Diseases of the esophagus

Attila Enyedi MD.

 Anatomy of the oesophagus I.

16-24 24-32 32-40

• 38-40 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%) • Acute (15-20%)

– Dysphagia – Dysphagia (sometimes
– Early Satiety total)
– – Haematemesis
Pain/Heartburn
– – Obstruction
Aspiration
– – Gangrene/Perforation
Anaemia
– 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

-Stomac 91%
- Colon 6%
- Jejunum 3%
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

• R1 resection, than adjuvans chemo-

radiotharpy?
• Stenting
• Feeding gastro/jejunostomy
– Via laparotomy
– PEJ/PEG