THE ESOPHAGUS

Dr. Henk Kartadinata, SpB, SpBD, FICS Bagian Ilmu Bedah Fakultas Kedokteran Ukrida

Two major 20 th century developments

1. Introduction of techniques permitting operations on the intrathoracic position of esophagus 2. Perfection and clinical application of sophisticated technique of measuring normal and abnormal esophagial function

Historical aspects
Before trans thoracic operation only cervical esophagus could be treated surgically Earliest operations were limited to cervical esophagotomy for removal of foreign body Billgoth and Czerny (latter part of 19 th century) : Surgical ablation for malignant lesions of cervical esophagus

Historical aspects
1886 : Resection of pharyngo esophagel diverticulum Early 1900 : -Transabdominal procedures for the relief of esophagial achalasia -Staged reconstructive operations for corrosive strictures and amlignant lesions

Historical aspects
Ohsawa (1933) : ones stage transpleural esophagus resection and esophagogastrotomy for carsinoma After world war II : Through the efforts of code cs and Ingelfinger, the heretofore poorly understood physiology of this important organ was carefully detailed and the information disseminated

Anatomy
Esophagus is a long muscular tube extending downward from pharynx above the level of C-VI to reach the stomach within the abdomen. Begins at level of the cricopharyngeal muscles. The cricopharyngeal muscles runs transversely across the posterion wall of the esophagus, connecting the two lateral borders of cricoid cartilago inferiorly benda to the circular and longitudinal muscle fibers of the upper esophagus. It reaches the abdomen through the esophageal liatus.

Anatomy
A noose of diaphragmatic muscle most often made up actively of the right diaphragmatic crus. An esophageal segment of variable length lies within the abdomen where it join the stomach.

The muscular wall

The muscular wall of the esophagus is composed of an inner circular layer and an outer longitudinal layer without a surrounding serosal covering. Striated muscle fibers make a considerable contribution to the outer longitudinal coat in the upper portion of the esophagus, where as smooth muscle predominates in the lower third

 1. 2. 3. 4.

A prominent sub mucosa contain : Mucous glands Blood vessels Meissner plexus of nerves A rich network of lymphatic vessels

Mucosa
The mucosal lining to characteristically made up of squamos

Epithelium
The distal an 2 cm is lined by columnar epithelium

Artery
The cervical esophagus : -Inferior thyroid arteries The thoracic esophagus : -Branches of aorta -Esophageal branches of the Bronchial arteries -Supplemented by vessels descending from the neck and ascending from arteries on the abdominal side of diaphragm

Artery
The abdominal onaph : -A phreinca inferior -A gastrica sinistra

Vein
Subepithelial and submucous venous channels course longitudinally to empty above and below into hypopharyngeal and gastric veins. The drainage from the cervical esophagus empty into inferior thyroid and vertebral veins From the thocaic portion into the azygos and hemiazygos veins From the abdominal portion mostly into the left gastric veins.

Lympatic vessels
Tend to run longitudinally in the wave of the esophagus before penetrating the muscle layers to reach regional mode -Tracheal -Tracheobronchial -Posterior mediastinal -Diaphragmatic

Nerve supply
From both the vagus and the symphatetic chain The recurrent nerves supply the upper portion of the esophagus which also recives branches from N IX, N X, cranial root N XI and symphatetic nerves Along most of the esophagus, the vagus nerves lie on either side, forming a plexus about it.

Nerve supply
As the hiatus is approached the two major trunks emerge, the left one coming to lie anteriorly and the right one posteriorly

Physiology
Function as channel through which ingested material is conveyed from the pharyns to the stomach. At either end of the tube are regulator mechanism, permitting one way passage only, except under unusual circumstances. At the upper end of the esophagus is a 3 cm zone of increased pressure which relaxes promptly with swallowing and constacts there after as a wave high pressure passes through it. This is the upper esophageal sphincter, which is composed of the cricopharyngeal muscles and a few cm of the upper cervical esophagus

Physiology
Contraction of the sphincter are in peristaltic sequence with those of the pharynx above and the esophagus below. The peristaltic pressure sweeps in an orderly fashion down the entire body of esophagus. Pressure reach an intensity of 50-100 cm of water and are slightly more forceful in the lower esophagus

Physiology
Resting pressures in the body of the esophagus are less than athmospheric pressure There is a zone of increased pressure at the lower end of the esophagus 3-5 cm. It is located in the region of the hiatus. In response to a swallowing effort relaxation of this zone can be identified, followed by sphinteric contraction. This constitutes the inferior esophageal sphincter

Physiology
The important factors which maintain gastro esophageal competence : - Diaphragm -The valve flap mechanism -The gastric sling fibers -The oblique angle of entry -The mucosal rosette

Physiology
It is likely that in most humans the musculature of the intrinsic sphincter in combination with prominent folds of gastric mucosa at the esophago gastric junction contributes to the reflux barrier. The sphincter functions better when in its normal position than when displaced and so the supporting structures must be credited with some ancillary function.

Innervation
Cervical esophagus : -Part by the recurrent nerves -Cricopharyngeal function is probably dependent on the nerve derived from the pharyngeal branch of the vague through the pharyngeal plexus. Body of the esophagus : -Under vagal controle, because division of the nerves produce low simultaneous pressure after diglutition

Innervation
Inferior esophageal sphincter -May continue to relax on swallowing even after lower thoracic vagotomy and symphatetic denervation. So it must possess a high autonomy -There is a rise in sphincteric pressure in response to injection of gastrin

Disorders of the Upper Sphincter

Cause of abnormalities of pharyngo esophageal function: 1. Central nervous systems -Bulbar poliomyelitis -C V A -Multiple sclerosis Abnormalities of sphincteric relaxation are said to characterize such lesions

Disorders of the Upper Sphincter

2. Diseases that directly affect muscular activity -Muscular dyshophy -Myasthenia gravis -Dermato myositis -Myopathy of thyrotoxicocis In such patients, failure to develop effective pharyngeal peristalsis seems to be the most common cause of swallowing difficulties.

Disorders of the Upper Sphincter

3. After extensive operations on the oropharyngeal region Spasm of the cricopharyngeal muscle has been considered contributory to the swallowing difficulties. Cricopharyngeal myotomy is advisable when extensive resections of this sort are performed

Achalasia
Synonym : Cardiospasm Ethiology : -Unknown -Characterized by absence of the inferior esophageal sphincter to relax in response of swallowing -First prescribed by Thomas Willis (1674) -There is a general agreement that is has a neurogenic basis

Achalasia
Pathology : -Disintegration or absence of ganglion cells of Auerbacks plexus in the esophagus, demonstrable at all levels of the thoracic esophagus although more prominent in the body. -It is not known whether they represent a primary or secondary manifestation of the disease

Achalasia
Pathology : In Brazil and other South American countries where there leishmaniacal forms of Trypanozoma cruzi exist, Chagas disease appears to have an esophageal condition indistinguishable from achalasia Incidence : An annual incidence rate of 0.6 per 100.000

Achalasia
Sex : Equal frequency in both sexes Age : Is may occurs at any age, but is seem most often between 30-50 years

Achalasia
Natural history : -The earliest and most constant symptom is obstruction to swallowing or dysphasia. At first intermittent but becomes more constant as the disease progresses -The patient experience more difficulty with cold than with warm food -Solid foods are said to pass more easily at first than liquids

Achalasia
Natural history : -Pain is relatively infrequent, more likely to occurs in the early stage of the disease and becomes less noticeable as the esophagus dilates

Achalasia
Regurgitation : -Particularly noticeable at night when the patient is declining -10% pulmonary complications in the form of aspiration pneumonitis. -An increased susceptibility to trhe development of Ca of the esophagus.

Achalasia
Rontgenologis signs : -The esophagus is dilated -The lower portion of the lumen appears conical and narrowed for a short distance with a beak like extension directed into narrowed segment Esophagoscopy -Is essential to distinguish early achalasia from Ca or from benign esophageal stricture

Achalasia
Esophageal motility studies: -Slight elevation of pressures -Lack of peristalsis in the body of esophagus after diglutation -Swallowing effort is accompanied by feeble elevation in pressyre that are stimultaneous throughout the body of the esophagus -The inferior esophageal sphincter fails to relax in response to swallowing efforts

Achalasia
Treatment : -Cannot be restored to normal and effective therapy must be directed to relief the distal esophageal obstruction -Forceful dilatation of the esophago gastric junction
Hydrostatic Pneumatic Mechanical

Complication : Perforation

Achalasia
Treatment : -Surgical therapy : esophagomyotomy This stems historically from the double cardio-myotomy first carried out by Heller (1913), Incidence of reflux esophagitis is minimal.

Differential Diagnosis
Symtoms of sign Pain Achalasia Uncommon Diffuse Vigorous spasm Achalasia Almost always Frequent

Obstruction
Regurgitation Retention

Always
Common Frequent

Sometimes

Nervousness Uncommon Radiologic Findings -Diffuse dilatation Common -Segmental Uncommon spasm

Nearly always Rare Frequent Never Frequent Almost always Occasionaly

Never Frequent Occasionaly Common

Diverticula
Classification : 1. Location : -Pharyngoesophageal -Midthoracic -Epiphrenic or subdiagprahmatic 2. Mode of development -Underlying esophagus mobility disturbance -Traction, pulse

Diverticula
Classification : 3. Status -True : include all layers of the esophageal wall -False : Consist of esophageal mucosa and submucosa

Pharyngo esophageal diverticulum

Pharyngo esophageal diverticulum : -Most common diverticulum of the esophagus -Arises between the oblique fibers of the inferior consicter muscle of the pahrynx and the transverse fibers of the cricopharyngeal muscle -Usually occurs in elderly patients

Pharyngo esophageal diverticulum

-Clearly represent in acquired abnormality, although a congenital weakness or deficiency in the supporting musculare of the area has been postulated as a possible cause -Motility study : an incoordination in the swallowing mechanism, pharyngeal contraction, occurs after closure of the cricopharyngeal muscle. This may well prove to be the cause of the pharyngeal pouch

Pharyngo esophageal diverticulum

-Incidens of coexisting hiatal hernia has been high and the resluting gastroesophageal reflux has been associated with high pressure in the uppr sphincter

Pharyngo esophageal diverticulum

Symptoms: -Dysphagia -Regurgitation -Noisy deglutition -Pulmonary manifestation teomastirated regurgitation The diverticulum enlarge, if untreated, total esophageal obstruction occurs Diagnosis : Is made rontgenograpically

Pharyngo esophageal diverticulum

Treatment : -Single stage resection *The sac is dissected up to its neck, divided and removed *The pharyngeal mucosa is closed with interenpted suture, this knods within the esophageal lumen * The edge of the muscle layers are approximated * Recurrence is rare -Cricopharyngeal myotomy, particularly for the small pharyngeal pouch

Mid thoracic diverticula

Seldom develop Rarely produce symptoms Symptoms usually caused by granulomatous infections of the mediastrinal lymph nodes, particularly the sub carinal and parabronchial region Rarely give rise to significant complication The most serious is a tracheo bronchial esophageal fistula. Excision and closure of the communication with inter position of normal tissue are usually succesful in preventing recurrence

Epiphrenic diverticulum
Less common than the upper pharyngeal pouches Less likely to produces symptoms Pathologic anatomy : Very similar to that of upper pharyngeal pouches Frequently associated with underlying motility disturbances, usually achalasia or diffuse spasm Ro : charateristic

Epiphrenic diverticulum
Operation is indicated when symptoms are progressive and severe : Resection of the diverticulum accompanised by a long extra mucosal esophagomyotomy *Recurrent is rare *Result are usually excellent

Hiatus Hernia
In its downward course through the thorax. The esophagus traverres the diaphragmathrong a defect. Pressure within the thorax is less than atmospheric whereas intraabdominal pressure is above atmospheric. This is one of the important factors that tend to promote passage of a portion of the stomach upward through the hiatus : an esophageal hiatal hernia

Hiatus Hernia
Types: 1. Para esophageal hiatus hernia 2. Sliding hiatus hernia Anatomy
The wall of esophageal hiatus is formed in the entirely of the skeleted muscle composing the diaphragm

 Anatomy :

Hiatus Hernia

There is a separation in the anterior posterior plane of muscle fibers composing the right crus of the diaphragm. Thuis seperation forms a sling anterior to the esophagus. But, there is a less definite reunion of the muscle fibers posteriorly, leaving a V shaped, tapered defect The hiatus is normally just large enough to comfortably permit passage of the esophagus: more or less 2.5 cm in diameter. The esophagus passes through the crural turned obliquely: Directly anterior to the aorta just above the hiatus To the left of the aorta just below the hiatus

Hiatus Hernia
Anatomy :
- Both

diaphragmatic crura arise from the lateral aspects of L I L IV - The esophagus hiatus contracts : *with inspiration *stimulation of the phrenic nerve - With inspiration the diaphragm and hiatus descend, increasing the angulation of the esophagus at the haitus -The acute angle between the left border of the abdomen esophagus and the medial border of the gastric fundus is known as the angle of His

Hiatus Hernia
Anatomy :
- The lower esophagus and esophagus-gastric junction are held loosely in the esophageal hiatus by a tethering device known as the phrenicesophageal ligament or membrane
- Arise circumferentially around the hiatal margin - A fibro elastic membrane - Is a continuation of the transversal fascia in the abdomen and the endothoracic fascia in the thorax - Insert circumferentially around the diaphragmatic esophagus close to the squamocolumnar junction, the upper leaf 3 cm above the squamocolumnar junction, the lower leaf 1.5 cm below the squamocolumnar junction This insertion becomes continuous with the fibroelastic tissue of the intermuscular fascia of the esophagus

Hiatus Hernia
Physiology of The Esophagogastric Junction The normal pressure relationship favors gastroesophageal reflux : - Intragastric pressure is above atmospheric - Intraesophageal pressure is negative to atmospheric pressure Ancillary factors in maintaining competence of the sphincter mechanism (but certainly not primarily important) - Oblique entrance of the esophagus into the cardia - The angle of His

Hiatus Hernia
Physiology of The Esophagogastric Junction
Physiologic studies have demonstrated this sphincter mechanism even more convincingly (Code cs and Ingelfinger cs) Careful study of the pressure indicated :
-A High pressure zone 3.5 cm at the level of the diaphragm

-The diaphragm is located by the pressure inversion point (PIP) : below the diaphragm inspiration cause a rise in pressure, above the diaphragm inspiration cause a fakk -In the junctional zone the intraluminal pressure in the esophagus is almost higher than that either stomach or esophagus above. This is true in all stages of the respiratory cycle and in any position of the body. -Deglutition initiated a peristaltic wave. As the peristaltic wave passed downward the pressure in the high pressure zone fell sharply

Hiatus Hernia
Paraesophageal Hiatus Hernia
5% of hiatal hernia Esophagogastric junction remains below the diaphragm Competence of the lower esophageal sphincter is preserve Hernial defect with sharply defined, firm borders Develops to the left of the esophagus The defect varies widely in the site and mey be as large as 10-12 cm in diameter.

Hiatus Hernia
Paraesophageal Hiatus Hernia
Has a well defined hernial sac compose of thickened and fibrosis diaphragmatic peritoneum. The greater curvature of the stomach rolls upward as the defect and the hernial sac become large rolling hernias Almost the entire stomach may rotated upward into the hernial sac to that only the pylorus and antrum remain below the diaphragm and are closer together 50% has a thoracic scoliosis

Hiatus Hernia
Paraesophageal Hiatus Hernia Clinical manifestation : Pain : epigastric and retrosternal Ingestion of a meal will provide a bolus that enters the thoracic stomach and distends it. The pain is closely associated with eating that the patient restrict intake Severe weight loss Respiratory distress Peptic ulcer in the thoracic stomach and usually is not influenced by antiacid medication

Hiatus Hernia
Paraesophageal Hiatus Hernia Clinical manifestation Acute and occult bleeding of the upper GIT Obstruction Incarceration Pressure necrosis Perforation Strangulation Volvulus (organo-axial)

Hiatus Hernia
Paraesophageal Hiatus Hernia Diagnosis : Radiologic examination:
*The thoracic stomach retains enough gas to show a radioluscent pocket within the usual cardiac silhouette . Two or three air fluid levels, 1 below and 1 or 2 about the diaphragm *Barium study to ascertain the location of the esophagogastric junction and to determine the presence and level of the obstruction

Esophagoscopy Usually only in the negative : *Subdiaphragmatic location of the esophagogastric junction *Absence of the esophagus

Hiatus Hernia
Paraesophageal Hiatus Hernia Diagnosis : Gastric secretory analysis Duodenal ulcer diathesis is seldom present Measuremen of pH No gastroesophageal reflux Manometry
Normal esophagogastric sphincter

Hiatus Hernia
Paraesophageal Hiatus Hernia
Pathogenesis :
The etiology is completely unknown It appears to be an acquired lesion since it is rare before late middle life and is most frequently seen in the elderly

Therapy :
Exclusively surgical The optimal approach is through the abdomen : *Repositioning of the hernial content *Repair of the defect by approximately the crux of the diaphragm in front or behind the esophagus *Reconstruction (suture) the angle of His *Fixation of the fundus to the diaphragm *Fixation of the antrum wall to the posterior right rectum sheath The result are extremely good and recurrent quite rare

 Sliding Hiatus Hernia

Pathologic anatomy
-It is essence a failure of the normal tethering device, the phrenoesophageal ligament to retain the esophagogastric junction within the esophageal hiatus -Unfavorable pressure relationship permit the cardiac portion of the stomech to herniate upward in concentric fashion through the esophageal hiatus -The phrenoesophageal ligament becomes lengthened and thinned out; whether it is primary or secondary is unclear. -The esophageal hiatus becomes dilated to a variable degree -The esophagogastric junction slides back and forth readily, depending in body posture, abdominal distention, gastric filling, etc

 Sliding Hiatus Hernia

Pathologic anatomy
-When the hernia is reduced it may be difficult for the radiologist to visualize it. -The diaphragmatic peritoneum reduces readily along with the cardia -Well develop hernial sac is present only in large hernias -Inflammation and scarring secondary to severe and longstanding reflux esophagitis may remove the sliding feature of concentric hiatus hernias -Fixation and contraction of scar tissue may produce acquired shortening of the esophagus and fixation of esophagogastric junction well above the diaphragm

 Sliding Hiatus Hernia Clinical manifestation A sliding hiatus hernia in and of itself is totally asymptomatic It is only when a lesion is associated with gastroesophageal reflux and reflux esophagitis that symptoms supervene The classic symptoms of esophagitis are easily recognized but unfortunately are so common