Oesophagus Stomach

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Oesophagus

Epithelium lined muscular tube from 6th cervical 11th thoracic vertebra

Passes through 3 regions; neck, thorax and abdomen

Upper and lower sphincters

Three areas of narrowing; cricoid cartilage, left main bronchus and aortic arch,diaphragmatic hiatus

Orderly passage of food {solids & liquids} from mouth to stomach.

Diseases are subdivided into:

Congenital; oesophageal atresia, tracheoesophageal fistula, vascular ring,

webs, duplication Diverticuli; Zenkers, midoesophageal, epiphrenic

Inflammatory; acid & alkaline reflux, caustic ingestion, Barretts

oesophagus, candidiasis, Crohns disease


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Oesophagus

Benign tumours; Leiomyoma, fibrous polyp, lipoma, haemagioma, etc

Malignant tumours; Carcinoma, leiomyosarcoma, fibrosarcoma, melanoma

Motor abnormalities; Achalasia, primary spasm, scleroderma, etc.

Miscellaneous; Foreign bodies, cartilaginous spur, presbyesophagus, acquired

oesophageal web(Plummer-Vinson Syndrome)


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Oesophagus

Zenkers diverticulum.

Pulsion diverticulum

Compressible mass in the neck

Associated with gurgling sound, dysphagia, regurgitation and aspiration

Diverticulectomy

Upper oesophageal webs (Plummer-Vinson Syndrome)

Fissured lips(cheilosis), dry skin, smooth tongue, flat brittle nails(Koilonychia),

weight loss, dsyphagia, & Fe def. Anaemia.

Women

Diagnosis with Ba. Swallow & endoscopy Replace Fe

Bouginage


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Oesophagus

Midoesophageal Webs;

Congenital or acquired in origin ie., oesophagitis in association with Barretts

Long history of reflux(heartburn) & dysphagia

Ba. Swallow shows stricture in mid oesophagus often with Hiatus hernia

Lower oesophageal Webs (Schatzkis ring)

Common xray finding

Endoscopy reveals a white membrane with a concentric opening

Treated by dilatation, electrocautery through endoscope, or by balloon tamponade


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Oesophagus

Achalasia

Thomas Willis in 1674 first described it.

Other names ascribed simple ectasia, and Cardiospasm

Motility disorder characterised by absence of oesophageal peristalsis and failure of

lower oesophageal sphincter to relax on swallowing

Most common neuroanatomic change is a decrease or loss of myenteric ganglion

cells.

Incidence of 0.4 to 0.6 per 100,000 & prevalence 0f 8 per 100,000.

Described from infancy to 9th decade, but majority present between 20 to 40 years

Paediatric cases account for 2% - 5% of all cases Dyspahgia for solids mainly, with variable dysphagia for liquids

Regurgitation (60%-90%), chest pain (505-75%), weight loss, recurrent aspiration.

Distal oesophageal diverticulum may develop


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Oesophagus

Diagnosis

Endoscopic finding

Dilated, patulous esophageal body with extensive mucosal friability & ulcerations

LES appears puckered and fails to open with air insufflation, but is easily traversedwith minimal pressure

Presence of a hiatal hernia (4-14%) or epiphrenic diverticulum

Manometry

Gold standard

Absent peristaltis of distal smooth muscle

LES relaxation pressures are elevated >35 mm Hg

Radiographic findings

PFA; Mediatinal widening, air-fluid level (midesophagus), absence of gastric air

bubble, abnormal pulmonary marking due to repeated aspiration


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Oesophagus

Barium swallow; dilated esophageal body tapering to a Birds beak at the levelof LES

Esophageal emptying scans; impaired propulsion and emptying

Achalasia & carcinoma; squamous cell carcinoma in approx. 5% after 20

years of diagnosis. Present a decade earlier than general population ie 40 years.

Treatment

Drug therapy

Smooth muscle relaxants; nitrates, calcium channel blockers

Results inconsistent & disappointing overall

Oesophageal dilatation

Began 4 centuries ago, Fabricus ab Aquadendente (1537-1675) pushed a foreignobject into stomach


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Oesophagus

Dilatation with mercury filled dilators & polyethylene balloons(pneumatic)

Complications; GIT bleeding, intramural haemorrhage, perforation

Response to pneumatic dilatation 32%-98%, most studies 60%-80%

Remission is not durable; 60% are symptom free for 1 year, with recurrence in50% of these patients in 5 years

Surgery

Heller's Myotomy. Open or laparoscopic

Laparoscopic technique first described in 1991, little morbidity, shorter hospital

stay, and earlier return to daily activities Overall mortality rate


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Oesophagus

Botulinum toxin

Potent inhibitor of acetylcholine release from presynaptic nerve terminals

Short term efficacy

Advantages are noninvasive, ease of administration & minimal side effects

Disadvantages; need for repeated injections, lack of response in 1/3rd of patients,

diminution of response with repeat injections of BoTx

GORD & Hiatal Hernias

S&S; Typical, heartburn (pyrosis), regurgitation, dysphagia/odynophagia, waterbrash

Atypical; pulmonary aspiration, severe chest pain, pulmonary asthma(adult onset),chronic hoarseness, choking, difficulty initiating swallows, chronic cough


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Oesophagus

Types of Hiatus hernias;

Type 1 (Sliding)

Type 1p a postoperative hernia

Type II (paraoesophageal)

Type IIp a postoperative hernia

Type III ( combined sliding & paraoesophageal hernia)

Type IIIp a postoperative that has no sac

Patient evaluation

History

Upper GIT series

24 hour pH monitoring & manometry; Gold standard

OGD


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Oesophagus

Medical therapy

Main aims are eliminate symptoms, heal injured esophageal mucosa, and manageand/or prevent complications

Life style modifications eg, diet alterations, avoid eating 2-3 hours before bedtime,

elevation of head of the bed 6-10 inches during sleep, sleep in in left lateraldecubitus, wt. Loss, avoidance of drugs that inhibit LES pressure

PPIs eg, omeprazole & lansoprazole

H2 receptor antagonists eg, cimetidine, ranitidine, famotidine, nizatidine

Prokinetic agents Cisapride and Metoclopramide

Antacids

Sucralfate

Strictures Dilatation with bougies( mercury filled), wire guided dilators, hydrostaticballoons

Endoscopic procedures, endoscopic suturing device(EdnoCinch), submucosalinjection(polymethylmethacrylate, ethylene ethyl alcohol, radiofrequency energydelivery


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Oesophagus

Surgical therapy

Patient selection is crucial

Preoperative evaluation

Types of operations; Nissens fundoplication 1956 360-degree wrap

Toupets partial wrap 1963 Dors anterior fundoplication

Mark IV operation by Skinner and Belsey

Hills gastropexy

Principles of fundoplication Creation of fundoplication just proximal to gastroesophageal junction with fixation to

esophagus No tension and construction over a 60F bougie inside esophagus

A total fundoplication should measure about 2 cms anteriorly

The wrapped portion of esophagus must lie below the diaphragm

The diaphragmatic hiatus must be snugged around the esophagus above the fundoplication


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Oesophagus

Problems after surgery

Dysphagia

Misdiagnosed achalasia

Recurrent reflux Abdominal bloating

Chest pain

Diarrhoea

Reflux gastritis

Severe fibrosis or total failure of esophageal body function


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Barretts oesophagus

Macroscopically seen on endoscopy as pink epithelium extending well above

the squamocolumnar junction

Histologically goblet cells

22.6 per 100,000

S&S heartburn, regurgitation, dysphagia

Potential progression to carcinoma

Medical treatment; PPIs

Surgical; low grade dysplasia antireflux procedure, argon plasma coagulation

High grade dysplasia; thermal ablation, PDT, ultrasonic energy,oesophagectomy


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Carcinoma of oesophagus

Risk factors; alcohol, tobacco, vitamin and mineral deficiency, nitrosamines,

food and water contaminants, strong family history, multiple cancers, especially

head and neck cancers, corrosive esophagitis, Barretts esophagus, achalasia,

Plummer-Vinson syndrome

S&S; None, dysphagia, wt. Loss, chest pain, retrosternal pain, feeling of

obstruction, etc.

5 year survival rate is 6%-9%

Two histologic types; SCC & adenocarcinoma

Assessment; Radiologic: plain and Barium studies, CT scan, MRI

Endoscopy; rigid and flexible, endoscopic ultrasound

Treatment; Oesophagectomy, 2 or 3 stage, transhiatal.

Neoadjuvant chemotherapy/chemoradiation, downstage tumour, improved

survival, higher pathologic response with combined chemoradiation


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Primary Tumour Regional LN Distant mets

Tx cannot be assessed NX cannot be assessed Mx cannot be assessed

TO No evidence of primarytumour

NO No regional nodes detected MO no mets

Tis Carcinoma in situ (highgrade dysplasia)

N1 regional nodes mets M1 distant mets

T1 invades lamina propria orsubmucosa

T2 invades muscularis propria

T3 invades adventitia

T4 invades adjacent structures


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Endoscopic therapy;

Endoscopic mucosal resection

Laser & Photodynamic therapy

Endoscopic dilatation & Stenting

BICAP/Tumour probe

Local injections

Brachytherapy


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Stomach

Benign Diseases

Chronic Gastric ulcer

Chronic Duodenal ulcer

Gastrinoma (Zollinger Ellison syndrome)

Tumours

Malignant ie., Carcinoma of stomach

Miscellaneous gastric pathology

Gastric bezoar, Menetriers disease, Mallory-Weiss syndrome, gastric volvulus, etc


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Stomach

Chronic Gastric ulcers

Greater frequency in elderly

Four types

Type I; lesser curve ulcers, usually antral, near antral-fundic border, occur in Patientswith gastric stasis, poor emptying & low acid output

Type II; combination of type I & present or past DU. High prevalence of blood group

O, high acid output

Type III; prepyloric in location, 1-2 cms proximal to pylorus

Type IV; other areas of stomach, drug induced


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Stomach

S&S and Diagnosis

Epigastric pain, relieved by eating/antacids

Sometimes worsening of pain on eating, esp, pyloric ulcers.

Ba. Studies, OGD & biopsy

Treatment

Antacids

Surgical options

Type I ulcers; antrectomy and Billroth anastomosis, vagotomy & pyloroplasty

Type II & III; similar to DU

Type IV; stress ulceration, curlings & cushing ulcers, if bleeding point easilyidentified, truncal vagotomy, pyloroplasty & oversewing of bleeding ulcer. Otherwise

gastrectomy in seriously ill Patients. For less seriously ill patients, vagotomy & distal

gatrectomy


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Stomach

Chronic DU

Younger age group

Men more often than women

Epigastric or RUQ pain Ba. Series and endoscopy

Treatment

Antacids, H2 receptors blockers, PPIs, H pylori treatment


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Stomach

Operation Mortality Recurrence rate(%)

Advantages (%)Disadvantage(%)

2/3-3/4 distalgastrectomy

~1 elective 5-15% None Small gastricreservoir,dumping

Vagotomy &drainage

< 1 5 10% Gastric reservoir Dumping,diarrhoea

Vagotomy &

distalgastrectomy

~1 2 3% Lowest RR Dumping,

diarrhoea

Parietal cellvagotomy

0-


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Stomach

Complications of peptic ulcers

Perforation

Haemorrhage

Pyloric obstruction

Complication of gastric surgery

Mortality

Recurrent ulcers

Gastrojujenocolic fistula

Postgastrectomy syndromes

Dumping

Diarrhoea, afferent loop syndrome, efferent loop syndrome, alkaline gastritis,

weight loss, anaemia, bone disease, TB, gastric cancer


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Gastric carcinoma

Risk factors

Polycyclic hydrocarbons, dimethylnitrosamines

Miners, metal workers, rubber workers

Helicobacter pylori

Gastric polyps

Pernicious anaemia, atrophic gastritis, gastric ulcer,

Pathology

95% adenocarcinomas

Two types; intestinal & diffuse


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Stomach

S&S

Vague epigastric discomfort

Wt. Loss, anaemia, anorexia, vomiting

Virchows node

Sister Mary Joseph nodule, ascites, jaundice, liver or pelvic mass

Preoperative evaluation

Endoscopy

CT scanning

Endoscopic ultrasound

CEA levels

Laparoscopy


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Carcinoma of Stomach

Surgical treatment

Overall 5 year survival rate 10 21% in western series

Japanese series 50%

Adjuvant therapy

VASAG Thiotepa & fluxuridine no survival benefit

GITSG 5-FU and methyl CCNU

Neoadjuvant therapy Response rates vary from 21 31% clinical response rate to complete response

rate of 0-15%


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Tumour Node Metastasis

T1 invades laminapropria or submucosa

N0 no mets in LN M0 no distant mets

T2 invades muscularispropria or subserosa

N1 mets in perigastric LN within 3cms of tumour

M1 Distant mets

T3 penetrates serosa N2 mets in perigastric LN . 3cms fromtumour, or left gastric, common

hepatic, splenic, or coeliac arteries

T4 invades adjacentorgans


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Surgical options

Proximal tumours

Total or proximal subtotal gastrectomy with Roux N- reconstruction

Mid-body tumours

Total gastrectomy

Distal tumours

Distal subtotal gastrectomy with or without regional lymphadenectomy

Splenectomy

Oesophagus Stomach

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