The Esophagus

Vic Vernenkar, D.O

Department of Surgery
St. Barnabas Hospital
Historical Aspects
The earliest esophageal procedures were
limited to the cervical region (removal of
foreign bodies-1863)
Modified ureteroscope used to diagnose
carcinoma of the thoracic esophagus-1868
Esophagoscopy with distal light source
developed around 1900
Flexible fiber-optic esophagoscopy-1964
Anatomy
A hollow muscular tube approximately 25 cm in length
divided into four segments
Pharyngoesophageal, Cervical, Thoracic and Abdominal
The cervical esophagus is a midline structure positioned
posterior and slightly to the left of the trachea
The thoracic esophagus passes into the posterior mediastinum
continuing on the left side of the mainstem bronchus and
eventually enters the abdomen through the crus in the
diaphragm
The abdominal esophagus attaches to the cardia (or EG
junction) of the stomach (is of variable length)
Anatomy
(Continued)
The esophagus has
three distinct areas of
naturally occurring
anatomic narrowing
Cervical constriction
Bronchoaortic
constriction
Diaphragmatic
constriction
Anatomy (Continued)
A mucosal-lined muscular tube that lacks a serosa
It is surrounded by adventita
The adventita surrounds a coat of longitudinal muscle
that overlies a inner layer of circular muscle
Between the two muscular layers is a thin intramuscular
layer of fine blood vessels and ganglion cells
The upper (two-thirds) layer of muscle is striated and
lower is not
The esophageal mucosa consists of squamous epithelium
except for the distal 1-2 cm
Anatomy (Continued)
The esophagus has both sympathetic and
parasympathetic innervation
The esophagus has an extensive lymphatic
drainage that consists of two lymphatic
plexuses
The esophagus has segmental blood supply
and is nourished by a number of arteries
Physiology
Its basic function is to transport swallowed
material from the pharynx into the stomach
Retrograde flow of gastric contents into the
esophagus is prevented by the lower
esophageal sphincter (LES)
Entry of air into the esophagus is prevented
by the upper esophageal sphincter (UES)
Physiology (Continued)
Esophageal contractions-three types:
Primary peristalsis
Secondary peristalsis
Tertiary contractions
Esophageal peristaltic pressures range from 20-100
mm Hg with a duration of contraction between 2-4
seconds
LES-no anatomic sphincter has ever been
demonstrated (resting pressures are elevated in this
area)
Disorders of Esophageal Motility
Are classified as functional disorders because they
interfere with a normal act of swallowing or
produce dysphagia without any associated organic
obstruction or extrinsic compression
Information from esophageal manometry is
extremely helpful
Some conditions are indistinguishable by x-rays
(barium) but have specific manometric characteristics
Disorders of Esophageal Motility
As a basic rule the tests below constitute the
basic evaluation of a patient with suspected
disorders of esophageal motility:
Barium swallow
Esophagoscopy
Esophageal manometry
Esophageal pH reflux testing
Disorders of Esophageal Motility
Upper esophageal sphincter dysfunction
Various (old) terms have been used:
• Achalasia
• Spasm
• Cricopharyngeal chalasia
The terms oropharyngeal dysphagia or cricopharyngeal
dysfunction better described the symptoms that occur
when there’s difficulty propelling liquid or solid food
from the oropharynx into the upper esophagus
Causes of Oropharyngeal
Dysphagia
Neurogenic
Myogenic
Structural causes
Mechanical causes
Iatrogenic causes
Gastroesophageal reflux
Clinical Presentation
The patient complains of cervical dysphagia which
is localized between the thyroid cartilage and the
suprasternal notch (the classical “lump in the
throat”)
Expectoration of excessive saliva is common
Intermittent hoarseness can occur
Weight loss secondary to impaired caloric intake
may occur
Diagnostic Tests and Treatment
Barium swallow may be normal especially in
patients with intermittent symptoms
Esophageal function studies (manometric and acid
reflux testing) should be performed whenever
possible
In patients with severe symptoms and no reflux,
surgical intervention may be necessary
Esophagomyotomy
Motor Disorders of the Body of
the Esophagus
Esophageal motor disorders range from
hypomotility (achalasia) to hypermotility (diffuse
spasm)
Achalasia is defined as a failure or lack of
relaxation
The name focuses on the distal sphincter however the
condition involves the entire esophageal body
Diffused esophageal spasm is poorly understood
and poorly treated
Achalasia
The etiology is not known
The characteristic clinical, radiographic and manometric
findings have occurred following a variety of situations:
Severe emotional stress
Major physical trauma
Chagas’ disease
Various animal model suggests a central or peripheral
vagal nerve dysfunction resulting in the development of
achalasia
The classic triad of presenting symptoms include
dysphagia, regurgitation and weight loss
Achalasia (Continued)
Retrosternal pain on swallowing (odynophagia) is not
characteristic
Effortless regurgitation after eating especially upon
bending forward is usually not associated with a sour
taste of undigested food-in contrast to acid regurgitation
Often results in recurrent respiratory symptoms due to
aspiration pneumonitis
Is a premalignant esophageal lesion with carcinoma
developing as a late complication in patients who have
this condition an average of 15-25 years
Radiographic Appearance of
Achalasia
Varies with the extent of the disease
Mild dilatation and early stages progressing
to massive dilatation and tortuosity and
later stages
Peristalsis is disordered in early stages and
lacking in later stages
The radiographic hallmark is the distal bird
beak taper of the (EG) junction
Testing
Manometric criteria of achalasia are failure
of the LES to relax with swallowing and a
lack of progressive peristalsis throughout
the length of the esophagus
Esophagoscopy is indicated an achalasia to
rule out severe retention esophagitis,
carcinoma or tumor of the cardia (stomach)
that mimics achalasia
Treatment
Incurable
Palliative measures
Nonsurgical
Surgical
Both are directed toward relieving the
obstruction caused by the nonrelaxing LES
Nonsurgical Treatment
Early stages
Sublingual nitroglycerin
Long-acting nitrates
Calcium channel blockers
Passage of Mercury weighted bougies
Surgical Treatment
Forceful dilatation (balloon)
Esophagomyotomy
Diffuse Esophageal Spasm
(DES)
Is poorly understood hypermotility disorder
Results from repetitive high amplitude esophageal contractions
The etiology is unknown
These patients typically are anxious and complain of
chest pain inconsistent to eating, exertion and position
The character of pain may mimic that of angina
Symptoms are greatest during periods of emotional stress
Patients may experience slow emptying of the esophagus
and obstructive symptoms are uncommon
Radiographic Findings
Frustratingly variable
Classic “corkscrew”
Beaklike taper
Increase in esophageal wall thickness
Testing
Esophagoscopy
Distal esophageal obstructing lesions may
produce proximal esophageal contractions that
are confused with DES
Esophageal manometry
Diagnostic when present
Classic criteria are:
• Simultaneous, multiphasic, repetitive, high
amplitude contractions that occur after a swallow
Treatment
Due to the lack of understanding of this
condition the treatment is less than
satisfactory
Antispasmodics are occasionally helpful
Response to sublingual nitroglycerin is
variable
Scleroderma
Esophageal motor disturbances occur in several of the
collagen vascular diseases
Dermatomyositis
Polymyositis
Lupus erythematosus
Scleroderma (extremely common)
Etiology is unknown
Characterized by induration of skin, fibrous replacement
of smooth muscle of internal organs and progressive loss
of visceral and cutaneous function
Disruption of esophageal peristalsis is common
Testing
Esophageal manometry and intraesophageal
pH readings are the most sensitive means of
detection
Treatment
Standard antireflux medicine includes H-2
blockers
Cimetidine
Ranitidine
In patients with intractable symptoms
gastroesophageal reflux surgery should be
considered
Diverticula of the
Esophagus
Esophageal Diverticula
Almost all are acquired and occur predominantly in
adulthood
Are classified according to their:
Site of occurrence
• Pharyngoesophageal
• Parabronchial
• Epiphrenic
Wall thickness
• True
• False
Mechanism of formation
• Pulsion
• Traction
Pharyngoesophageal Diverticula
(Zenker)
The most common esophageal diverticulum
Occurs between the ages of 30-50 (believed to be acquired)
Arises within the inferior pharyngeal constrictor, between
the oblique fibers of the thyropharyngeus muscle and the
cricopharyngeus muscle
Is a pulsion diverticulum
Complaints are of cervical dysplasia, effortless regurgitation
of food or pills sometimes consumed hours earlier
Sometimes a gurgling sensation in the neck after swallowing
is felt
Diagnosis and Treatment
Barium swallow establishes the diagnosis
Surgery is indicated in symptomatic
patients regardless of the size
It is the degree of cricopharyngeal muscle
dysfunction and not the size of the diverticulum
that determines the relative severity of cervical
dysphagia
Midesophageal (Traction)
Diverticula
Are typically associated with mediastinal
granulomatous disease (TB, histoplasmosis)
They are usually small with a blunt tapered tip that
points upward
These are usually an incidental finding on barium
swallow
They rarely cause symptoms or require treatment
Need to be differentiated from pulsion diverticula
which can also occur in this location (associated
with neuromotor esophageal dysfunction)
Epiphrenic (Supradiaphragmatic)
Diverticula
Generally occur within the distal 10cm of the
thoracic esophagus
These are pulsion diverticula that arise due to
esophageal motor dysfunction or mechanical distal
obstruction
Many patients are asymptomatic when diagnosed
When symptomatic their symptoms are difficult to
differentiate from: hiatal hernia, DES, achalasia,
reflux esophagitis and carcinoma
Dysphagia and regurgitation are common symptoms
Diagnosis and Treatment
Diagnosis is easily made with barium
swallow
Esophageal function studies should also be
performed to rule out any motor
disturbances
Lesions < 3 cm often require no treatment
Extreme symptomatic patients sometimes
require surgical repair
Miscellaneous Condition of the
Esophagus
Mallory-Weiss syndrome
During the act of forceful emesis against a closed
glottis increased intra-abdominal pressure can cause a
tear in the mucosa (Mallory-Weiss tear) of the
esophagus at the esophagogastric junction
A transmural esophageal tear is called Boerhaave’s
syndrome
A history of emesis followed by melena or
hematemesis is suggestive for a Mallory-Weiss tear
Esophagoscopy
Indications and Contraindications
Indications include:
Dysphagia
Reflux
Hematemesis
Atypical chest pain
Many other conditions
Contraindications:
To assess reflux symptoms that respond to medical
management
A uncomplicated sliding hiatal hernia
General Considerations
The esophagoscopy should be performed
after barium swallow
Bacteremia during upper GI endoscopy has
been well documented therefore
prophylactic antibiotic treatment should be
administered
Patient should be in NPO for 6-8 hours
Complications
The minor ones:
Lacerations of the lips or tongue
Dislodgment or fracture of teeth and possible aspiration
Major complication
Esophageal perforation
• Cervical esophagus (40%)
• Mid esophagus (25%)
• Distal esophagus (35%)
Morbidity and mortality from perforation is directly
related to the time interval between the occurrence of
injury, diagnosis and repair
Tumors of the Esophagus
Benign Esophageal Tumors and
Cysts
Benign tumors are rare (< 1 %)
Classified in two groups
Mucosal
Extramucosal (intramural)
More useful classification:
60% of benign neoplasms are leiomyomas
20% are cysts
5% are polyps
Others (< 2 percent)
Leiomyomas
Most common benign tumor of the esophagus
Intramural
Occur between 20-50 years of age with no gender
preponderance
80% occur in the middle and lower third of the
esophagus, they are rare in the cervical region
Obstruction and regurgitation may occur in large
lesions
Bleeding is a more common symptom of the
malignant form of the tumor: leiomyosarcoma
Esophageal Cysts
Arise as diverticula of the embryonic foregut
¾ of this cyst present in childhood
Over 60% are located along the right side of the esophagus
Are often associated with vertebral anomalies (ex: spina
bifida)
60% present in the first year of life with either respiratory
or esophageal symptoms
Cyst found in the upper third of the esophagus present in
infancy while lower third lesions present later in childhood
Pedunculated Intraluminal
Tumors (Polyps)
Benign polyps are rare
Usually occur in older men and may cause
intermittent dysphagia
Are sometimes easily missed with barium
swallow and esophagoscopy
Malignant Tumors of the
Esophagus
Usually are in advanced stages at the time of diagnosis
(involving the muscular wall and extending into adjacent
tissues)
Alcohol consumption and cigarette smoking seem to be
the most consistent risk factors
Esophageal squamous cell carcinoma (95% of all
esophageal cancers) is a disease of men (5: 1)
Squamous cell esophageal cancer occurs least frequently
in the cervical esophagus and
Squamous cell esophageal cancer occurs most often in the
upper and midthoracic segments
Malignant Tumors of the
Esophagus
Adenocarcinoma constitute approximate 8% of primary
esophageal cancers
The frequency of adenocarcinoma is increasing
dramatically in the U.S. at a rate surpassing any other
cancer
Most often occur in the distal third of the esophagus in the
6th decade of life.
Male to female ratio is 3:1
Patients with Barretts metaplasia are 40 times more likely
to develop adenocarcinoma
These tumors are aggressive as well
Clinical Presentation
Dysphagia is the presenting complaint in 80-90%
of patients with esophageal carcinoma
Early symptoms are sometimes nonspecific
retrosternal discomfort or indigestion
As the tumor enlarges, dysphagia becomes more
progressive.
Later symptoms include weight loss, odynophagia,
chest pain and hematemesis
Diagnosis
Esophageal biopsy
Brushings for cytologic evaluation
Barium swallow
Lugol’s solution
Staging of Tumors
Endoscopic ultrasound-to define the depth
of invasion and presence of paraesophageal
lymph nodes
Chest x-ray ± abnormal findings
CT scan (most widely used and now
standard radiographic means of staging)
Bronchoscopy for tumors which are
proximal to the trachea
TMN Classification for Staging
The esophagus is first divided into four segments
Cervical
Upper thoracic
Middle thoracic
Lower
“T” defines the depth of invasion
“N” defines regional lymph node involvement
“M” defines the presence or absence of distant metastasis
The TNM categories are grouped into stages which have
been shown to reflect the prognosis of tumors
Perforation of the
Esophagus
Causes of Perforation
Iatrogenic Spontaneous
Endoscopy Postemetic
Dilators Radiation therapy
Esophageal intubation Traumatic
Variceal sclerosis Blunt and penetrating
Intraopoerative Caustic
Mediastinoscopy Carcinomas
Thyroid surgery
Clinical Presentation
Symptoms and signs vary with the cause and location
of the perforation
Pain is the most consistent symptom (70-90%)
Blood tainted emesis is present and 30% of these
patients
The pain pattern is often misdiagnose as a dissecting
aortic aneurysm, spontaneous pneumothorax or
myocardial infarction
Tachycardia and tachypnea is common
Hypotension and shock can occur
Diagnosis
Chest x-ray (plain film)
When obtained early may appear normal
Mediastinal emphysema may appear in one hour
Pleural effusions may take several hours
Definitive diagnosis-contrast studies
CT scan’s for atypical presentations
Esophagoscopy is rarely used for diagnosis of
perforation
Treatment
Three factors affect management of
esophageal perforation
Etiology
Location
The delay between rupture and treatment
Surgical treatment remains the mainstay of
management in esophageal perforations
 Hiatal Hernia and
Gastroesophageal Reflux
Factors Affecting Reflux
Gastric juices
Gastric acid and bile
Gastric emptying
Abnormal emptying patterns (prolonged fundal distention)
Previous gastroesophageal operations
Social habits and medication
Fatty foods, chocolate and peppermint reduces LES tone
Smoking causes a significant decrease in LES resting pressures
All medication affecting smooth muscle contraction have been
shown to affect LES pressures
Signs and Symptoms of
Gastroesophageal Reflux
Diagnosis
Esophagoscopy
To note mucosal changes
Esophageal biopsies
To note changes at the cellular level
Motilitiy studies
Low LES pressures are associated with reflux
pH monitoring
The most precise measure for the presence of acid in
the esophageal lumen (24 hour monitoring)
Final Staging
The results from the four studies above are
scored and patients are put into one of four
categories
The treatment regimen depends on the stage
of the disease
Medical Treatment
Surgical Treatment
Indications for surgical treatment are somewhat
controversial
Stage 0 and Stage 1 disease should never be an
indication for surgery
Stage 2 disease should always undergo a well supervised
period of medical management for at least six months to
a year
Stage 3 disease should also undergo medical therapy first
In stage2 and in Stage 3 disease surgical options should
be entertained after failed medical management
Surgical Treatment
Nissen fundoplication
Total or partial
Their aim is to:
Restore normal anatomy (intra-abdominal
segment of esophagus)
Re-creating an appropriate high-pressure sound
at the esophagogastric junction
Maintaining this repair in the normal anatomic
position
Corrosive Strictures of the
Esophagus
Etiolgy
The most common chemicals implicated in corrosive
burns of the esophagus include:
Alkaline caustics
• Household drain cleaners
• Dishwashing detergent
• Washing soda
• Ammonia
• Disk shaped alkaline batteries
Acid or acid like corrosives
• Automobile battery acids
• A variety of commercial cleaners
Household bleach
Important Elements in Successful
Management of a Corrosive Burn
Immediate verification of the corrosive agent
Accurate assessment of the depth and extent of injury
(esophagoscopy)
Superficial injuries
• Erythema
• Edema or blistering
Deep injuries
• ulceration
Subsequent treatment is individualized on the basis of these
findings
In the presence of injury the esophageal status should be assessed
at repeated intervals of 3 weeks, 3 months and between 6 months
to a year
Treatment Options
Mechanical
Intraluminal Silastic stents
Pharmacological
Corticosteroids to modify the inflammatory
response
Antibiotics to control secondary infection
Strictures
Most frequent complication of caustic burns
Usually develops between three and eight
weeks after initial injury
Multiple areas of stricture can occur
Treatment Options for Strictures
Esophageal dilatation by the passage of
bougies
Surgical reconstruction
Special Note
There is an increased incidence in patients
who have previously suffered corrosive
esophageal burns to develop esophageal
carcinoma later in life (1000 fold increase)
The End