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Cardiovascular and Thoracic Surgery Dr.Wallaa AlFalluji

1

The Esophagus

is a long muscular tube approximately 40 cm from the incisor
teeth ( 25 cm from cricopharyngeus ) ,that extends from the
pharynx at the level of 6
th
. Cervical vertebra to the stomach
,which it joins opposite the body of 11
th
. thoracic vertebra.It is
arbitrary divided into Cervical ,Thoracic and Abdominal parts.
The esophagus has three distinct areas of naturally occurring
anatomic narrowing :-1-The crico pharyngeal constriction
2-Broncho aortic constriction .
3-The diaphragmatic constriction .
Blood supply : -
Cervical esophagus Inf.thyroid Ar.
Thoracic esophagus esophageal branches (Aorta) and segmental
vessels (intercostal & phrenic) .
Venous drainage :-
Cervical esophagus inferior thyroid &vertebral V.
Thoracic esophagus azygous & hemi azygous
Abdominal esophagus gastric veins
Lymphatic :- regional lymph nodes , The flow of the upper 2/3
is upward while the flow of the lower 1/3 is downward.
Nerve supply :- the nerve supply to the normal esophagus is
cholinergic and causes contraction every where except for the
circular muscle of the cardia where its adrenergic and causes
relaxation .
Esophageal Hiatus :-It is a sling of muscle fiber that arises
from the right crus in approximately 45% of the patients ,
however both right and left crus contribute to the hiatus
Physiology : - It is a muscular tube that begins proximally with
upper esophageal sphincter (UES) and ends distally with lower
esophageal sphincter (LES) .Its function is to transport the
swallowed material from t he pharynx down to the stomach

Cardiovascular and Thoracic Surgery Dr.Wallaa AlFalluji

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Clinical manifestation of esopha geal diseases

it include : - Dysphagia ( difficulty in swallowing ) , Odynophagia
(pain on swallowing ) , Regurgitation & vomiting , Drooling of
saliva , Heart burn (substernal burning sensation ) ,Weight loss
& cachexia .
Investigations
1-Plain X -Ray chest : - it show : - a dilated esophagus
(especially in lateral view ) , in the lung (fluid level ) from the
spill over of the esophageal content , radio opaque foreign body
2-Barium swallow It is very essential and may be diagnostic in
some esophageal diseases such as achalasia of the cardia .
3-Esophagoscopy : It is the direct visualization of the interior of
, carried under GA rigid esophagoscope phagus by either the eso
,carried under local anesthesia flexible esophagoscope or by the
Indications :-
evaluate symptoms of dysphagia & o T -: diagnostic- A
odynoph agia ..etc , To asses establis hed esophageal pathology ,
To define or confirm radi ological abnormalities ..etc ,It is of
great value in assessment of post operative problems as
anastomotic stricture ,tumor recurrence ,bleeding and recurrent
GER
f Dilatation o Removal of foreign bodies , - Therapeutic :- B
stric ture , Placement of endoluminal prosthesis (stent )
,Sclerotherapy , Lase r photo coagulation for bleeding or tumor
de bulking
ceration of the lips or tongue , La -: Minor Complications-1
Fracture or dislodgment of teeth , Pharyngeal laceration
% of 2-1 which occurs in Perforation Major Complications_2
patients after(F.B removal ,Dil atation of stricture or biopsy

Cardiovascular and Thoracic Surgery Dr.Wallaa AlFalluji

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Management

4-Manometry :
It is the classical test to examine (LES) function .Hypertensive
Lower Esophageal Sphincter is s een in achalasia of the cardia
Loss of the tone is seen in pregnancy & a lcholism
Disorders of esophageal motility
Functional disorders of the esophagus Are those conditions that
interfere with the normal act of swallowing or produce
dysphagia without any associated intra – luminal, mural
organic obstruction or extrinsic compression.
Upper esophageal sphincter dysfunction : -Crico pharyngeal
dysfunction (oro pharyngeal dysphagia
)
: - Symptoms complex
that result when there is a difficulty in propelling liquid or solid
food from the pharynx into the upper esophagus .
Causes : - Neuro genic CNS (MS) , vascular (CVA) ,tumors
,trauma , Myogenic myasthenia gravis , inflammatory (poly
myositis) , Structural divertuculum , Mechanical intra or
extra luminal , Iatrogenic surgical or irradiation , Gastro
esophageal reflux .
Motor dis orders of the body of the esophagus
1-Achlasia of the cardia .
2-Diffuse esophageal spasm & related hyper motility disorders
Achalasia of the cardia
Is a disease entity of unknown etiology Characterized by
absence of peristalsis in the body of the esophagus, a high
resting pressure at the (LES) and failure of this sphincter to
relax in r esponse to swallowing .

Cardiovascular and Thoracic Surgery Dr.Wallaa AlFalluji

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Etiology :- attributes to a neuromuscular dysfunction affecting

both the narrowed and the dilated segments of the esophagus
occurs at any age. The highest incidence -: Clinical features
is( 25 -60 ) Mostly equal sex incidence or > in female , The
durati on of symptoms (Days to years) , The onset ,sudden or
insidious .sudden( emotional stress ) ,The symptoms include : -
dysphagia ,Regurgitation , Pain ,Weight loss & Cachexia
. Heart burn ,Emotional Disturbance ,Respiratory symptoms ,
air bubble. Visible Absence of gastric- CXR : -1 -: Diagnosis
Esophagus, Fluid level .
2-Barium Swallow : Dilated Esophagus ,food residue , Little
barium passed to the stomach ,Mo rphological forms : Cork -
Screw, Cucumber ,Tortuous & Sigmoid , Bird s beak appearance
3-Esophagoscopy :To confirm the diagn osis ,exclude other path
4-Manometry: Absence of perist alsis(body), high LES pressure
Differential diagnosis: Diffuse esophageal spasm OR Syst emic
sclerosis OR Organic obstruction( stricture , tumors)
Treatment : 1-Medical treatment - adalat , isordil 2-Dilatation
(bougiena ge) pneumatic or hydrostatic 3-Surgery -- ---
Heller’s cardio myotomy …. R ecently -- Laparoscopic cardio
myotomy
Complications of achalasia :- 1- Those related to retention &
stasis ( Retention esophagitis ) 2-Air way obstructi on &
repeated chest infection 3-Pre malignant (squamous cell
carcinoma )
Perforation of the esophagus
either by instrumentation Esophageal perforation following-1
the rigid esophagoscope or by bougienage

Cardiovascular and Thoracic Surgery Dr.Wallaa AlFalluji

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perforation , Foreign bodies ingestion or blunt and Traumatic-2

penetrating trauma
haave’ s syndrome ) due to the - ( Boer Spontaneous rupture-3
strain of emesis with or without predisposing disease .
of the normal anatomical constriction are the most sites The
of the 2/3 upper common sites of perforation .The
esophagus will perforate into the rt. Pleural cavity while the
will perforate into the lt. Pleural cavity .
rd
1/3 lower
Pain ,Fever ,Dysphagia ,Cervical pain : Clinical manifestations
or crepitation , Dyspnea , Pneumothorax and in severe
cases dyspnea and cyanosis .
:Mediastinal emphysema . Pleural effusion ray - Chest X
alize the site of perforation can loc Barium study
),IVF , Nasogasric feeding, NBM = NPO( Medical ; Treatment
Surgical to close the perforation.
Stricture of the Esophagus
the ingestion of solid or resulting from It : Caustic Strictures-1
liquid caustics most frequently seen in children who have
accidentally swallowed the material or in adult who have
ingested the material for suicidal purposes .
like & - included alkaline caustics, acids or acid The chemicals
household bleaches .Strong alkalis (Na&KOH)
Ranges from(minimal to shock ) . Dyspnea may : Symptoms
occur .
ation of the etiological agent , Identific-: Management
Administra tion of the neutralizing agent , Assessment of the
extent of the injury , Early Esophagoscopy ! to determine
whether there is esophageal injury or not , Cortico steroid
dec reases the degree of stricture , Antibiotics togethe r with
steroid for ( 3-6 week ) , Barium –swallow two weeks later to
se e if there is stricture or not , Dilatation ( Bougenage) may be
needed after( 3-4 weeks) and many pa tients need regular
dilatation , May need Esophageal replacement .
Esophageal stricture is a premalignant.

Cardiovascular and Thoracic Surgery Dr.Wallaa AlFalluji

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stricture Esophageal - e: Reflux Esophagitis and Strictur-2

secondary to the reflux of acid or alkaline secretions into the
esophagus caused by esophagogastric incompetence as a result
of hypotensive (LES ) . it is a co ntinuous process of destruction
and healing that may stop at any stage or may progress to
fibrosis ,stricture with the resulting dysphagia.
Low stricture -1 -: to reflux are of three types Stricture secondary
occur at the esophagogastric junction
2- High stricture occur at higher level ,associated with barrett
esophagus; it is an acquired condition in which the squamous
epithelium has been eroded by the damaging effects of GE
reflux and has subsequently been replaced by columnar
junctional epithelium, it is a rare ,but it is PRE MALIGNANT
and the malignancy is adenocarcinoma .
3- long stricture rarest type , occur in postpartum vomiting .
. Resection \ Surgery-2 . Dilatation \ Bougienage -1: Treatment
CARCINOMA ESOPHAGUS
Carcinoma of the esophagus is a disease of men between
age ( 50 -70 ) .Two risk factors: - smoking and high
consumption of alcohol.
Achalasia , Barret esophagus & Predisposing lesions :
Corrosive stricture
most common 95% Squamous cell carcinoma > Pathology
(body) , Primary adenocarcinoma < 1-7% most common of
them is adenocarcinom a arise in Barrett’s esophagus
,Mucoepidermoid &Adenocystic carcinoma .
Spread : Dir ect extension OR Lymphatic to cervical
,med iastinal and sub diaphragmatic OR Blood metastases liver
,lung & bone

Cardiovascular and Thoracic Surgery Dr.Wallaa AlFalluji

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Clinical manifestations : Dysphagia ,to solid later to liquid

,Weight loss ,Aspiration pneumonia .Pressure symptoms .
Barium –swallow : irregular ragged mucosal pattern with
annular luminal narrowing .
Esophagoscopy : to see the tumor , to take biopsy(tissue
diagnosis) ,and esophageal wash for cytology .
CT with oral contrast
Treatment : 1-Chemo -therapy : little value 2-Radio -therapy :
useful b ut it may cause post radiation str icture ,radiation
pneumonitis . 3-Surgery : a- palliative
b- Resection - partial gastrectomy ,partial esophagectomy
&gastro esophageal anastomosis (Ivor lewis operation ) thr ough
lapratomy & thoracotomy .
Gastro Oesophageal Reflux Disease (GORD)
Heartburn: -Mild , intermittent reflux of gastric content into the
esophagus without tissue injury .Common among adult .
GORD :-Esophagitis with varying degree of erythema ,
edema & friability of the distal esophageal mucosa .
A etiology : - Lower esophageal sphincter (LES ) incompetence ,
Gastric outlet obstruction , 50% of patients ha ve an associated
hiatal hernia , Defective esophageal function (Scleroderma )
Mechanism of Anti –Reflux ……..
1-High resting pressure in the distal esophagus ( 10 -20 mm Hg).
2- the right crus of the diaphragm around the esophago -gastric
junction .
3-The phreno esophageal membrane .
4-The presence of the intra abdominal segment of the esophagus
5-The oblique angle of insertion of the esophagus into the
stomach (angle of His ) .
6-The small diameter of the esophagus entering abruptly into the
large diameter (stomach) Law of Laplace .

Cardiovascular and Thoracic Surgery Dr.Wallaa AlFalluji

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Clinical features : - Epigastric or retro sternal pain , aft er meal or

at night , Pain similar to angina , Reflux of food or gastric
content , oc curs with bend ing , Odyno phagia , Pulmonary
aspiration , nocturnal cough
Diagnosis : - History and physical examination , Barium swallow
,Oesophago gastr o dudenoscopy (OGD ) & biopsy ,
Ambulat ory 24 hours PH monitoring , Esophageal manometry
Treatment :- 1- Medical : - Weight reduction , Change diet (light
frequent meal ) , Stop smoking , Elevate the head of the bed ( 4-
5 inches ) , Anti acid , Metoclopromide increase LES pressure
& gastric emptying , H 2 receptor blockers , Ranitidine (Zantac ),
Proton pump inhibitor omeprazole. 2- Surgical :- Indications
:- Failure of medical treatment , Presence of complications
(str icture , respiratory symptoms) , Patient preference . Surgery
:-Laparoscopic Nissen ‘s fundoplication , Lapratomy
Nissen ‘s fundoplication , Thoracotomy Belsy’s mark 1V
repair
Esophageal hiatal hernia It is the herniation of the
stomach through the esophageal hiatus of the diaphragm. H iatal
Hernia are of two types ; 1-Type 1 axial (sliding H.H.) is
common , usually insignificant ,in which there is hiatus opening
dilatation and or stretching of phrenoesophageal membrane ,
so that a portion of the fundus will slide upward into the hiatus
.No true sac. In some patients a large pouch can occur producing
abnormal degree of GE reflux . (significant) ..
on but more less comm ) esophageal (rolling- The Para-2
significant ,there is a defect of phreno –esophageal mm. So this
allows protrusion of the peritonium through the fascia (true
hernial sac ) .this will lead to progressive enlargement of the

Cardiovascular and Thoracic Surgery Dr.Wallaa AlFalluji

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hernia .the entire stomach may herniated. May lead t o gastric

volvulus, strangulation and intrathoracic gastric distention.
In which herniation of the cardia well above . Combined H.H
the diaphragm in add ition to paraesophageal hernia .
colon , small other organs herniated ( Multiorgan H.H.
intest ine) .
Heart burn &Regurgitation Clinical presentation ;
aggravated by posture Commonly after meal , Dysphagia ,
Aspiration into the chest can o ccur often awaken the patient
can lead to lung abscess .
eal type (II) hag paraesop is cipal indication the prin Treatment :
H.H. & n o indication for repair of type(I) unless severe
reflux. Medical: - should started once reflux diagnosed
Surgical :-Nissen ‘s fundoplication (lapratomy or
laparascopic) , Beksy’s mrak IV repair (Thoracotomy )
Esophageal divertuculae Are epithelial -lined mucosal
pouches that protrude from the esophageal l umen. Classified
into : -Pharyngo esophageal , Parabronchial (midesophageal) ,
Epiphrenic (Supra diaphragmatic)
Sideropenic Dysphagia (Plummer -Vinson or Patterson -
Kelly syndrome ) .Cervical dysphagia in patien ts with iron
deffiency Anemia , Usually wo men over the age of ( 40 ) years , It
is pre malignant condition, Treatment d ila tation &correction of
anemia
Schatzki s Ring (Distal esophageal web) Commonly seen in
patient with a sliding H.H.,appearing as annular strictures
projecting into the lumen.
Mallory -Weiss Syndrome A history of emesis followed
by either melena or hematemesis ,May occur in pregnancy
,alcoholism, bowel obstruction


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