Diseases of the esophagus Attila Enyedi MD.

Anatomy of the oesophagus I cm lenth, (upper-middle-lower ) Blood supply: inf.thyreoid a., direct arteries from the aorta, bronchial, gastric & phrenic arteries Cervical, cardial, celiac lymphnodes, Jumping metastases UES,LES (upper-lower oesophageal sphincter) No serosa

Anatomy of the oesophagus II.

Diagnosis of the oesophageal diseases Native X-ray, swalloving X-ray CT, PET Endoscopy, biopsy Endoscopic US Manometry, pH monitoring

Achalasia Symptoms (Dysphagia, regurgitation of food, weigh loss, pain) Complications (aspiration, ulceration) Radiology (absent of peristalsis, dilatation) Manometry Endoscopy, biopsy

Achalasia Therapy Medical treatment Baloon dilatation Heller’s myotomy Laparoscopic myotomy

Perforation the oesophagus Foreign body Iatrogenic (intubation, endoscopy, dilatation) Accident Complaints Dysphagia Pain Subcutaneous emphysema Fever –mediastinitis, empyema thoracis, peritonitis

Perforation the oesophagus Diagnosis (in general late) Case history –Bone, fishbone, previous interventions Physical examination Swallowing X-ray CT (contrast enhanced) Endoscopy????

Perforation the oesophagus Treatment Conservative –AB, relieving nasogastric tube, stenting Surgery –Suture (in early stage) + covering of the suture –Drainage (mediastinotomy, Chest tube drainage) –Resection with cervical oesophagostomy (Thorec operation) –Transgastric drainage

Transgastric drainage

Oesophageal diverticulum Zenker’s diverticulum Dysphagia Pressure symptoms Gurgling sounds in the neck region Regurgitation of undigested food Manual emptying of the diverticulum by the patient

Oesophageal diverticulum Diagnosis of Zenker’s diverticulum Typical clinical signs Swalloving X-ray CT scan

Oesophageal diverticulum Diagnosis of Zenker’s diverticulum

Oesophageal diverticulum Therapy of Zenker’s diverticulum Oesophago-diverticulostomy

Oesophageal diverticulum Therapy of Zenker’s diverticulum resection

Oesophageal diverticulum Epiphrenic diverticulum Dysphagia Sensation of pressure in the lower oesophagus Intermittent vomiting Retrosternalsternal pain Regurgitation

Oesophageal diverticulum Diagnosis of the Epiphrenic diverticulum Typical clinical signs Radiologic contour on native chest X-ray Swalloving X-ray CT scan Associated with hiatal hernia

Oesophageal diverticulum Therapy of the Epiphrenic diverticulum Medicine therapy Resection of the diverticulum –Via thortacotomy –Via thoracoscopy (VATS) –Via laparotomy –Via laparoscopy

Hiatal hernia Types of hiatal hernia Paraoesophageal hernia Sliding hernia with GERD Mixed form Upside-down stomach

Hiatal hernia Symptoms of Paraoesophageal hiatal hernia Often asymptomatic Obstruction Pain Dysphagia Incarceration Ulcer diasesae/Barret oesophagus

Hiatal hernia Diagnosis of Paraoesophageal hiatal hernia Clinical signs Native chest X-ray Swalling X-ray Endoscopy

Hiatal hernia Diagnosis of Paraoesophageal hiatal hernia

Hiatal hernia Symptoms of Sliding hiatal hernia Chronic (80-85%) –Dysphagia –Early Satiety –Pain/Heartburn –Aspiration –Anaemia Acute (15-20%) –Dysphagia (sometimes total) –Haematemesis –Obstruction –Gangrene/Perforation –Peritonitis

Hiatal hernia Diagnosis of Sliding hiatal hernia Clinical signs Native chest X-ray Swalloving X-ray Endoscopy with biopsy (oesophagitis) Manometry Ph monitoring

Hiatal hernia Indication of surgical therapy Uneffective conservative treatment Morphologic disorders (eg. Oesophagitis, Barret oesophagus) Chronic aspiration (pneumonia) Bad complience of the patient

Hiatal hernia Surgical therapy I.

Hiatal hernia Surgical therapy II.

Hiatal hernia Surgical therapy III.

Hiatal hernia Surgical therapy IV.

Hiatal hernia Surgical therapy IV.

Oesophageal tumours Benignal –Papillomas –myomas –Leiomyomas Malignant –Squamouscell cancer –Adenomatous cancer

Oesophageal tumours Symptoms Dysphagia (solid food, than fluids) Weight loss Pain in 30% Coughing (oesophygotracheal fistule) Regurgitation Aspiration

Oesophageal tumours Diagnosis Clinical signs CT Swalloving X ray Endoscopy with biopsy Endoscopic US Bronchoscopy

Treatment of benign oesphageal tumours Surgical treatment/resection –VATS –Thoracotomy –Laparoscopy –laparotomy

Treatment of benign oesphageal tumours

Treatment of oesophageal cancer Radiotherapy Chemotherapy Surgery Protocol Resection than adjuvant chemo-radiotharpy Neoadjuvant chemo-radiotherapy than resection, than chemo-raditherapy Palliative treatment

Oesophageal tumours Suegical treatment Transthoracal or transhiatal resection Subtotal resection of the oesophagus Oesophago-gastrostomy (cervical or intrathoracic) Feeding and decompression jejunostomy

Subtotal oesophagectomy I.

Subtotal oesophagectomy II.

Subtotal oesophagectomy III.

Subtotal oesophagectomy IV.

Subtotal oesophagectomy V.

Subtotal oesophagectomy VI.

Subtotal oesophagectomy VII.

Subtotal oesophagectomy VIII.

Subtotal oesophagectomy IX.

Subtotal oesophagectomy X.

Subtotal oesophagectomy XI.

Subtotal oesophagectomy XII.

Subtotal oesophagectomy XIII.

Subtotal oesophagectomy XIV.

Neooesophagus -Stomac91% - Colon6% - Jejunum3%

Subtotal oesophagectomy XV.

Subtotal oesophagectomy XVI.

Subtotal oesophagectomy XVII.

Subtotal oesophagectomy XVIII.

Contraindication of radical resection Distant metastasis (eg. Liver, lung) Local spread to the surrounding organs –Aorta –Bronchial tree (oesophago-tracheal fistula) Poor general condititon Severe concomitant disease –Cirrhosis hepatic –Ischemic heart disease –poor lung function

Palliative treatment of oesophageal cancer R 1 resection, than adjuvans chemo- radiotharpy? Stenting Feeding gastro/jejunostomy –Via laparotomy –PEJ/PEG