Esophagus

Œsophage esófago:

Œsophage esófago Οισοφάγος 식도 食 道 घुटकी นพ.จักรพันธ์ จิริสิริธรรม (Ken)

Surgical Anatomy:

Surgical Anatomy Esophagus start at C6 = cricoid cartilage Fixed parts = cricoid & diaphragm Deviation = left – mid – left/anterior Narrowing Circopharyngeal muscle (its entrance) Ø 1.5cm Lt main bronchus crossing Aorta Ø 1.6cm Diaphragmatic hiatus (GES) Ø 1.6-1.9cm Length = จำรูปไป Cervical portion length 5 cm From C6 to T1,2(jugular notch) Thoracic portion length 20 cm Abdominal portion length 2 cm

Surgical Anatomy:

Surgical Anatomy Blood supply Cervical = inferior thyroid a. Thoracic = bronchial a. + 2 x esophageal branch from aorta Abodominal = ascending branch of left gastric a . Venous drainage Cevical = inferior thyroid v. Thoracic = bronchial, azygos , hemiazygos v. Abdominal = coronary v. Musculature : outer-long, inner-circular Upper 2-6 cm contain only striated muscle Lower = more smooth muscle fiber Lymphatic in submucosa form single complex tumor cells can flow freely in longitudinal direction cervical esophagus is more direct to regional LN

Physiology:

Physiology Swallowing mechanism 1/3 in mouth- hypopharynx = piston pump + 3 valves 2/3 in esophagus = worm-drive pump + 1 valve (LES) Peristalsis contraction main = posterior pharyngeal constrictors Sucked into tharocic esophagus by negative pressure Soft palate Epiglottis Cricopharyngeus Oropharyngeal phase 1.5 sec Pressure in hypharynx 60 mmHg

Physiology:

Physiology Swallowing mechanism Afferent nerves = Efferent nerves = Striated muscles (1/3) are activated by motor fiber vagus n. + recurrent laryngeal n. Primary peristalsis Secondary peritalsis = independent local reflex for clearing material Glossopharyngeal n. Sup. Laryngeal br. of vagus n. Swallowing center(medulla) CN V, VII, X, XI, XII + C1-C3 Pressure 30- 120 mmHg Wave cycle 3-5 sec Speed 2-4 cm/s Total time 9 sec Continuity of muscle isn’t necessary if nerves are intact

Physiology:

Physiology Physiologic reflux Antireflux mechanism in human Normal reflux = common in upright and awake !!! LES = intrinsic tone α neural ( vagus ) & hormonal response Vagus = both excite and inhibit Effective LES Efficient esophageal c learance Adequate gastric reservoir function Activity -> loss GE barrier 12 mmHg gradient Abd -thoracic ↑LES pressure in supine ↑ LES tone Alpha agonist Β eta blocker Gastrin / Motilin Antacids Motilium Plasil PGF2 ↓ LES tone Alpha blocker Beta agonist Estrogen/Progesterone CCK/Glucagon Somatostatin Secretin GI hormonal peptide Diazepam, Barbiturate Ca chan. blocker Pethidine PGE1 PGE2 Caffeine, chocolate, peppermint เหล้า

Assessment of Esophageal function:

Assessment of Esophageal function Structural abnormality Functional abnormality Gastric juice exposure Duodenogastric function

Detect structural Abnormalities:

Detect structural Abnormalities Radiagraphic Barium swallow (full-column technique) = 1 st diagnostic test Can assess : motility(cine-), hiatal hernia(Prone position), circumferential cancer, peptic stricture, large ulcer, Complete study = eso+stomach+duodenum If dysphagia but Barium study normal try Barium+marshmallow or bread or Hamburger Intrathoracic stomach + large hiatal hernia

Detect structural Abnormalities:

Deeper biopsies required Closer assessment of cricophryngeus and cx esophagus Endoscopic exam Pre-barium study may help in Flexible fiber-optic esophagoscope = instrument of choice Rigid esophagoscope when … When suspected GERD look for Esophagitis grading Detect structural Abnormalities C ervical vertebral osteophyte Deep penetrating ulcer Diverticulum Carcinoma Esophagitis & Barrett’s CLE(C-line) Grade I small, circular, nonconfluent erosion Grade II linear erosion + granulation tissue/contact bleed Grade III circumferential epithelial loss, Cobblestone Grade IV Stricture present (± pass 36F scope)

Detect structural Abnormalities:

Detect structural Abnormalities Endoscopic exam Barrett’s esophagus = columnar instead of squamous ( intestinal hyperplasia) Suspected when Confirmed by Bx (multiple in cephalad direction 2 cm apart x 4 samples) Earliest sign of CA = severe dysplasia or intramucosal adenoCA Gastroesophageal flap valve (detect by retroflexion view) Hill’s grading Grade I valve 3-4 cm along lesser curve Grade II valve less well defined + rarely open in respiration Grade III ridge barely seen + rarely closed + usually hiatal hernia Grade IV no muscular ridge + always open + always hiatal hernia Difficult to identify Squamocolumnar junction Redder and luxuriant mucosa of distal esophagus

Detect structural Abnormalities:

Detect structural Abnormalities Endoscopic exam Hiatal hernia = A pouch lined with gastric rugal fold ≥ 2 cm above crus (↑identified by sniffing) → Paraesophageal hernia(PEH) → Esophageal diverticulum → Submucosal mass → Biopsy? must exclude gastritis or ulcer in the pouch ↑ gastric juice exposure must exclude CA and ulcer

Detect Functional Abnormalities:

Suspected motor abnormal on complaint of dysphagia, odenophagia , chest pain which EGD/Barium normal Stationary/Conventional manometry Indication : Use : High-Resolution Manometry ↑ recording sites & 3D assessment Impedance test ↑ Identify both Detect Functional Abnormalities 1. Confirm Dx 1 0 or 2 0 motility disorder 2. Preop evaluation in Anti-reflux Sx ↑ identify focal motor abnormality ↑ability to predict bolus propagation ↑ sensitivity to measure pressure gradient Impedance = resistance , Air > Food/content/saliva 1. Esophageal function 2. Gastroesophageal reflux pH probe

Detect Functional Abnormalities:

Esophageal Transit Scintigraphy 10-ml water bolus + 99m Tc sulfur colloid Cine/ videoradiography Benefit in Combined video + manometry = “ Manofluorography ” 1. Pharyngeal phase of swallowing 2. Small abnormality (diverticulum or web ) Detect Functional Abnormalities Cricopharyngeal Achalasia Best for complex functional abnormalities

Detecting ↑ gastric juice exposure:

24-Hour ambulatory pH monitoring The device : transoral /nasal, mucosal clip Not test for reflux ! Assess Sense 96% Spec 96% PPV 96% NPV 96% … Accuracy 96% Combined 24-Hour gastric & esophagus pH monitoring Detecting ↑ gastric juice exposure Cumulative time the esophageal pH <4 Frequency of reflux episodes Duration of the episodes (>5 min) Gold standard for Dx GERD

Test for duodenogastric function:

Test for duodenogastric function Esophagus and duodenogastric function relations Tests Abnormal gastric reservoir, ↑acid secretion Duodenal Reflux of alkaline, bile salt, pancreatic enzyme, HCO 3 Gastric emptying Gastric acid analysis Cholescintigraphy radionuclide-labeled meal normal clearance = 59% in 90min measure basal and max gastric acid secretion (basal/fasting = 0-5 mmol /h, max ≤ 30 mmol /h in normal) For assess duodenogastric reflux IV injection like 99m Tc-DISIDA scan + IV choloecystokinin → monitor radioisotope in stomach 24-Hour Gastric pH monitoring ↑ acid exposure & Esophagitis Esophagitis, Barrett’s

Gastroesophageal reflux disease:

Resting pressure Overall length Intra- abd length Gastroesophageal reflux disease Clinical Antireflux mechanism High pressure zone = LES = Collar sling(greater curve) + Clasp fibers(Lesser) LES characteristics After medication Rx mucosa healed but Reflux Don’t ! Hiatal hernia Heartburn = substernal burning discomfort, radiate upward, ↑by meal/ choco / alc / กาแฟ /supine Regurgitation : severe at night or supine → cause pulmonary symptoms Dysphagia : Oropharyngeal and esophageal dysphagia , 6 grades Chest pain : 50%pt with severe chest pain + normal  had 24-H pH positive No Anatomical landmark 1 0 cause of GERD = permanent attenuation of collar sling (Loss high pressure zone) Resting pressure < 6mmHg Overall length < 2 cm Intra- abd . Length< 1 cm defect Most common Repeat gastric distention Sling & fiber weaken Open angle of His Stretch phrenoesophageal lig . Hiatal hernia↑

Gastroesophageal reflux disease:

Pathophysiology Complications Noxious agents = gastric acid, pepsin, bile acid, pancreatic enz . Predisposing factors = Gastro+Duo reflux = more severe than gastric alone Barrett’s → AdenoCA = 1%/year Gastroesophageal reflux disease Stomach( fusdus ) distend Unrolling sphincter ↑Exposed gastric juice Turn to columnar epithelium ↑Swallowing for ↓symptom Aerophagia , bloating, belching Over-eaten Delay gastric emptying High-fat diet Ulcer/ esophagitis Barrett’s (BE) Cancer Peptic Stricture Schatzki ring Respi complication “Vicious cycle” 1. Defective LES 2. ↑Exposure to pH<4 or >7

Gastroesophageal reflux disease:

Gastroesophageal reflux disease Metaplastic and Neoplastic complication BE was identified by columnar extent ≥ 3cm into esophagus, proved by Bx showing IM Hallmark of IM = Intestinal goblet cell Antireflux surgery Rx → excellent result in long-term control symptoms BE ulcer more like peptic ulcer > erosion BE stricture typical higher > peptic stricture Long segment columnar mucosa w/o IM = congenital/rare Cardia also have IM with same malignant potential Old indications = complications : stricture, ulceration, progressive IM segment Recently = symptomatic, uncomplicated, young patient 1/3 of BE present with Malignancy Low grade dysplasia → PPI x 3wk with repeat Bx High grade dysplasia → Esophageal resection

Gastroesophageal reflux disease:

Gastroesophageal reflux disease Respiratory complication Treatment Laryngopharyngeal reflux Adult –onset Asthma Idiopathic pulmonary fibrosis Respiratory symptoms 50% relief with Medication 70% with Sx (adult) 90% with Sx (children)

Gastroesophageal reflux disease:

Gastroesophageal reflux disease Medical tharapy for GERD Mild/Early symptoms Persistent symptoms Antacid, Alginic acid Plasil , Motilium Elevate HOB Avoid tight-fitting cloth Eat small, Frequent meals Avoid night meal Avoid alc. coffee, coco, peppermint Add PPI 40mg/day … life long … For relief symptoms + control esophagitis/stricture If fail Endoscope 24hr pH Impedance test Manometry + Risks* Lap Antireflux surgery *Risks Supine reflux Esophageal body dysfunction Erosive esophagitis Barrett esophagitis Bile reflux Defective LES

Gastroesophageal reflux disease:

Gastroesophageal reflux disease Surgical therapy for GERD (in the past) 1. Presence of esophagitis 2. Structurally defective LES Now = symptomatic patients, especially in … Young patient (most cost effective in < 49yr) Severe esophagitis (endoscope) Stricture presence Barrett’s CLE Indication Good responder in medication = excellent outcome in Antireflux Sx Standard = Lap Nissen fundoplication Questionable esophageal length = Transthoracic approach Absent contraction/peristalsis = partial fundoplication Short LES = add Collis gastroplasty Procedure selection Esophagectomy in … Global failure of esophageal contractility BE with high-grade dysplasia CA esophagus detected

Gastroesophageal reflux disease:

Gastroesophageal reflux disease Surgical therapy for GERD Preop evaluation Primary goal 5 Principles of surgery Esophageal body contractility ( Manometry ) Anatomic shortening (Barium swallow) Complaint of N/V, loss of apetite (may persist) H. pylori Restore the structure of the sphincter Preserve ability to swallow, belch and vomit Restore pressure of LES = 2x resting gastric pressure LES length ≥ 3 cm (restore 1.5-2 cm) Allow reconstructed cardia to relax on deglutition Not too much fundoplication (just 2cm and over 60F bougie ) Fundoplication without undue tension and fixed with crura

Gastroesophageal reflux disease:

Gastroesophageal reflux disease Primary anti-reflux repair Open Nissen Fundoplication 360 o Crural dissection , preserve vagus nerve Esophageal mobilization Posterior crural closure Divide short gastric and posterior fundus Create fundoplication over the dilator Lap Nissen fundoplication Modified lithotomy position 10-mm ports x 5 HOB 45 o

Gastroesophageal reflux disease:

Gastroesophageal reflux disease Primary anti-reflux repair Transthoracic Nissen fundoplication Left posterior lateral thoracotomy 6 th ICS Incised diaphragm circumferentially + laterally Mobilized esophagus from diaphragm to aortic arch Fundoplication performed in chest, placed back to abd . Indication Previous hiatal hernia repair Concomitant esophageal myotomy Short esophagus (stricture or BE) Irreducible sliding hernia Evaluate pulmonary pathology Obese patient Lap partial fundoplication ( Toupet ) 270 o ,4 cm Transthoracic partial fundop ( Belsey Mark IV) 270 o , 4 cm Collis gastroplasty

Gastroesophageal reflux disease:

Gastroesophageal reflux disease Outcome of anti-reflux surgery 90% relief reflux-symptoms 70% relief respiratory-symptoms 90% pH normalized Side effects Outcome in BE patient Does antireflux Sx cause regression of BE ? Does Sx prevent progression ? Can BE be prevented with early Sx ? Temporary dysphagia is common (resolved in 3 mo.) Inability to vomit Hyperflatulence In early state, YES YES if recognized and treated early YES, before dysplasia occur

Gastroesophageal reflux disease:

Gastroesophageal reflux disease Re-operation for failed anti-reflux repair Fail = Cause = Unable to swallow normally Recurrence/Persistent reflux symptoms U pper abd discomfort, postpandial Wrapping around stomach (M/C in open) Herniation into chest (M/C in Lap) Fundoplication breakdown Too tight, too long fundoplication Undiagnosed motor disorder Re-Operation in Technical failure = immediate post-op dysphagia (wrap around stomach) Recurrence reflux-symptoms without dysphagia (with also good motility) Resection in Dysphagia + poor motility + multiple previous repairs

Giant diaphragmatic(hiatal) hernia:

Giant diaphragmatic(hiatal) hernia 4 Types Type I Sliding hernia (upward dislocation of cardia ) Type II Rolling hernia/PEH (dislocation of fundus) Type III combined type I + II Type IV additional organ (Colon) herniation Clinicals PEH = ʢ , dysphagia, postprandial fullness, Anemia Sliding = reflux symptoms Indication Sx = all PEH Approachs Lap(standard), Open, Transthoracic Primary repair Mesh repair (Synthetic , Biomaterial) Add fundoplication ? (controversy) Type III Type I Type II

Schatzki’s ring:

Schatzki’s ring Thin submucosal ring at SCJ Associated with hiatal hernia Ring = Protective mechanism of reflux Clinical = brief episode of dysphagia (รีบกินๆๆ) Treatment = Dilation alone Plus Antireflux Sx in reflux proven Scleroderma Diagnosis absent absent Systemic disease involve Esophagus 80% ʢ 40 yr CREST syndrome, Anti-Scl70 Smooth muscle atrophy + collagen deposit Absent peristalsis distal part ↓ LES pressure, GERD Sx = controversy Lap partial fundoplication

Motility disorder of pharynx/esophagus:

Motility disorder of pharynx/esophagus Disorder of pharyngoesophageal segment Discoordination of neuromuscular Inadequate orophryngeal bolus transport Inability to pressurized pharynx Inability to elevate larynx Discoordination of pharyngeal contraction/relax Decrease compliance of pharyngoesophageal segment Congenital Acquired : CNS/PNS, Pure motor disease Extrinsic compression Common Dx = Video/Cineradiography ± Manometry Dysphagia Surgery = Pharyngocricocervical esophageal myotomy

Motility disorder of pharynx/esophagus:

Motility disorder of pharynx/esophagus Disorder of pharyngoesophageal segment Zenker’s diverticulum M/C recognized sign of pharyngoesophageal dysfunction Enlarged due to ↓ compliance of skeletal portion Clinical = Dysphagia, regurgitation, interrupting eating/drinking chronic aspiration, recurrent respiratory infection Dx = Barium swallow Endoscope is dangerous (perforation) 1. Cricopharyngeal myotomy 2. Diverticulopexy (large, persist after myotomy ) 3. Diverticulectomy (Very large, thick wall) Surgery Endoscopic stapled diverticulotomy Endoscopic stapled cricopharyngotomy Endoscope For Diverticulum > 2cm Diverticuloscope 3 cm

Motility disorder of pharynx/esophagus:

Motility disorder of pharynx/esophagus Disorder of esophageal body and LES Pseudoachalasia = tumor infiltration tight antireflux procedure Vigorous achalasia = auto-contraction of esophageal body with high amplitude *chest pain is common *mimic DES

Motility disorder of pharynx/esophagus:

Motility disorder of pharynx/esophagus Disorder of esophageal body and LES DES Substernal chest pain, less dysphagia Primary disease at the body (Achalasia = LES) Abnormal manometry confined to distal 2/3 Nutcracker Hypertensive/high-amplitude peristalsis M/C primary esophageal motility disorder Chest pain ! (from GERD not the squeezing) Treatment aim to treat GERD Hypertensive LES ↑ basal pressure of LES Myotomy only in fail Med and dilation Nonspecific motor disorder Not meet the critieria Sx = N o role unless associated with diverticulum

Motility disorder of pharynx/esophagus:

Motility disorder of pharynx/esophagus Disorder of esophageal body and LES Diverticulum of the body Pulsion diverticulum A ssociate with motor disorder Epiphrenic diverticulum (distal 1/3) Traction diverticulum Associate inflammatory, TB, Asper , Lymphoma, Sarcoid Midesophageal diverticulum (TB with mediastinal LN involved) - Mostly asymptomatic Treatment option (Depend on size + proximity to vertebra) Diverticulectomy + Myotomy Suspension + Myotomy Treatments (depend on degree of symptom) Exclude motor disorder Suspended ± Myotomy

Operation for motility disorder and diverticulum:

Operation for motility disorder and diverticulum Long esophageal myotomy Dysphagia Prevalence of effective contraction Indication dysphagia cause by motor disorder + fail medication (chest pain not the indication) Lt 6 th ICS 2 cm incision 1 cm stomach Covered 4 cm

Operation for motility disorder and diverticulum:

Operation for motility disorder and diverticulum Myotomy of LES (Heller myotomy ) Important issues Long term result : Sx > Dilation > Botulinum Sx approach : Abdomen > Chest Add antireflux Sx : YES, partially Disease is curable : NO Lap > open in achalasia Indication of Myotomy Failed dilation Dilated/tortuous esophagus Hiatal hernia associated 4 Principles in myotomy Complete division of circular+collar sling muscles Adequate distal myotomy Adequate undermining the muscularis Prevent postop reflux Epiphrenic diverticulum

Operation for motility disorder and diverticulum:

Operation for motility disorder and diverticulum Lap Cardiomyotomy (Lap Heller myotomy ) Position, ports and incision as Lap Nissen Divide short gastric vessels Preserve vagus nerve Anterior ( Dor ) fundoplication Posterior ( Toupet ) 2-3 cm in stomach 4-5 cm in esophagus Myotomy all layer muscles Lap Heller + Partial fundoplication Is the best Rx for Achalasia From RCT Result = 93% improved 5% complication <10% reflux

CA Esophagus:

CA Esophagus Risk factors Squamous cell Smoking Alcohol South Africa, China, Kazakhstan Nitroso compound = pickled vegies, smoked meat Mineral deficiency (Zn, Molybdenum) Long standing achalasia Lye stricture Tylosis (autosomal dominant) HPV Adenocarcinoma GERD BE (40-50x) Almost always originate in metaplastic BE 10-15% of GERD have BE 1/100-1/200 pt-yr of BE have adenoCA Resemble gastric cancer Clinical Asymptomatic, dysphagia, stridor, coughing, choking, TE fistula, asp pneumonia, Invade vocal cord, Lt recurrent laryngeal nerve, erosion of aorta/pulmonary vessels Significant dysphagia = involved ≥ 60% lumen Present with TE fistula → 40% have distant metastasis M/C metastasis = lung, liver, peritoneum, bone W/U Initial = CXR, CT, Endoscope, Barium EUS to identified curative resection (accuracy 80%)

CA Esophagus:

CA Esophagus AJCC 7 th

CA Esophagus:

CA Esophagus Approach Tumor location Age Cardiopulmonary reserve Nutritional status Clinical staging Cervical Usually unresectable (invade larynx, vessels, trachea) Rx = Stereotactic radiation + chemo Middle 1/3 M/C = squamous cell CA, usually LN metastasis Rx = Resection alone in Early/Confined disease (T1-T2,N0) Neoadjuvant + Resection in locally advance disease (T3, N1) Lower + EGJ M/C = AdenoCA Spread along submucosa lymphatic + skip area Curative resection required margin 10 cm with ≥ 50% proximal gastrectomy

CA Esophagus:

CA Esophagus Sx Contraindication Age >75 yr LVEF < 40% FEV 1 < 1.25 L Can’t tolerate GA Metastasis 12 month from initial Mx Salvage esophagectomy Palliative Rx for dysphagia Grade I-III = Definitive chemoradiation therapy GradeIV -VI = Esophageal stent + Chemoradiation CA EGJ = Lap jejunostomy

Surgical treatment CA Esophagus:

Surgical treatment CA Esophagus No Esophagectomy if R0 not possible Options Transthoracic esophagectomy McKeown technique (3-field) Ivor Lewis technique (2-field) En bloc (Radical) esophagectomy Transhiatal esophagectomy (blunt esophagectomy ) Thoracoabdominal esophagectomy Minimal invasive esophagectomy MIS transthoracic 2-field esophagectomy MIS transthoracic 3-field esophagectomy MIS transhiatal esophagectomy Endoscopic mucosal resection (EMR) Salvage esophagectomy Only for Tis and T1a If margin + ve then esophagectomy After fail/complete chemoradiation No distant metastasis Primary remain + symptomatic 12 month after initial Rx Quickest way

Surgical treatment CA Esophagus:

Surgical treatment CA Esophagus EMR Infiltrate saline → suction cap → resect with snare Surveillance q 3-6 mo. RF ablation for high-grade dysplasia lesion remained MIS Transhiatal esophagectomy Only for high grade dysplasia and microscopically cancer Can’t get LNs 4-5 abdomen ports + transverse cervical incision Remove esophagus with “inversion” technique Conduit = gastric tube → cervical esophagogastrostomy Open Transhiatal esophagectomy Suitable for CA lower esophagus or EGJ Can’t get mediastinal LNs above inf pulmo vein

Surgical treatment CA Esophagus:

Surgical treatment CA Esophagus MIS 3-field esophagectomy Left lateral decubitus, VAT at 9 th ICS Mini-thoracotomy at Rt 6 th ICS All LNs removed, divide Azygos v. and thoracic duct Supine position + 5 ports Created gastric conduit ± pyloroplasty Transverse cervical incision + cervical anastomosis MIS 2-field esophagectomy Supine + 5 ports first Create gastric conduit + mobilized EGJ Left lateral decubitus + VAT Dissect esophagus all length, remove LNs …. EEA created with stapler Complications ตามลำดับ Pneumonia Atrial fibrillation Anastomosis leakage Ivor Lewis (En Bloc) esophagectomy Start in upper abdomen, midline Extensive LN dissection (include Gr. 8, 9, 11, 12) Created 4-cm gastric conduit Left lateral decubitus, anterolateral thoracotomy 6 th ICS Resect : Azygos v, thoracic duct, periaortic + mediastinum tissue and all mediastinal LNs Anastomosis = upper thoracic esophagus + conduit Highest complication rate … Greatest survival though

Surgical treatment CA Esophagus:

Surgical treatment CA Esophagus Esophagectomy technique Transthoracic VS Transhiatal Schwartz said : mortality and morbidity of Transhiatal is Less 2 Metaanalysis + 3 RCT : No difference in Mortality, Blood loss, Pneumonia, AF *but trend better survival in transthoracic No thoracotomy Less op time Good for elderly For valvular heart or Atherosclerosis (can’t tolerate BP fluctuated) Routes Posterior mediastinum : 1 st choice, shortest, native, less dissection Retrosternum : for R2 resection or Radiation, ↑ leakage&mortality Subcutaneous Transpleura Conduits Stomach : Pros = Good blood supply, single anastomosis, easily reach to neck Cons = tumor/LN involved, RT region, PU, prior Sx /gastrostomy, reflux Colon : Left side = proper size, less vascular variation, more length acquired Right side = Less diverticulum, Less effect of atherosclerosis, easier technique Jejunum (REY, Pedicle interposition, Free jejunal graft using superior thyroid or internal mammary) Anastomosis In Neck : Leakage is less severe In Chest : Less injury to neck strcuture (recurrent laryngeal n.) Resected margin Proximal < 5 cm recurrence 20% 5-10cm recurrence 8% >10 cm recurrence 0% Distal = all lesser curve of stomach

Surgical treatment CA Esophagus:

Surgical treatment CA Esophagus Radiation Therapy Use for dysphagia, lasting 2-3 mo. Chemoradiation Therapy Benefit in neoadjuvant setting 13% survival advantage (7% in Chemo alone) Benefit in AdenoCA > Squamous cell CA R0 resection = most important for long-term survival Timing of surgery after neoadjuvant = 6-8 wk

CA Esophagus:

CA Esophagus Role of Adjuvant ChemoRT ? Chemo regimen = 5FU-base, Taxane -base, Platinum-base, Trastuzumab

Sarcoma of Esophagus:

Sarcoma of Esophagus Age group & clinical dysphagia = same as CA Gross = Smooth, large, polypoid , intraluminal mass ± necrosis Sarcomatous lesion subtypes 1. Epidermoid carcinoma ( Carcinosarcoma ) : spindle cell type 2. True sarcoma : Mesenchymal tissue( Leiomyosarcoma , Fibrosarcoma , Rhabdomyosarcoma ) Surgical resection = Rx of choice both palliative and curative (Better prognosis than CA) Leiomyosarcoma Leiomyosarcoma Leiomyoblastoma Leiomyoblastoma = malignant Poor prognosis in Nuclear hyperchromatism present ↑ Mitosis (>1 per HPF) Size > 10 cm Clinical > 6 mo. long

Benign tumors and cysts:

Benign tumors and cysts Uncommon Intramural lesions : Leiomyoma, fibroma, myoma , fibromyoma , lipoma , neurofibroma , hemangioma , osteochondroma , glomus tumor Intraluminal lesions : Fibrovascular polyps, myxoma , fibroma, fibrolipoma 50% of benign tumor in esophagus 90% locate in lower 2/3 Clinical = dysphagia + pain Dx = Barium + scope **Don’t Bx ** RX = surgical enucleation Leiomyoma Esophageal cyst Congenital = ciliated columnar( respi ), glandular(gastric), squamous, transitional cell Acquired = result from obstructed excretory duct M/C = bronchogenic or enteric cysts (anomaly) Locate intramural + mid to lower 1/3 esophagus Rx = surgical enucleation

Esophageal perforation:

Management key = early Dx Good outcome if correct in 24hr, 80-90% survival Surgical Rx = explore like myotomy → gastric flap + modified Gambee stitch → pleural patch/fundoplication Clinical = cervical/ substernal pain + subQ emphysema * misDx as pneumothorax or pancreatitis* Dx = Clinical + CXR, Confirm with contrast ( Gastrografin ) 2/3 on left side, 1/5 on right side, 1/10 bilaterally True emergency Esophageal perforation 65% Iatrogenic 15% Spontaneous ( Boerhaave’s ) 14% Foreign bodies 10% Trauma High mortality (delay recognition) Usually Lt side above EGJ 50% have GERD Mediastinal emphysema ; found 40% Cervical emphysema Pneumothorax ; found 77% Normal ; found 10%

Esophageal perforation:

True emergency Esophageal perforation Management If delay > 24hr + tissue inflammed (Mortality rate upto 50%) resect diseased portion of esophagus + end cervical esophagostomy + feeding jej . subsequent reconstruction with colon interposition, substernal route Conservative management Cameron criteria must met 3/3 1. barium show perforation contained within mediastinum and drain back into esophagus 2. Mild symptom 3. Minimal sepsis Rx = hyperalimentation + Antibiotics + Cimethidine + NPO 7-14 days Mechanism acute ↑ intra- abd pressure against closed-glottis in patient with hiatal hernia characterized as longitudinal tear with arterial bleeding Usually bleeding stop with Non-operative Mx Management Decompress stomach + Blood replacement + Antiemetics Endoscopic injection with Adrenaline Sx = High gastrotomy + oversewing linear tear Mallory-Weiss syndrome

Caustic injury:

Caustic injury Pathology Acute phase : control tissue injury and perforation 1. Acute necrotic phase (1-3 day) : inflammatory reaction 2. U lceration+granulation phase (4-12 day) : esophagus is weakest 3. Cicatrization+scarring phase (3 rd wk ) : adhesion, contraction Chronic phase : treatment of stricture and swallow problem Clinical Pain in mouth/ substernal , adenophagia , dysphagia, fever, bleeding Stricture (60% in 1 mo , 80% in 2 mo , beyond 8 mo → not stricture) Hypovolemia+acidosis (renal damage) from strong acid Laryngospasm/edema, pulmonary edema from strong acid aspiration Treatment (acute phase) Neutralization (within 1 st hour) Alkaline/Lye → use ½ strength vinegar, lemon juice, orange juice Acid → use milk, egg, antacid Prevent emesis, Correct hypovolemia , Broad-spectrum antibiotic Early scope (don’t pass scope beyond lesion) Feeding jejunostomy

Caustic injury:

Caustic injury Treatment (acute phase) Dilation started at 1 st day ! Steroid used = controversy Esophagectomy in extensive necrosis (air in esophageal wall) Intraluminal stent kept for 21 day Treatment (chronic phase) Dilation ( antegrade = Hurst or Maloney bougie ) (retrograde= Tucker bougie ) Adequate lumen should establish in 6-12 mo Indication for surgery Complete stenosis with fail dilation Marked irregular and pocketing esophagus Severe periesophageal reaction or mediastinitis Fistula Fail to dilate > 40 Fr bougie Patient unwilling to be dilated Routes : post mediastinum - Retrosternum Conduits : Colon > stomach > jejunum Proximal anastomosis Cervical esophagus – pyriform sinus – post pharynx

Caustic injury:

Caustic injury Routes : posterior mediastinum - Retrosternum Conduits : Colon > stomach > jejunum Proximal anastomosis Cervical esophagus – pyriform sinus – posterior pharynx Esophageal reconstruction Pyriform sinus anastomosis Posterior pharynx (ฟื้นช้า ปัญหาเยอะ) Remove damaged esophagus : ↓ulcer, ↓risk CA, ↓risk abscess Acquired fistula Cause Malignancy Trauma diverticulum Clinical Coughing after ingest liquid (delay for 30-60 sec) Recurrent/chronic respiratory infection Rare spontaneous closure Surgical treatment Divide fistula tract+Resect damaged lung tissue+Close defect+Pleural flap Palliative Rx = Esophageal stent or Diversion+feeding jejunostomy Colon used in benign or curable cancer

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