Download General Principles of General Thoracic Surgery

Disease of Esophagus
浙江大学附属第一医院胸外科 张翀
Disease of Esophagus
1, Gastroesophageal Reflux
2, Neoplasms ---Esophageal Cancer
3, Neuromuscular Disorders
4, Trauma
Esophagus- Anatomy
Location
End
Distance from
Incisors
Cervical Esophagus
Below the
cricopharyngeus
muscle (C6)
Thoracic inlet
15~20cm
Upper Thoracic
Thoracic inlet
Inferior azygus
arch
20~25cm
Middle Thoracic
Inferior azygus arch
Inferior
Pulmonary Vein
25~30cm
cardia of the
stomach at T11.
>30cm
Beginning
Parts of Eso
Lower Thoracic and
Abdominal
Inferior Pulmonary
Vein
Esophageal Anatomy
The esophagus is a two-layered mucosa-lined muscular tube that journeys through the neck, chest, and abdomen and rests
unobtrusively in the posterior mediastinum.
It commences at the base of the pharynx at C6 and terminates in the abdomen, where it joins the cardia of the stomach at T11.
Esophagus- Anatomy (Narrowings)
Narrowing
Location
Clinical
Diameter
Superiormost
Narrowing
the anatomic border of
the pharynx and proximal
esophagus
This narrowest point of the
esophagus , it is the most
common site of iatrogenic
perforation.
(M: 15cm, F: 14cm)
1.5 cm
Second Narrowing
crossing of the left
mainstem bronchus and
the aortic arch
Indentation of the anterior
and left lateral esophageal
wall.
(M: 25cm, F:23cm )
1.6 cm
Most inferior
Narrowing
the diaphragmatic hiatus
(caused by LES)
great variation of the
luminal diameter
(M: 30cm, F:28cm )
1.6 to 2.5
cm
Esophageal Anatomy
Narrowings
Esophageal Carcinoma- Anatomy (Cervical)
The triangular areas of the sparse muscle cover are shown in the scheme. Zenker’s diverticulum arises from Killian’s triangle.
The surgical approach to the cervical esophagus may be from either side of the neck through an incision along the medial border of the
sternocleidomastoid muscle. The left-sided approach is preferred to avoid injury to the right recurrent nerve.
Muscular architecture of the pharyngoesophageal junction, which is the region of the upper esophageal sphincter.
Esophagus- Anatomy (Thoracic)
a. The thoracic portion of the esophagus is approximately 20 cm long .
b. It starts at the thoracic inlet, in the upper portion of the thorax, it is closely related to the posterior wall of the trachea. This close
relationship is responsible for the early spread of cancer of the upper esophagus into the trachea.(a big limitaion!)
c. The lower thoracic esophagus is buttressed only by mediastinal pleura on the left, making this portion the weakest and the most
common the site of perforation in Boerhaave’s syndrome.
Esophagus- Anatomy (Abdominal)
a. The abdominal portion of the esophagus is approximately 2 cm long and includes a part of the LES.
Squamous epithelium
Columnar epithelium
The distal 1 to 2 cm of esophageal mucosa transitions to cardiac mucosa or
junctional columnar epithelium at a point known as the Z-line .
Chapter 1
Esophageal Cancer
Esophageal Cancer - Epidemiology
Esophageal cancer is the fastest growing cancer in the United States.
6th most common malignancy with an incidence of 20 per 100,000 and represents 4% of
newly diagnosed cancers in North America.
South Africa and China: 160 / 100,000
Kazakhstan: 540 / 100,000.
Iran : 165.5/100,000 (M), 195.3/100,000(F)
Linxian China: 478.87/100,000
Esophageal Cancer-Etiology
Carcinogens
Tobacco
Alcohol
Nitrosamines
Fungal toxins
Spices
Nutritional deficiencies
Vitamins A, C, riboflavin
Physical factors
Thermal trauma
Hot food or drinks
Abrasive material (soil) and food
Predisposing factors
Tylosis (胼胝症)
Plummer-Vinson syndrome
Achalasia
Celiac sprue (乳糜泻)
Esophageal Cancer-Pathology
Esophageal carcinoma is originated from the epithelium between pharynx and junctional
area of esophagus and stomach.
Mostly occurred in the MIDDLE segment (52.7%).
Early stage: circumscribed within mucosal or sub-mucosal layer :
①occult type
②erosive
③plague
④papillary
Advanced stage: invading muscular or adventitial layer
① medullary（60%）
② fungoid（15%）
③ ulcerative（10%）
④ constrictive（10%）
⑤ intra-cavity（5%）
A. William Blackstcok , et al. Esophageal Cancer principle and Practice, 2009
Medullary
Fungoid
Ulcerative
Constrictive
Common symptoms of esophgeal cancer
presentation
Symptom onset is late
Progressive dysphagia is most common.
Initially with meat, then soft foods and liquids.
Pain develops late. (Substernal, epigastric, or back areas). Increases with
swallowing, may radiate.
Weight loss
Regurgitation of blood-flecked esophageal contents
Anorexia (poor appetite)
Fatigue
If tumor is in upper third of esophagus( Sore throat, Choking, Hoarseness)
Metastasis
In the advanced pathologic stages of the disease, direct extension through the wall of the
esophagus is common, as are lymphatic metastases. Lymphatic metastases were found in
about 60% of patients undergoing esophagectomy.
1. Intraesophageal Spread:
a. proximal resection margin: Submucosal lymphatic spread occurs often and may result in
tumor emboli producing satellite nodules
2. Direct Extension
a. tumor may invade adjacent structures, including the pleura, trachea, left mainstem
bronchus, pericardium, great vessels, thoracic duct, and the anterior ligaments of the
vertebral column.
b. Upper esophagus: the recurrent laryngeal nerves , Lowe esophagus: diaphragm,
stomach, and liver.
3. Lymphatic Spread:
a. upper third of the esophagus drains primarily to the upper mediastinum and neck
b. lower esophagus flows to the abdomen.
4. Distant Metastatic Disease:
a. Visceral metastases may be present in up to 30% of patients at the time of diagnosis
and are manifestations of advanced disease.
b. Metastases were found in the lungs, liver, pleura, bone, kidneys, and adrenal glands.
Esophageal Cancer – Diagnostic Workup
Endoscopy with biopsy: Necessary for definitive diagnosis, the location of the lesion,
degree of obstruction, and longitudinal as well as circumferential extent of the lesion can
be determined.
Endoscopic ultrasonography (EUS): Important tool to staging, is important in the evaluation
of possible tracheal or bronchial invasion by a carcinoma in the cervical and the upper or
middle thirds of the thoracic esophagus.
Barium swallow with fluoroscopy: is the MOST commonly used contrast agent for
fluoroscopic examination of the esophagus and the gastrointestinal tract. It permits a safe,
expedient study of the esophageal mucosa, luminal distensibility, motility, and any
anatomic pathology.
Bronchoscopic examination: Detect involvement of lung
Computed tomography (chest + upper abdominal CT): is used to determine the local
extent of the tumor, the relationship to adjacent structures, and distant metastases.
Magnetic resonance imaging (MRI): The capability of MRI to demonstrate a tumor in the
coronal and sagittal planes is superior in the estimation of the tumor length, but this
information has only limited clinical value.
Esophageal Cancer - Treatment
Endoscopic mucosal resection (EMR)
Types of Esophageal Resection: (maybe Open or minimally invasive)
-Sweet Esophagectomy (Left Thoracic or Left Thoracoabdominal
Esophagectomy)
-Ivor Lewis Esophagectomy Laparotomy and preparation of gastric
or colon conduit + Right thoracotomy for esophageal mobilization
and resection with mediastinal lymph node dissection)
-Mcown Esophagectomy (Ivor Lewis Esophagectomy + Neck )
-Transhiatal Esophagectomy (THE)
Dr. Frank Torek. Credited with the first
transthoracic esophageal resection,
performed in 1913.
Dr. Richard Sweet. Developed the basis for
the modern approach to transthoracic
esophagectomies with Dr. Churchill at the
Massachusetts General Hospital in the
1940s and 1950s.
Ivor Lewis. A British surgeon who
performed the two-stage
esophagectomy via an abdominal
approach and subsequent right
thoracotomy that bears his name
today.
Abdominal exposure in an Ivor Lewis
esophagectomy.
A pyloric drainage procedure is now
performed. Choices include
pyloromyotomy, pyloroplasty, and more
recently botox injection. Some perform no
drainage procedure. Pyloromyotomy was
the author’s preferred procedure,
but recent experience with botox injection
has been satisfactory. Two hundred units
of botox is mixed in 5 mL of
normal saline and approximately 1.25mL
is injected into the pyloricmuscle at the
one o’clock, 3 o’clock, 6 o’clock, and
9 o’clock positions. To aid in the resection
of the proximal stomach when drawn into
the right chest, the gastrohepatic
tissue at the point of resection of the
distal lesser curvature is cleared. This
point is about six vascular arcades distal to
the esophagogastric junction. The celiac
axis is marked with a long stitch to aid
pathologic examination. A jejunostomy
tube is then placed 30 to 40 cm beyond
the ligament of Treitz. The abdomen is
closed.
The patient is placed in the left lateral decubitus position, prepped, and draped. A right posterolateral
thoracotomy incision is made, and the fifth intercostal space is entered. The lung is deflated using the double lumen
endobronchial tube placed at the beginning of anesthesia. The azygos vein is divided using the endo GIA 30, 2.5 stapler
(Endo GI Universal, US Surgical, Norwalk, CT). The pleura is scored with the electrocautery from posterior to the
azygos down to the hiatus. The inferior ligament is incised and the pleura scored back to the cut azygos vein. Boundaries
of dissection are now marked. The esophagus is then dissected and encircled with a large penrose drain at the level of
the arching azygos vein. Care must be taken with this maneuver to avoid entering the esophageal muscularis propria as
the posterior muscle fibers are often “splayed” deep into the mediastinum. v. =vein.
Using the penrose as a traction device, the esophagus and the attached lymphoareolar tissue aremobilized from
the mediastinal bed. Aortic branches are clipped. The dissection includes mobilization of the subcarinal lymph node
packet, which is kept intact with the specimen and marked with a double stitch. The pericardium is “bared.” The vagal
nerve trunks are cut as the esophagus is mobilized from the lower superior mediastinum. Once the hiatus is reached,
final attachments are released. Level 15 (diaphragmatic) lymph nodes are carefully identified and resected. The thoracic
duct is purposely ligated at this level by mass ligature of all tissue between the aorta, spine, and azygos vein using a
0-silk tie.
The nasogastric tube that was placed after the endoscopy is withdrawn to the thoracic
inlet. The esophagus is stapled above the azygos vein using a GI stapler with a “green
load” (such as PI 30 mm stapler; US Surgical).
With care to preserve proper orientation, the stomach is delivered through the hiatus into the chest. The
gastric conduit is formed by several applications of the ILA 100-mm stapler (US Surgical) or use of the 60-mm
endostapler (Endo GIA Universal, US Surgical). The previously cleared portion of the distal lesser curvature serves as
a distal marker. The highest point of the fundus is easily identified when the stomach is put on “stretch.” If the tumor
is at the gastroesophageal junction, a more “V-shaped” staple line will increase the radial gastric margin. The highest
point of the staple line is oversewn with a 3-0 silk horizontal mattress suture as well as where staple lines have
crossed each other.
Transdiaphragmatic approach
through a circumferential
incision.
McKeown modification
Perioperative complications - Esophageal Cancer
1. Anastomotic Leak
The incidence of intrathoracic leak following Ivor Lewis esophagectomy is typically 5–10%.
An intrathoracic leak is a life-threatening event that usually requires immediate operative
intervention.
2. Anastomotic Stricture
Anastomotic stricture is never life threatening,
A large retrospective meta-analysis concluded that the incidence of symptomatic stricture
was somewhat higher following anastomosis in the cervical position (28%) than after Ivor
Lewis resection (16%).
3.Recurrent Laryngeal Nerve Injury
4. Respiratory Complications (Pneumonia, atelectasis, and respiratory failure)
The incidence of pneumonia following esophagectomy ranges from 2% to 47%. Respiratory
failure following esophagectomy occurs in 4% of patients.
5. Bleeding
6. Chyle Leak
7. Postresection Reflux
8. Impaired Conduit Emptying
9. Local Recurrence
Chapter 2
Gastroesophageal Reflux
Chapter 3
Benign tumor of Esophagus
Leiomyoma
Leiomyoma
Duplication
Polyp and Squamous Papilloma
Chapter 4
Neuromuscular Disorders
Diverticulum
Achalasia
Achalasia
Achalasia
Chapter 5
Trauma
Caustic injury
Foreign Body
Peforation and Boerhaave
Peforation and Boerhaave