The benign disorders of the

esophagus

Paszt Attila

ESOPHAGEAL DIVERTICULUM

• PULSION TYPE: the protrusion of

mucosa and submucosa through a

weakness or defect in the musculature

• TRACTION TYPE: The pulling

outward of the esophageal wall from

inflamed and scarred peribronchial

mediastinal lymph nodes

PHARYNGOESOPHAGEAL

(ZENKER’S) DIVERTICULUM

GENERAL CONSIDERATIONS

• Most common of the esophageal

diverticula

• Pulsion type

• More frequent in men

• Most patients are over 60

PHARYNGOESOPHAGEAL

(ZENKERS’S) DIVERTICULUM

CLINICAL FINDINGS

• Dysphagia, pressure symptoms, gurgling

sounds in the neck

• Regurgitation of undigested food

• Manual emptying of the diverticulum by the

patients

• Swelling of the neck, a sour metallic taste in

the mouth

PHARYNGOESOPHAGEAL

(ZENKER’S) DIVERTICULUM

COMPLICATIONS

• Regurgitation, aspiration, pulmonary infection

• Perforation, mediastinitis, paraoesophageal abscess

• Bleeding, fistula formation

PHARYNGOESOPHAGEAL

(ZENKERS’S) DIVERTICULUM

Diagnostic tests

• Barium swallow, fluoroscopic examination

(a smoothly rounded outpouching arising

posteriorly in the midline of the neck)

• Esophagoscopy

• Manometry

Surgical treatment for Zenker

diverticulum

Conventional surgery: crycopharyngeal myotomy +

diverticulectomy or diverticulum suspension

Endoscopic approach (Mosher, 1917)

diathermic/laser dissection (Dohlman, Mattsson

1960)

Endoscopic stapling diverticulostomy (Collard,

1993)

• Light and short general anaesthesia

• Short operation time and hospital stay

• Low risk of perforation of diverticular pouch

• No injury of reccurent nerve

• Early resumption of oral feeding

• Complete relief of dysphagia

• No scar in neck

Advantages of endoscopic stapling

diverticulostomy

Endoscopic stapling

diverticulostomy

Operative technique

• General anaesthesia

• Surgical equipments:

– Rigid, fixable, double –lipped laryngoscope

(Weerda, Karl Stortz)

– Endostapler (Endopath ETS, Ethicon)

– 5 mm rigid telescope

Midesophageal Diverticulum

• Traction type (associated mediastinal

granulomatous disease)

• Pulsion type (with or without

motility disorders)

Midesophageal Diverticulum

Diagnostic tests

• Barium swallow, fluoroscopic

examination (a smoothly rounded

outpouching arising posteriorly in the

midline of the neck)

• Esophagoscopy

• Manometry

Barium swallow

Midesophageal Diverticulum

Treatment

• Diverticulectomy with or without

myotomy

• Thoracotomy/thoracoscopy

Surgical technique I.

Thoracoscopic diverticulectomy

• Lateral decubitus position

• Selective intubation

• CO2 insufflation was not required

• Endoluminal endoscopic controll

Surgical technique

II.

Port sites

Thoracoscopic diverticulectomy

Barium swallow after surgery

Epiphrenic Diverticulum

• Rare condition

• Pulsion type

• Commonly associated esophageal motor

abnormalities (achalasia, hypertensive

LES etc.)

Epiphrenic Diverticulum

Diagnostic tests

• Barium swallow

• Esophagoscopy

• Manometry

Epiphrenic Diverticulum

Treatment

• Diverticulectomy with myotomy• Myotomy alone

• Traditional technique (laparotomy, thorcotomy)

• Minimal invasive technique (laparoscopy/thoracoscopy)

Barium swallow before/after

surgery

Hiatal hernias

PARAESOPHAGEAL HIATAL

HERNIA

All or part of the stomach herniates

into the thorax immediately adjacent

and to the left of an undisplaced

gastroesophageal junction

Less than 10% of hernias of the

esophageal hiatus

PARAESOPHAGEAL HIATAL

HERNIA

SYMPTOMS AND SIGNS• Often asymptomatic• Gaseous eructations• Sense of pressure• Palpitation due to cardiac dysrhythmias

COMPLICATIONS• Ulceration – bleeding• Obstruction• Strangulation, incarceration

PARAESOPHAGEAL HIATAL

HERNIA

TREATMENT

SURGERY

SLIDING HIATAL HERNIA

GENERAL CONSIDERATION

• 90% of hernias at the esophageal hiatus

• The upper stomach, along with the cardioesophageal junction, is displaced upward into the posterior mediastinum

SLIDING HIATAL HERNIA - GERD

Confusing pathogenic relationship

• Most patients (>80%) with clinically significant reflux have a hiatal hernia

• The converse is not true – the majority of the patients with sliding hiatal hernia do not have esophagitis (GERD)

• The LES pressure is the deciding factor• Reflux is more likely to occur at given LES pressure

in patients with hernias• Reflux is unlikely in the presence of higher LES

pressure regardless of hernia status

SLIDING HIATAL HERNIA

SYMPTOMS AND SIGNS

Typical

• Heartburn

• Acid regurgitation

• Hypersalivation

• Odynophagia

• Unobstructive

dysphagia

Atypical

• Angina like chest pain

• Cough

• Nonallergic asthma

• Chronic bronchitis

• Pneumonia

• Hoarsness

SLIDING HIATAL HERNIA

DIAGNOSIS

• 24-hour pH monitoring• Manometry of LES• Endoscopy with biopsy• Barium esophagogram• Prolonged motility monitoring• Acid perfusion test (Bernstein test)• Radionuclide studies

SLIDING HIATAL HERNIA

COMPLICATIONS

• Esophagitis

GR. 1. Redness without erosions

GR. 2. Linear erosions

GR. 3. Erosions coalesce

GR. 4. Stricture, ulcer

• Stricture (10%)

• Barrett’s esophagus

SLIDING HIATAL HERNIATREATMENT

1. Lifestyle changes

• Modify diet if symptoms are related to diet

• Lose weight if overweight (is always

beneficial)

• Reduce smoking and alcohol intake (is

always beneficial)

• Avoid supine position after meals

• Avoid certain drugs if they related to

symptoms

SLIDING HIATAL HERNIA

TREATMENT

II. Pharmacologic management

• Antacids

• Sucralfate

• Prokinetic drugs

• H2 receptor antagonists

• Acid pump inhibitors

SLIDING HIATAL HERNIA

TREATMENT

SurgeryIndications• Persistant or recurrent symptoms despite

good medical therapy• Recurrent esophageal stricture• Esophagotracheal aspiration resulting

recurrent pneumonia, asthma or laryngitis

• Barrett esophagus, linear gastric erosions

SLIDING HIATAL HERNIA

TREATMENT

Surgery

Laparoscopic or open antireflux procedure

• Nissen fundoplication (wrapping part of the

fundus completely around the lower 4-6 cm of

the esophagus)

• Belsey-Mark IV fundoplication

• Collis procedure (acquiered short esophagus)

SLIDING HIATAL HERNIA

STRICTURES

• Endoscopic dilatations

• Esophagus resection with jejunum or

colon interposition

ACHALASIA

DEFINITION

• Achalasia „lack of relaxation”

• Achalasia is an esophageal motility disorder

characterized by abscence of esophageal

peristalsis and failure of the lower

esophageal sphincter (LES) to relax

completely on swallowing

ACHALASIA

GENERAL CONSIDERATIONS

• Neuromuscular disorders• Etiology• Abscence, atrophy or desintegration of the

ganglion cells Auerbach’s myenteric plexuses• Infectious cause – Chagas’ disease

(trypanosoma cruzi) • Incidence:

0.5 per 100 000no sex predilectionpeak years are 30-60

ACHALASIACLINICAL FINDINGS

• SymptomsDysphagiaRegurgitation, aspirationHeartburnWeight loss (variable)

• ComplicationsUlceration – haemorrhage (occult)Aspiration – pneumonitis, pulmonary abscessMalnutritionCarcinoma (5% of all cases)

ACHALASIA

DIAGNOSIS

• X-ray findings/barium esophagogram- narrowing at the cardia- dilated body of the esophagus

• Manometry- absent peristalsis of the distal segment of the esophagus- elevated LES pressure- incomplete sphincter relaxation

• Endoscopy

ACHALASIA

DIFFERENTIAL DIAGNOSIS

• Benign strictures

• Infiltrating intramural carcinoma

• Scleroderma

ACHALASIATREATMENT

• Drug therapynitrates, calcium channel blockers, nifedipine

• Pneumatic dilatationsuccessful in 75% of casescomplications (bleeding, perforation)

• Surgery(1) extramucous cardiomyotomy (Heller

operation)Laparoscopic – traditional technique(2) esophagus resection

INSTRUMENTAL PERFORATION

OF THE ESOPHAGUS

GENERAL CONSIDERATIONS

• Occur during diagnostic esophagoscopy,

gastroscopy, gastroesophageal balloon

tamponade, esophageal dilation

• Most common at natural site of narrowing (at

the level of cricoid cartilage, the left main stem

bronchus and the diaphragmatic hiatus)

INSTRUMENTAL PERFORATION

OF THE ESOPHAGUS

CLINICAL FINDINGS

• Pain in the neck or chest

• Dysphagia, change of voice into bass-like tone

• Crepitus in the neck owing to extravasation of air

• Subcutaneous emphysema (mainly in the cervical region)

• Cervical tenderness

• Fever, leukocytosis

• Shock (develops earlier in thoracic perforation)

INSTRUMENTAL PERFORATION

OF THE ESOPHAGUS

CLINICAL FINDINGS / X-RAY

FINDINGS

• Demonstrating the perforation

• Locating the exact site of the injury

INSTRUMENTAL PERFORATION

OF THE ESOPHAGUS

PERFORATION OF THE CERVICAL

ESOPHAGUS

• Air in the soft tissues (along the cervical

spine)

• Trachea may be displaced anteriorly by air

and fluid in the space behind the esophagus

• Widening of the superior mediastinum

INSTRUMENTAL PERFORATION

OF THE ESOPHAGUS

PERFORATION OF BODY OF THE

ESOPHAGUS

• Mediastinal widening

• Emphysema

• Pleural effusion with or without

pneumothorax

• Localization of the injury by fluoroscopic

studies with water-soluble opaque media

COMPLICATIONS OF

INSTRUMENTAL PERFORATION

OF THE ESOPHAGUS

• Fulminant mediastinitis,

bronchopneumonia, pericarditis,

severe sepsis, septic shock

• Abscess formation, empyema

TREATMENT OF INSTRUMENTAL

PERFORATION OF THE

ESOPHAGUS

• Immediate operation

• Closure of the perforation, external

drainage

• Total parenteral nutrition, nasogastric

decompression or gastrostomy

• Massive doses of antibiotics

TREATMENT OF INSTRUMENTAL

PERFORATION OF THE

ESOPHAGUS

LATE DIAGNOSIS

• Transhiatal esophagectomy, cervical

esophagectomy, gastrostomy,

mediastinal drainage

SPONTANEOUS (POSTEMETIC)

PERFORATION OF THE ESOPHAGUS

GENERAL CONSIDERATION I

• Described by Herman Boerhaave in 1724

• Usually in males

• History of alcoholic debauch, excessive

food intake or both

SPONTANEOUS (POSTEMETIC)

PERFORATION OF THE ESOPHAGUS

GENERAL CONSIDERATION II

• No preexisting esophageal disease

• Rupture involves all layers of the esophageal

wall

• Most common site of perforation

• The left posterolateral aspect 3-5 cm above the

gastroesophageal junction

SPONTANEOUS (POSTEMETIC)

PERFORATION OF THE ESOPHAGUS

SYMPTOMS AND SIGNS

• Violent vomiting or retching followed by agonizing pain in the epigastrium and lower anterior thorax

• Rigid abdomen• Crepitus in the neck• Hematemesis may occur• Fever, shock

SPONTANEOUS (POSTEMETIC)

PERFORATION OF THE ESOPHAGUS

X-RAY FINDINGS

• Mediastinal widening

• Emphysema

• Pleural effusion with or without

pneumothorax in the left chest

• Localization of the injury by

esophagogram

using water-soluble contrast media

SPONTANEOUS (POSTEMETIC)

PERFORATION OF THE ESOPHAGUS

SPECIAL STUDIES

• Thoracocentesis

Cloudy or purulent pleural fluid,

elevated amylase concentration,

low pH

SPONTANEOUS (POSTEMETIC)

PERFORATION OF THE ESOPHAGUS

DIFFERENTIAL DIAGNOSIS

• Myocardial infarction

• Pulmonary embolus

• Ruptured intraabdominal viscus

• Pancreatitis

SPONTANEOUS (POSTEMETIC)

PERFORATION OF THE ESOPHAGUS

TREATMENT

• Immediate operation• Closure of the perforation, external drainage• The repair reinforced with a flap of nearby

healthy tissue (pleura, pericardium, diaphragm)

• Total parenteral nutrition, nasogastric decompression or gastrostomy

• Massive doses of antibiotics

SPONTANEOUS (POSTEMETIC)

PERFORATION OF THE ESOPHAGUS

LATE DIAGNOSIS

• Transhiatal esophagectomy, cervical

esophagectomy, gastrostomy,

mediastinal drainage

Prognosis: overall death rate: 50%

FOREIGN BODIES IN THE

ESOPHAGUS

• Children, mentally disturbed patients

• History of recent ingestion of food or foreign material

FOREIGN BODIES IN THE

ESOPHAGUS

CLINICAL FINDINGS

• Pain in the midline of the thorax or neck

• Dysphagia (varying from mild distress to

complete obstruction)

• Occassionally, respiratory distress

Radiographic discovery of foreign matter

or of esophageal obstruction

Esophagoscopy

FOREIGN BODIES IN THE

ESOPHAGUS

DIAGNOSTIC INVESTIGATIONS

Radiographic discovery of foreign matter

or of esophageal obstruction

• Esophagoscopy

FOREIGN BODIES IN THE

ESOPHAGUS

COMPLICATIONS

• Esophageal inflammation

• Esophageal perforation

• Mediastinitis, hemorrhage

• Abscess formation

• Tracheoesophageal fistula

• Late strictures

FOREIGN BODIES IN THE

ESOPHAGUS

TREATMENT

• Esophagoscopy/extraction

• Surgery

CORROSIVE ESOPHAGITIS

• Ingestion of strong solutions of acid or

alkali or of solid substances

• Concentration, duration of exposition

CORROSIVE ESOPHAGITIS

CLINICAL FINDINGS

• Burns of the lips, mouth and tongue

pain and dysphagia

• Edema, inflammation of the submucosa,

thrombosis of the esophageal vessels,

infection, perforation, mediastinitis

• Respiratory distress, tracheobronchitis

CORROSIVE ESOPHAGITIS

TREATMENT

• Emergency treatment• Broad-spectrum antibiotics• Corticosteroids• Esophagoscopy and dilatations• Surgical treatment

esophago-gastrectomy (Thorek procedure)feeding gastrostomy, late reconstructiongastric resection

Benign tumours of the esophagus

I. Leiomyoma

II. Cyst /enterogenic, bronchogenic/

III. Polyp

0,5 – 1 %

Symptoms

Many lesions are discovered

incidentally

• Dysphagia

• Epigastric or substernal pain

• Odynophagia

• Dyspnoe

BENIGN TUMORS OF THE

ESOPHAGUS

COMPLICATIONS

• Hemorrhage

• Progressive dysphagia

• Laryngeal obstruction

BENIGN TUMORS OF THE

ESOPHAGUS

DIAGNOSIS

• Radiographic demonstration of intra- or

extraluminal mass, snooth in outline

ESOPHAGOSCOPY

• Intramural lesions should not be

biopsied, because (1) there is a risk of

haemorrhage and (2) an adhesion

develops

Diagnostic tests

• Barium swallow

• Esophagoscopy

• Endoscopic UH

• Chest CT

Diagnostic tests

• Barium swallow

• Esophagoscopy

• Endoscopic UH

• Chest CT

Diagnostic tests

• Barium swallow

• Oesophagoscopy

• Endoscopic UH

• Chest CT

Diagnostic tests

• Barium swallow

• Esophagoscopy

• Endoscopic UH

• Chest CT

Surgical treatment of benign

esophageal tumours

Traditional surgical

technique

Via thoracotomy

Minimal invasiv surgical

technique

Videothoracoscopy

EXCISION

Surgical technique I.

• Lateral decubitus position

• Selective intubation

• CO2 insufflation was not required

• Endoluminal endoscopic controll

Surgical technique

II.

Port sites