ABOUT THE ESOPHAGUS
The esophagus is a tube of mostly muscle fibers that connects the mouth to the stomach; it begins where the throad ends in the neck and is responsible for the one-way delivery of liquids and solids to the stomach. A specialized spinchter at this junction of the throat and esophagus keep food and liquid going one way when swallowing is initiated. These foods and liquids are then propelled down the esophagus by coordinated muscular contractions to the stomach. The esophagus attaches to the stomach at the level of the diaphragm, which is the muscle separating the chest and abdominal cavities. At this junction between the esophagus and stomach there is another sphincter which acts like a one-way valve keeping food and liquids in the stomach, not allowing them to reflux backward into the esophagus. Patients can develop problems with these sphincters, as well as the muscle fibers in the esophagus which require surgery. Cancer can also develop in any part of the esophagus, and surgery is often undertaken for these problems.
SURGICAL PROBLEMS OF THE ESOPHAGUS
Zenker’s Diverticulum is most likely a problem with the upper sphincter located between the throat and the esophagus. Due to pressure abnormalites there is an outpouching of the inner lining of the esophagus. Over time this can grow into large pouches that may hold large amounts of undigested food and water. Typical symptoms include difficulty swallowing, choking, regurgitation and bad breath. Patients may occasionally aspirate the contents of the pouch into the lungs causing pneumonia. When Zenker’s is large and symptomatic they require treatment; the surgical approach needs to address the outpouching and the abnormality in the sphincter mechanism. The outpouching can either be removed, (diverticulectomy), or the pouch can be dissected out, turned upside down and sutured in place (diverticulopexy). The muscle problem is dealt with by dividing all the muscle fibers (myotomy) on the the side of the upper sphincter, which involves the lower throat and upper esophagus.
Dysfunction of the lower sphincter between the stomach and esophagus can lead to problems with reflux of stomach contents into the esophagus. The most common symptom of reflux is heartburn, although patients can also have asthma, cough, reflux of food in one’s throat, and even aspiration pneumonia. The refluxed material includes food, liquid, acid and bile which can then damage the lining of the esophagus. With medicine such as proton pump inhibitors, many of the complications of gastroesophageal reflux are avoided and surgery is rarely needed. Severe scarring and bleeding from the irritatition of the refluxed material into the esophagus are rare.
Barrett’s Esophagus is a complication of reflux, where the lining cells of the esophagus are changed, most likely by the irritation. Some of these cells become pre-malignant (dysplastic), and cancer may also develop. With the medicines used to treat reflux, there has been a decrease in patients referred for surgery. However occasionally anti-reflux operations for dysplasia or esophageal removal for cancer are performed.
One of the motility disorders of the esophagus is achalasia, which is the most common condition for operation on the esophagus for motility problems. The condition involves both the lower esophageal sphincter, which does not relax, and the muscle fibers of the lower esophagus that do not work together to contract. This lower portion of the esophagus can then dilate and fill with food and liquid and not pass into the stomach. Patients may experience difficulty swallowing, regurgitation of food, cough, and pain. Aspiration of the esophageal contents into the lungs can lead to pneumonia.
If found early achalasia may be treated by dilitation of the sphincter through endoscopic techniques. When achalsia is advanced, surgery is initiated. The treatment involves cutting the muscle fibers (myotomy) on both the esophagus and sphinter down to the stomach. Historically, this was done through a large incision on the chest but it is now preformed through minimally invasive techniques such as thoracoscopic or robotic. Both procedures are practiced by WMCTS surgeons.
Hiatal hernia refers to the herniation of the stomach through the opening in the diaphragm. There are two major types of herniation: the most common type invloves the stretching of the opening through the diaphragm (sliding type). There is no hole where abdominal contents can slide into the chest. As a result, the top part of the stomach may slide up through the diaphragm. The major problem associated with this type of hernia is reflux disease. This is easily managed with medical therapy and surgery is not required.
The second type of hernia, which is quite rare, is a rolling hernia. A defect exists where the stomach or any other contents of the abdomen can herniate into the chest. This can result in significant problems and should be repaired as soon as identified.
RUPTURE OF THE ESOPHAGUS
Rupture of the esophagus is a medical emergency. Gastrointestinal contents spill into the chest cavity and mediastinum causing severe pain (mimicking a heart attack) and a dramatic presentation with shock. The most common reason for esophageal rupture is related to endoscopic procedures. The second most common reason may be induced after vomitting. If the rupture occurs in the neck, usually from endoscopy, it can usually be managed without surgery. If however the perforation goes into the chest, emergency surgery is usually required.
Cancer of the esophagus is a complex problem. It usually involves a multi-disciplinary team that includes gastroenterolgy, oncology, radiation oncology and the surgeon. Esophageal cancer typically carries a poor prognosis due to late stage discovery. Patients in early stage may be surgical candidates for removal of the esophagus and possible cure. The procedure involves the removal of the esophagus and replacing it with a tube fashioned out of the stomach.
For more information on esophageal cancer, visit:The Society of Thoracic Surgeons