Esophagus

Surgery

1. OESOPHAGUS

2. Surgical anatomy The esophagus is a two-layered mucosa-lined muscular tube that journeys through the neck, chest, and abdomen and rests unobtrusively in the posterior mediastinum . It commences at the base of the pharynx at C6 and terminates in the abdomen, where it joins the cardia of the stomach at T11

3. anatomy

4. Anatomy Arch of aorta makes an impression on oesophagus –radiograph & endoscopy

5. Symptoms of oesophageal disorders

6. Dysphagia . This term means a sensation of obstruction during the passage of liquid or solid through the pharynx or oesophagus, i.e. within 15 seconds of food leaving the mouth. The characteristics of the progression of dysphagia to solids can be helpful, e.g. intermittent slow progression with a history of heartburn suggests a benign peptic stricture; Relentless progression over a few weeks suggests a malignant stricture. The slow onset of dysphagia for solids and liquids at the same time suggests a motility disorder

7. Odynophagia is pain during the act of swallowing and is suggestive of oesophagitis . Causes include reflux, infection, chemical oesophagitis

8. Substernal discomfort, heartburn. This is a common symptom of reflux of gastric contents into the oesophagus usually a retrosternal burning pain that can spread to the neck, across the chest, and when severe can be difficult to distinguish from the pain of ischaemic heart disease.

9. Chest pain- GERD;motility disorders

10. Regurgitation is the effortless reflux of oesophageal contents into the mouth and pharynx. it occurs frequently in patients with gastro-oesophageal reflux disease or organic stenosis .

11. reflux Passive return of gastro duodenal contents to mouth Occurs in GERD Symptoms- loss of weight Change of voice-irritation of vocal cord Cough or dyspnoe -tracheal aspiration

12. Investigation of oesophageal disorders Barium swallow and meal. endoscopy Oesophagoscopy . Video endoscopy Manometry PH recording

13. Radiographic Evaluation The first diagnostic test in patients with suspected esophageal disease should be a barium swallow including a full assessment of the stomach and duodenum

14. radiography Plain x-ray-foreign body Barium swallow-motility disorders,space occupying lesion

15. OESOPHAGEOGRAM

16. endoscopy To view inside of oesophagus & oesophagogastric jn Types Rigid oesophagoscope Flexible video endoscope

17. BARRET OESOPHAGUS

18. carcinoma

19. Oesophageal candidiasis

20. Oesophageal manometry manometry is particularly necessary to confirm the diagnosis of specific primary esophageal motility disorders (i.e., achalasia , diffuse esophageal spasm, nutcracker esophagus , and hypertensive LES).

21. 24hr ph monitoring Prolonged monitoring of esophageal pH is performed by placing the pH probe or telemetry capsule 5 cm above the manometrically measured upper border of the distal sphincter for 24 h. It measures the actual time the esophageal mucosa is exposed to gastric juice, measures the ability of the esophagus to clear refluxed acid, and correlates esophageal acid exposure with the patient’s symptoms.

22. Congenital anomalies Ectopic gastric mucosa can occur in upper third of oesophagus Atresia - lack of lumen formation- usually asso-tracheo-oesophageal fistula Fistula- aspiration & paroxysmal suffocation from food are obvious hazards-detected immediately after birth- aspiration pneumonia- O.stenosis -narrowing of lumen Dysphagia lusoria due to vascular anomaly

23. Esophageal atresia and tracheooesophageal fistula Commonest C C.Blind upper segment,fistula between the lower segment & trachea

24. Clinical features- oesophageal atresia Baby regurgitates all feeds Saliva – continuosly from mouth Coughing & cyanosis on feeding As a part of; V ertibral body segmentation A nal atresia C vs -PDA T E fistula R enal agenesis

25. diagnosis NG tube comes against an obstuction with in 10 cm Lateral CXR -lucent proximal pouch that displace the trachea anteriorly

26. Corrective surgery – thoracotomy at the level of 5 th ics Lower segment is divided at its entrance in to trachea & fistula is closed treatment

27. complication Pneumonia Leakage from anastamosis

28. Foreign bodies-common impacted material is food in children- coin,pin …

29. Foreign body The flexible upper gastrointestinal endoscope should be inserted under direct visualization to avoid inadvertently striking an object and further impacting it or causing it to penetrate the esophageal wall. Blunt foreign bodies such as coins can be securely grasped with a forceps or a snare. A firm grasp on the foreign body is required before withdrawal is attempted.

30. COIN IN OESOPHAGUS

31. Button Batteries A button battery lodged in the esophagus is a true emergency and immediate removal is indicated to avoid the rapid corrosive action of the alkaline substance on the mucosa and subsequent complications.

32. perforation Perforation of the esophagus is a surgical emergency. Early detection and surgical repair within the first 24 hours results in 80% to 90% survival; after 24 hours, survival decreases to less than 50%. Upon presentation, patients suspected of having a perforation based on initial history and physical exam are evaluated quickly so that surgical intervention may be initiated promptly. Perforation from forceful vomiting ( Boerhaave's syndrome), foreign body ingestion, or trauma accounts for 15%, 14%, and 10% of cases, respectively. Most esophageal perforations occur after endoscopic instrumentation for a diagnostic or therapeutic procedure, including dilation, stent placement, and laser fulguration. Other iatrogenic causes that have been noted include difficult endotracheal intubation, blind insertion of a mini- tracheostomy , and inadvertent injury during dissections in the neck, chest and abdomen.

33. Boerhaave's Syndrome- baro trauma recurrent emesis disrupts the normal vomiting reflex that enables sphincter relaxation, resulting in an increase in intrathoracic esophageal pressure and perforation. Postemetic rupture of the esophagus , now known as Boerhaave's syndrome, is only one of many causes of esophageal rupture.

34. C/F Severe pain in chest following meal Upper abdomen rigid Mistaken as MI or perforated peptic ulcer

35. 2.Pathological perforation Perforation of ulcers( barret ulcer or tumours ) Causes erosion in to aorta or ventricle-fatal 3 . Penetrating injury by knifes & bullet -un common 4.During removal of foreign body 5.Instumental perforation

36. Diagnosis Mediastinal emphysema, a strong indicator of perforation The diagnosis is confirmed with a contrast esophagogram , which will demonstrate extravasation in 90 percent of patients. The use of a watersoluble medium such as Gastrografin is preferred

37. Treatment The management of patients with esophageal perforation takes place in both the ICU and in the operating room. Patients with an esophageal perforation can progress rapidly to hemodynamic instability and shock. If perforation is suspected, appropriate resuscitation measures with the placement of large-bore peripheral IV catheters, a urinary catheter, and a secured airway are undertaken before the patient is sent for diagnostic testing. IV fluids and broad-spectrum antibiotics are started immediately, and the patient is monitored in an ICU

38. Surgery is not indicated for every patient with a perforation of the esophagus , and management is dependent on several variables: stability of the patient, extent of contamination, degree of inflammation, underlying esophageal disease, and location of perforation

39. three criteria for the nonoperative management of esophageal perforation: (1) the barium swallow must show the perforation to be contained within the mediastinum and drain well back into the esophagus , (2) symptoms should be mild, and (3) there should be minimal evidence of clinical sepsis.

40. Principles of non op mgmnt Analgesia Nil by mouth Abx IV fluids

41. Op management Thoracotomy & repair of perforation done with in few hours of perforation Insertion of stents for treatment of perforated cancer

42. 3/2/2011 43 Thank You For The Patient Hearing