroderma, rheumatoid arthritis, Most often seen in scleroderma, rheumatoid arthritis,

SLE, DM, alcoholismSLE, DM, alcoholism Most patients present with dysphagia and refluxMost patients present with dysphagia and reflux Contrast esophagogram shows a “lead-pipe” esophagusContrast esophagogram shows a “lead-pipe” esophagus Manometry shows low amplitude contractions, Manometry shows low amplitude contractions,

ineffective peristalsis and decreased LES resting ineffective peristalsis and decreased LES resting pressurepressure

Therapy involves medical anti-reflux therapy. Therapy involves medical anti-reflux therapy. Esophageal shortening may occur in these patientsEsophageal shortening may occur in these patients


A 55 yr old woman has a 6 month history of A 55 yr old woman has a 6 month history of intermittent heartburn and dysphagia. intermittent heartburn and dysphagia. Endoscopy shows severe esophagitis. The Endoscopy shows severe esophagitis. The barium swallow shows a lead-pipe esophagus. barium swallow shows a lead-pipe esophagus. The LES resting pressure is < 5 mmHg with The LES resting pressure is < 5 mmHg with markedly diminished peristaltic activity. The markedly diminished peristaltic activity. The most likely diagnosis is:most likely diagnosis is:

1.1. AchalasiaAchalasia

2.2. GERDGERD

3.3. Cohn's diseaseCohn's disease

4.4. SclerodermaScleroderma

5.5. Sjogren’s syndromeSjogren’s syndrome

Esophageal DiverticulumEsophageal Diverticulum A 65 yr old man has worsening dysphagia A 65 yr old man has worsening dysphagia

and regurgitation. Barium swallow shows and regurgitation. Barium swallow shows a 5 cm epiphrenic diverticulum. a 5 cm epiphrenic diverticulum. Treatment should be:Treatment should be:

1.1. Distal esophageal resectionDistal esophageal resection2.2. Esophageal dilation and fundoplicationEsophageal dilation and fundoplication3.3. Resection of the diverticulum and long Resection of the diverticulum and long

myotomymyotomy4.4. Resection of the diverticulum onlyResection of the diverticulum only5.5. DiverticulopexyDiverticulopexy

Esophageal DiverticulumEsophageal Diverticulum

Epiphrenic DiverticulumEpiphrenic Diverticulum Usually pulsion diverticulum located within the distal 10 Usually pulsion diverticulum located within the distal 10

cm of the thoracic esophaguscm of the thoracic esophagus Usually right sidedUsually right sided Most are found incidentally, however, the most common Most are found incidentally, however, the most common

symptoms are dysphagia, regurgitation symptoms are dysphagia, regurgitation Barium esophagogram remains the best test for diagnosisBarium esophagogram remains the best test for diagnosis Endoscopy, 24 Hr PH and manometry should be performedEndoscopy, 24 Hr PH and manometry should be performed Symptomatic, anatomically dependent and enlarging Symptomatic, anatomically dependent and enlarging

diverticulum should be surgically repaireddiverticulum should be surgically repaired Surgical therapy includes diverticulectomy, myotomy and a Surgical therapy includes diverticulectomy, myotomy and a

partial fundoplication as indicated (Transthoracic or partial fundoplication as indicated (Transthoracic or Transabdominal)Transabdominal)


Zenker’s DiverticulumZenker’s Diverticulum Most common esophageal diverticulumMost common esophageal diverticulum Killian’s triangle is usually the site of weaknessKillian’s triangle is usually the site of weakness Symptoms include regurgitation, halitosis, Symptoms include regurgitation, halitosis,

chocking, aspiration, nocturnal coughing, chocking, aspiration, nocturnal coughing, laryngitis. Motility determines symptoms and laryngitis. Motility determines symptoms and not the pouch sizenot the pouch size

Diagnosis made on barium swallowDiagnosis made on barium swallow Endoscopy to rule out malignancyEndoscopy to rule out malignancy Surgical treatment recommended if symptomaticSurgical treatment recommended if symptomatic Treatment consists of cervical esophagomyotomy Treatment consists of cervical esophagomyotomy

and pouch resectionand pouch resection


Midesophageal DiverticulumMidesophageal Diverticulum Usually traction diverticulumUsually traction diverticulum These are due to TB and histoplasmosis. Most These are due to TB and histoplasmosis. Most

asymptomatic and need no interventionasymptomatic and need no intervention Midesophageal pulsion diverticulum are due to an Midesophageal pulsion diverticulum are due to an

underlying motility disorder and are due to pulsion. underlying motility disorder and are due to pulsion. Manometry is helpful to define the extent of Manometry is helpful to define the extent of

myotomy myotomy Surgical intervention for large (> 5 cm) and Surgical intervention for large (> 5 cm) and

symptomatic diverticulumsymptomatic diverticulum Buttress repair with pleura, pericardial fat or Buttress repair with pleura, pericardial fat or

omentumomentum

Esophagus Lecture Part 2Esophagus Lecture Part 2

Esophageal PerforationEsophageal Perforation

65 yr old female with achalasia complains of back 65 yr old female with achalasia complains of back pain after pneumatic dilation. The CXR is pain after pneumatic dilation. The CXR is normal post procedure. The next best course of normal post procedure. The next best course of action is:action is:

1.1. Repeat endoscopy to identify any mucosal injuryRepeat endoscopy to identify any mucosal injury

2.2. VATS/or thoracotomy and operative repair as you VATS/or thoracotomy and operative repair as you suspect an esophageal perforationsuspect an esophageal perforation

3.3. Infectious disease consult for the prompt Infectious disease consult for the prompt administration of antibiotic therapyadministration of antibiotic therapy

4.4. Contrast study of the esophagusContrast study of the esophagus

5.5. Admit to ICU, IV hydration. If stable and CXR Admit to ICU, IV hydration. If stable and CXR normal, upper GI endoscopy or gastrografin swallow normal, upper GI endoscopy or gastrografin swallow the next morningthe next morning


Common Causes of Esophageal PerforationCommon Causes of Esophageal Perforation Endoscopy, esophageal dilation, NG tube Endoscopy, esophageal dilation, NG tube

insertion, traumainsertion, trauma Operative procedures associated with Operative procedures associated with

perforation: anterior spine surgery (cervical), perforation: anterior spine surgery (cervical), gastric fundoplication, thyroidectomy, gastric fundoplication, thyroidectomy, pneumonectomypneumonectomy

Common Sites of Esophageal PerforationCommon Sites of Esophageal Perforation Cricopharyngeus, aortic knob, gastro esophageal Cricopharyngeus, aortic knob, gastro esophageal

junctionjunction

Esophageal PerforationEsophageal PerforationPresentation and DiagnosisPresentation and Diagnosis

Differential diagnosis includes myocardial infarction, pancreatitis, Differential diagnosis includes myocardial infarction, pancreatitis, perforated peptic ulcer disease, aortic dissection, acute gastric perforated peptic ulcer disease, aortic dissection, acute gastric volvulusvolvulus

Symptoms vary depending on site, mechanism and interval to Symptoms vary depending on site, mechanism and interval to presentation. However, pain is the most common complaintpresentation. However, pain is the most common complaint

Fever, tachycardia, leucocytosis, subcutaneous emphysema and Fever, tachycardia, leucocytosis, subcutaneous emphysema and crepitus, dysphagia, pleural effusion, peritonitis, sepsiscrepitus, dysphagia, pleural effusion, peritonitis, sepsis

Rapid diagnosis is the key: mortality of untreated esophageal Rapid diagnosis is the key: mortality of untreated esophageal perforation increases from 10-20% to 40-60% after the first 24 hoursperforation increases from 10-20% to 40-60% after the first 24 hours

CXR: mediastinal emphysema, pleural effusion, hydropneumothoraxCXR: mediastinal emphysema, pleural effusion, hydropneumothorax Gastrografin swallow (10% missed injuries), followed by thin bariumGastrografin swallow (10% missed injuries), followed by thin barium CT may be helpful in equivocal cases and to help guide non-operative CT may be helpful in equivocal cases and to help guide non-operative

treatmenttreatment


When to Manage an Esophageal Perforation Non-When to Manage an Esophageal Perforation Non-Operatively?Operatively?

Minimal SymptomsMinimal Symptoms Contrast study shows small, contained leakContrast study shows small, contained leak1.1. About 25% of esophageal perforations meet About 25% of esophageal perforations meet

this criterionthis criterion2.2. Lower tolerance of conservative management Lower tolerance of conservative management

with thoracic and abdominal vs cervical with thoracic and abdominal vs cervical perforationsperforations

3.3. All patients must be admitted to a monitored All patients must be admitted to a monitored setting with initiation of hydration, antibiotics setting with initiation of hydration, antibiotics and monitoring of urine outputand monitoring of urine output


Operative Management of Cervical PerforationOperative Management of Cervical Perforation Drainage usually is sufficientDrainage usually is sufficient Incision made anterior to the sternocleidomastoid Incision made anterior to the sternocleidomastoid

musclemuscle Mediastinoscopy can be used to drain the middle Mediastinoscopy can be used to drain the middle

mediastinummediastinum Neck drained with closed suction or penrose drainsNeck drained with closed suction or penrose drains Direct operative repair if perforation easily Direct operative repair if perforation easily

localizedlocalized May be combined with thoracic drainage if May be combined with thoracic drainage if

extensive mediastinal and pleural soilage presentextensive mediastinal and pleural soilage present

Esophageal PerforationEsophageal PerforationOperative Management of Thoracic PerforationOperative Management of Thoracic Perforation Most cases can be primarily repaired. Upper 2/3 approached Most cases can be primarily repaired. Upper 2/3 approached

via right 5via right 5thth intercostal space and lower 1/3 via left 7 intercostal space and lower 1/3 via left 7thth intercostal spaceintercostal space

Must debride all necrotic muscle and identify the mucosa. Must debride all necrotic muscle and identify the mucosa. Mucosa closed as a separate layer (4-0 vicryl). Close muscle Mucosa closed as a separate layer (4-0 vicryl). Close muscle over the repair if possible. Reinforce with intercostal, pleural over the repair if possible. Reinforce with intercostal, pleural or pericardial flapor pericardial flap

Widely open the mediastinal pleura and drain the pleural cavityWidely open the mediastinal pleura and drain the pleural cavity NG drainage for 7 days, followed by a contrast studyNG drainage for 7 days, followed by a contrast study

1.1. Esophageal exclusion should rarely be used primarilyEsophageal exclusion should rarely be used primarily

2.2. Esophagectomy reserved if there is an underlying malignancy Esophagectomy reserved if there is an underlying malignancy or with end-stage achalasiaor with end-stage achalasia

3.3. The use of esophageal stent is controversial, but very promisingThe use of esophageal stent is controversial, but very promising

Paraesophageal HerniasParaesophageal Hernias OrganoaxialOrganoaxial stomach rotates about its longitudinal stomach rotates about its longitudinal MesoaxialMesoaxial stomach rotates about a line perpendicular to the stomach rotates about a line perpendicular to the

cardiopyloric linecardiopyloric line

ClassificationClassificationType I: Sliding, fundus only, 1-5 cm, no rotationType I: Sliding, fundus only, 1-5 cm, no rotationType II: True Paraesophageal, fundus/body, 1-5 cm, organoaxial Type II: True Paraesophageal, fundus/body, 1-5 cm, organoaxial

rotationrotationType III: Mixed, fundus and body, ½ or more of stomach, Type III: Mixed, fundus and body, ½ or more of stomach,

organoaxial and mesoaxial rotationorganoaxial and mesoaxial rotationType IV: Mixed with other organs, fundus and body plus other Type IV: Mixed with other organs, fundus and body plus other

organs, ½ or more of stomach and colon, organoaxial and organs, ½ or more of stomach and colon, organoaxial and mesoaxial rotationmesoaxial rotation

Paraesophageal HerniasParaesophageal Hernias

Symptoms and SignsSymptoms and Signs 50% are asymptomatic, although minor 50% are asymptomatic, although minor

symptoms are usually overlookedsymptoms are usually overlooked Typical symptoms include epigastric pain, post-Typical symptoms include epigastric pain, post-

prandial discomfort in the chest, heartburn, prandial discomfort in the chest, heartburn, regurgitation, vomiting, weight loss, dyspnearegurgitation, vomiting, weight loss, dyspnea

Important signs include anemia, pneumoniaImportant signs include anemia, pneumonia An incarcerated intrathoracic stomach is a An incarcerated intrathoracic stomach is a

surgical emergency. These patients present with surgical emergency. These patients present with acute chest or epigastric pain and retching, but acute chest or epigastric pain and retching, but the inability to vomitthe inability to vomit


DiagnosisDiagnosis CXR shows a retro cardiac air bubble, with or CXR shows a retro cardiac air bubble, with or

without an air fluid levelwithout an air fluid level Barium swallow confirms the diagnosis and Barium swallow confirms the diagnosis and

usually shows a large, intrathoracic upside down usually shows a large, intrathoracic upside down stomachstomach

Endoscopy helpful to evaluate for ulcers, Endoscopy helpful to evaluate for ulcers, Barrett’s and neoplasmsBarrett’s and neoplasms

Esophageal motility studies helpful in an elective Esophageal motility studies helpful in an elective setting to help guide decisions regarding a wrapsetting to help guide decisions regarding a wrap


TreatmentTreatment

All patients with symptoms or signs should undergo All patients with symptoms or signs should undergo elective repair in the absence of prohibitive elective repair in the absence of prohibitive surgical risksurgical risk

Approaches include transthoracic, abdominal or laparoscopicApproaches include transthoracic, abdominal or laparoscopic Transthoracic approach provides the ability to mobilize the Transthoracic approach provides the ability to mobilize the

esophagus, relative ease of dissection of the hernia sac, and esophagus, relative ease of dissection of the hernia sac, and optimal exposure for secure crural closure. A Collis gastroplasty optimal exposure for secure crural closure. A Collis gastroplasty can also easily be performedcan also easily be performed

The main advantage of the abdominal approach is the ability to The main advantage of the abdominal approach is the ability to place the stomach in the appropriate anatomic orientation place the stomach in the appropriate anatomic orientation

Laparoscopy is associated with 5-8% incidence of esophageal Laparoscopy is associated with 5-8% incidence of esophageal perforation, and higher recurrence rate than the open procedureperforation, and higher recurrence rate than the open procedure


TreatmentTreatment

All patients with symptoms or signs should All patients with symptoms or signs should undergo elective repair in the absence of undergo elective repair in the absence of prohibitive surgical riskprohibitive surgical risk

Need for esophageal mobilization and Need for esophageal mobilization and lengtheninglengthening

The importance of sac excisionThe importance of sac excision The role of gastrostomy and gastropexyThe role of gastrostomy and gastropexy The need for mesh in crural repairThe need for mesh in crural repair

Caustic IngestionCaustic Ingestion

A 7 year old boy swallowed some ammonia (glass A 7 year old boy swallowed some ammonia (glass cleaner). He is crying, complaining of pain and cleaner). He is crying, complaining of pain and is drooling. Which of the following is true:is drooling. Which of the following is true:

1.1. The patient should immediately be intubated to The patient should immediately be intubated to secure his airwaysecure his airway

2.2. Endoscopy is contraindicated, as it could exacerbate Endoscopy is contraindicated, as it could exacerbate the injurythe injury

3.3. Sodium hypochlorite (bleach) ingestion has the Sodium hypochlorite (bleach) ingestion has the highest likelihood of perforationhighest likelihood of perforation

4.4. Gastrografin swallow is performed at 3 weeks and Gastrografin swallow is performed at 3 weeks and helps guide dilation of strictureshelps guide dilation of strictures

5.5. Steroids help decrease the incidence of stricturesSteroids help decrease the incidence of strictures

Gastroesophageal Reflux Gastroesophageal Reflux DiseaseDisease

True statements regarding an abdominal approach True statements regarding an abdominal approach versus a thoracic approach to anti-reflux versus a thoracic approach to anti-reflux surgery include:surgery include:

1.1. A Collis gastroplasty for a shortened esophagus is A Collis gastroplasty for a shortened esophagus is easier performed through the abdomeneasier performed through the abdomen

2.2. Large hernias are easier repaired laparoscopically Large hernias are easier repaired laparoscopically with better resultswith better results

3.3. Redo operations are better performed through the Redo operations are better performed through the abdomenabdomen

4.4. There is a lower incidence of esophageal perforationThere is a lower incidence of esophageal perforation

5.5. The Nissen repair is easier performed The Nissen repair is easier performed transabdominallytransabdominally


Preoperative Work-upPreoperative Work-up

1) esophagogastroduodenoscopy 1) esophagogastroduodenoscopy

2) esophageal manometric evaluation. 2) esophageal manometric evaluation.

3) 24-hour intraesophageal pH monitoring3) 24-hour intraesophageal pH monitoring

4) barium cineradiography4) barium cineradiography


Indications for SurgeryIndications for Surgery Surgical therapy should be considered in those individuals with Surgical therapy should be considered in those individuals with

documented GERD who:documented GERD who:

1) have failed medical management1) have failed medical management2) opt for surgery despite successful medical management 2) opt for surgery despite successful medical management

(due to life style considerations including age, time or (due to life style considerations including age, time or expense of medications, etc.)expense of medications, etc.)

3) have complications of GERD (e.g. Barrett's esophagus; 3) have complications of GERD (e.g. Barrett's esophagus; grade III or IV esophagitis)grade III or IV esophagitis)

4) have medical complications attributable to a large hiatal 4) have medical complications attributable to a large hiatal hernia. (e.g. bleeding, dysphagia)hernia. (e.g. bleeding, dysphagia)

5) have "atypical" symptoms (asthma, hoarseness, cough, 5) have "atypical" symptoms (asthma, hoarseness, cough, chest pain, aspiration) and reflux documented on 24 hour chest pain, aspiration) and reflux documented on 24 hour pH monitoringpH monitoring


Types of Repairs:Types of Repairs: NissenNissen HillHill ToupetToupet DorDor Belsey Mark IVBelsey Mark IV Collis GastroplastyCollis Gastroplasty

Barrett’s EsophagusBarrett’s Esophagus False statements regarding Barrett’s False statements regarding Barrett’s

esophagus include:esophagus include:1.1. 20-40% of patients with severe dysplasia will have 20-40% of patients with severe dysplasia will have

invasive carcinoma in the resected specimeninvasive carcinoma in the resected specimen2.2. The likelihood of developing cancer in the first 3-5 The likelihood of developing cancer in the first 3-5

years after severe dysplasia has been identified is years after severe dysplasia has been identified is 25-50%25-50%

3.3. The ideal therapy for Barrett's with severe dysplasia The ideal therapy for Barrett's with severe dysplasia is endoscopic laser ablation of the mucosa and an is endoscopic laser ablation of the mucosa and an anti-reflux procedureanti-reflux procedure

4.4. The ideal therapy for uncomplicated Barrett's The ideal therapy for uncomplicated Barrett's esophagus is controversialesophagus is controversial

5.5. It is a premalignant condition and occurs in 10% of It is a premalignant condition and occurs in 10% of all patients with refluxall patients with reflux

Esophageal CancerEsophageal Cancer 14,000 new cases each year, more common in 14,000 new cases each year, more common in

menmen Adenocarcinoma now represents about 60-70% Adenocarcinoma now represents about 60-70%

of these tumorsof these tumors

PresentationPresentation

1.1. 90% present with dysphagia90% present with dysphagia

2.2. 70% present with weight loss70% present with weight loss

3.3. 50% present with substernal or epigastric pain50% present with substernal or epigastric pain

4.4. Hoarseness is rareHoarseness is rare

Esophageal CancerEsophageal Cancer

Role of EUS in T Stage AssessmentRole of EUS in T Stage Assessment Esophageal carcinoma presents as a hypo echoic mass Esophageal carcinoma presents as a hypo echoic mass

that disrupts the normal anatomy of the esophagusthat disrupts the normal anatomy of the esophagus Accuracy for assessing depth of tumor penetration is Accuracy for assessing depth of tumor penetration is

85-90%85-90%

Role of EUS in N Stage AssessmentRole of EUS in N Stage Assessment Hypo echoic nodes, sharply demarcated and larger Hypo echoic nodes, sharply demarcated and larger

than 5 mm are likely to be malignantthan 5 mm are likely to be malignant Accuracy for overall N stage accuracy is 77%. FNA Accuracy for overall N stage accuracy is 77%. FNA

added to EUS increases the accuracy to 91%added to EUS increases the accuracy to 91%


PET/CT now widely used for pre operative PET/CT now widely used for pre operative assessmentassessment

Bronchoscopy is done if tracheal or Bronchoscopy is done if tracheal or bronchial involvement is suggestedbronchial involvement is suggested


StagingStaging

T1: invades lamina propria or sub mucosaT1: invades lamina propria or sub mucosa

T2: invades muscularis propriaT2: invades muscularis propria

T3: invades adventitiaT3: invades adventitia

T4: invades adjacent structuresT4: invades adjacent structures

N0: no lymph nodesN0: no lymph nodes

N1: regional lymph nodesN1: regional lymph nodes

M1: distant metastasis, including celiac or cervical nodesM1: distant metastasis, including celiac or cervical nodes


StagingStagingT1: invades lamina propria or sub mucosaT1: invades lamina propria or sub mucosa

T2: invades muscularis propriaT2: invades muscularis propria

T3: invades adventitiaT3: invades adventitia

T4: invades adjacent structuresT4: invades adjacent structures

N0: no lymph nodesN0: no lymph nodes

N1: regional lymph nodesN1: regional lymph nodes

M1: distant metastasis, including celiac or cervical nodesM1: distant metastasis, including celiac or cervical nodes

Stage IStage I : T1 N0: T1 N0

Stage 2AStage 2A : T2 N0 and T3 N0: T2 N0 and T3 N0

Stage 2BStage 2B : T1 N1 and T2 N1: T1 N1 and T2 N1

Stage 3Stage 3 : T3 N1 and T4 any N: T3 N1 and T4 any N

Stage 4Stage 4 : M1: M1


Neoadjuvant TherapyNeoadjuvant Therapy 5 yr survival with surgery alone is 25%5 yr survival with surgery alone is 25% Although 7 randomized trials have been done, Although 7 randomized trials have been done,

only one 1996 study (Walsh) shows a survival only one 1996 study (Walsh) shows a survival benefit at 3 yearsbenefit at 3 years

We employ neoadjuvant therapy for Stage 2B or We employ neoadjuvant therapy for Stage 2B or higherhigher

Chemotherapy is 5FU and CisplatinChemotherapy is 5FU and Cisplatin Radiation is about 40GRadiation is about 40G


Surgical ApproachesSurgical Approaches Transhiatal esophagectomyTranshiatal esophagectomy Ivor-Lewis esophagectomyIvor-Lewis esophagectomy Esophagectomy with cervical Esophagectomy with cervical

anastomosisanastomosis Thoracoabdominal with left chest Thoracoabdominal with left chest

anastomosisanastomosis

Esophageal CancerEsophageal Cancer Regarding esophageal cancer and its Regarding esophageal cancer and its

management, which statement is false:management, which statement is false:

1.1. Its incidence is rising in the USIts incidence is rising in the US

2.2. Preoperative workup should include EUS, Preoperative workup should include EUS, PET/CT and PFT’sPET/CT and PFT’s

3.3. Neoadjuvant treatment is the standard of care for Neoadjuvant treatment is the standard of care for T2, N0 esophageal cancerT2, N0 esophageal cancer

4.4. There is no significant difference in survival There is no significant difference in survival between the transhiatal or transthoracic between the transhiatal or transthoracic approachapproach

5.5. The leak rate is higher with the transhiatal The leak rate is higher with the transhiatal approachapproach

Documents

Esophageal Diseases ABSITE Lecture Series Faiz Bhora, MD Attending Thoracic Surgeon St. Luke’s Roosevelt Medical Center, NY,