Oesophagus Lecture 4 PDF

Oesophagus Lecture 4 Ihsan Al-Shoek PARAOESOPHAGEAL (‘ROLLING’) HERNIA True paraoesophageal hernias in which the cardia remains in its normal anatomical position are rare. The vast majority of rolling hernias are mixed hernias in which the cardia is displaced into the chest and the...

Oesophagus Lecture 4 Ihsan Al-Shoek PARAOESOPHAGEAL (‘ROLLING’) HERNIA True paraoesophageal hernias in which the cardia remains in its normal anatomical position are rare. The vast majority of rolling hernias are mixed hernias in which the cardia is displaced into the chest and the greater curve of the stomach rolls into the mediastinum paraoesophageal hernia showing the gastrooesophageal junction just above the diaphragm and the fundus alongside the oesophagus, compressing the lumen. a  Potentially dangerous, because of volvulus, the symptoms of rolling hernia are mostly due to twisting and distortion of the oesophagus and stomach. Dysphagia is common. Chest pain may occur from distension of an obstructed stomach. Classically, the pain is relieved by a loud belch. Symptoms of GORD are variable. Strangulation, gastric perforation and gangrene can occur.  Diagnosis of Paraosophageal hernia The hernia may be visible on a plain radiograph of the chest as a gas bubble, often with a fluid level behind the heart. A barium meal is the best method of diagnosis. The endoscopic appearances may be confusing, especially in large hernias when it is easy to become disorientated  Treatment Symptomatic rolling hernias nearly always require surgical repair as they are potentially dangerous. Patients who present as an emergency with acute chest pain may be treated initially by nasogastric tube to relieve the distension that causes the pain, followed by operative repair. If the pain is not relieved or perforation is suspected, immediate operation is mandatory. A gas bubble seen on a plain chest radiograph, showing the fundus of the stomach in the chest  MALLORY-WEISS SYNDROME Forceful vomiting may produce a mucosal tear at the cardia rather than a full perforation. The mechanism of injury is different. In Boerhaave's syndrome, vomiting occurs against a closed glottis, and pressure builds up in the oesophagus. In Mallory–Weiss syndrome, vigorous vomiting produces a vertical split in the gastric mucosa, immediately below the squamocolumnar junction at the cardia in 90 per cent of cases. In only 10 per cent is the tear in the oesophagus The condition presents with haematemesis.  CORROSIVE INJURY Corrosives such as sodium hydroxide or sulphuric acid may be taken in attempted suicide. Accidental ingestion occurs in children and when corrosives are stored in bottles labelled as beverages. All can cause severe damage to the mouth, pharynx, larynx, oesophagus and stomach. The type of agent, its concentration and the volume ingested largely determine the extent of damage. In general, alkalis are relatively odourless and Alkalis cause liquefactive necrosis which could lead to perforation. Acids cause coagulative necrosis with eschar formation, and this coagulant may limit penetration to deeper layers of the oesophageal wall. Acids also cause more gastric damage than alkalis because of the induction of intense pylorospasm with pooling in the antrum. Symptoms and signs are notoriously unreliable in predicting the severity of injury.  Presentation History is clear usually Pain, in the throat, neck, chest and even the abdomen Drooling of saliva Dysphagia and odynophagia can be present. Hoarseness of voice airway obstruction  Investigations Endoscopy CT scan  Management Airway management Fluid management Pain management Nutrition Emergency Oesophagectomy/ stoma The key to management is early endoscopy by an experienced endoscopist to inspect the whole of the oesophagus and stomach These patients can safely be fed. With more severe injuries, a feeding jejunostomy may be appropriate until the patient can swallow saliva satisfactorily. The widespread use of broad-spectrum antibiotics and steroids is not supported by evidence. Acute caustic burn in the haemorrhagic phase. Caustic or lye stricture with marked stenosis high in the body of the oesophagus. The strictures are frequently multiple and difficult to dilate unless treated energetically at an early Neoplasm of the Oesophagus  Benign Papillomas, fibrovascular polyps, glycogen acanthosis, parakeratosis, lipomas, lymphangiomas and haemangiomas Leiomyomas are the most common solid benign tumours of the oesophagus  They are mostly found incidentally as a submucosal mass on endoscopy but may produce compressive symptoms when large. EUS shows a hypoechoic mass arising from the muscularis propria or the submucosal layer. Leiomyosarcoma is rare and resection offers a chance of cure. Oesophageal gastrointestinal stromal tumours (GISTs) are uncommon and are usually found at the OGJ/proximal stomach. Malignant Oesophageal Tumours  Epidemiology 8th most common cancer and the 6th cancer related death 60-70 years old Squamous cell carcinoma and adenocarcinoma are the most common cell types Other malignancies such as melanoma and small cell carcinomas are rare. Secondary malignancies are likewise rare; however, bronchogenic carcinoma or metastatic lymph nodes can invade the oesophagus.  Epidemiology Squamous is the commonest type. In white population (Western) adenocarcima is rising and has surpassed the squamous.  Epidemiology Squamous cell cancer is endemic in South Africa and in the middle of Asian from northern Iran to China. The cause of the disease in the endemic areas is not known, but it is probably due to a combination of fungal contamination of food and nutritional deficiencies. Obesity and GORD are risk factors Cardia and distal osophagus ca has increased with falling rate of distal stomach ca.  Supplementation of the diet with betacarotene, vitamin E and selenium has been shown to reduce the incidence. Clinical features ( Carcinoma of the oesophagus Mechanical symptoms, principally dysphagia, but sometimes also regurgitation, vomiting, odynophagia and weight loss Patients with early disease may have non-specific dyspeptic symptoms or a vague feeling of ‘something that is not quite right’ during swallowing. Clinical findings suggestive of advanced malignancy include recurrent laryngeal nerve palsy, Horner's syndrome, chronic spinal pain and diaphragmatic paralysis, loss of appetite and enlarged supraclavicular lymph node. The classic appearances of a mid-oesophageal proliferative squamous cell carcinoma. Squamous cell carcinoma of the oesophagus producing an irregular stricture  Both adenocarcinomas and squamous cell carcinomas tend to disseminate early. Sadly, the classical presenting symptoms of dysphagia, regurgitation and weight loss are often absent until the primary tumour has become advanced, and so the tumour is often well established before the diagnosis is made Tumours can spread in three ways: invasion directly through the oesophageal wall, via lymphatics or in the bloodstream Adenocarcinoma of the lower oesophagus, spreading upwards from the cardia.  Carcinoma in situ showing the varied presentations: (a) occult form; (b) erythroplakia; (c) leukoplakia. The right-hand pictures in (a) and (b) demonstrate the use of vital staining with methylene blue.  Investigations in Ca Oesophagus Endoscopy is the first-line investigation for most patients. Cytology and/or histology specimens taken via the endoscope are crucial for accurate diagnosis. The chief limitation of conventional endoscopy is that only the mucosal surface can be studied and biopsied. Only those patients suitable for potentially curative therapies should proceed to staging investigations to rule out haematogenous spread and then to assess locoregional stage The most widely used pathological staging system is the World Health Organization (tumour–nodes–metastasis TNM) classificication. Tis =High-grade dysplasia T1 =Tumour invading lamina propria or submucosa T2 =Tumour invading muscularis propria T3 =Tumour invading beyond muscularis propria T4a =Tumour invading adjacent structures (pleura, pericardium, diaphragm) T4b =Tumour invading adjacent structures (trachea, bone, aorta) N0 = No lymph node metastases N1 =Lymph node metastases in 1–2 nodes N2 =Lymph nodes metastases in 3–6 nodes N3 = Lymph node metastases in 7 or more. M0 = No distal organ involved. Algorithm for the management of oesophageal cancer. CT Scan (Chest abdomen and pelvis) *The best modality used to identify haematogenous metastases. * Distant organs are easily seen and metastases within them visualised with high accuracy (94–100 per cent). * The normal thoracic oesophagus is easily demonstrated by CT scanning. * Smaller nodes cannot be reliably visualised, and it is not possible to distinguish between enlarged lymph nodes that have reactive changes only and metastatic nodes. Endoscopic ultrasound The two principal prognostic factors for oesophageal cancer are the depth of tumour penetration through the oesophageal wall and regional lymph node spread. * CT can detect distant metastasis, its limited axial resolution precludes a reliable assessment of both the depth of wall penetration and lymph node involvement. Endoscopic ultrasound can determine the depth of spread of a malignant tumour through the oesophageal wall (T1–3), the invasion of adjacent organs (T4) and metastasis to lymph nodes (N0 or N1) * It can also detect contiguous spread downward into the cardia and more distant metastases to the left lobe of the liver. Positron emission tomography Relies on the generally high metabolic activity of tumours compared with normal tissues. The patient is given a small dose of the radio pharmaceutical agent 18F-fluorodeoxyglucose (FDG). After intravenous injection of FDG, it continuously accumulates in metabolically active cells. Primary oesophageal cancers are usually sufficiently active to be easily visible, and spatial resolution of positive PET areas occurs down to about 5–8 mm. Reduction in PET activity following chemotherapy might be a way of predicting ‘responders’ to this approach.  Laparoscopy This is a useful technique for the diagnosis of intra- abdominal and hepatic metastases. the only modality reliably able to detect peritoneal tumour seedlings.  Treatment of Ca Oesophagus Principles At the time of diagnosis, around two-thirds of all patients with oesophageal cancer will already have incurable disease. The aim of palliative treatment is to overcome debilitating or distressing symptoms while maintaining the best quality of life possible for the patient. As dysphagia is the predominant symptom in advanced oesophageal cancer, the principal aim of palliation is to restore adequate swallowing. A variety of methods are available and, given the short life expectancy of most patients, it is important that the choice of treatment should be tailored to each individual.  The principle of oesophagectomy is to deal adequately with the local tumour in order to minimise the risk of local recurrence and achieve an adequate lymphadenectomy to reduce the risk of staging error. the proximal extent of resection should ideally be 10 cm above the macroscopic tumour and 5 cm distal. Adenocarcinoma commonly involves the gastric cardia and may therefore extend into the fundus or down the lesser curve. Some degree of gastric excision is essential in order to achieve adequate local clearance and accomplish an appropriate lymphadenectomy. in Barrett's oesophagus, where high-grade dysplasia and early cancer coexist, many centres favour oesophagectomy in fit patients.  Photodynamic therapy (PDT) Photodynamic therapy (PDT) is an alternative approach that has largely been used in patients who were either unfit or unwilling to undergo surgery This endoscopic technique relies on the administration of a photosensitiser that is taken up preferentially by dysplastic and malignant cells followed by exposure of an appropriate segment of the oesophagus to laser light The main drawback is skin photosensitisation, so patients must avoid sunlight exposure in the short term also associated with a risk of stricture formation  Radical oesophagectomy is the most important aspect of curative treatment Neoadjuvant treatments before surgery may improve survival in a proportion of patients Chemoradiotherapy alone may cure selected patients, particularly those with squamous cell cancers Useful palliation may be achieved by chemo/radiotherapy or endoscopic treatments  The two usual approaches for surgery of the oesophagus are the thoracoabdominal (a), which opens the abdominal and thoracic cavities together, and the two-stage Ivor Lewis approach (b), in which the abdomen is opened first, closed and then the thoracotomy is performed. In the McKeown operation, a third incision in the neck is made to complete the cervical anastomosis.  Palliation Intubation The technology of intubation has now moved on with the development of various types of expanding metal stent.These are also inserted under radiographic or endoscopic control. The stent is collapsed during insertion and released when it is in the correct position. Expanding stents produce a wider lumen for swallowing than rigid tubes. More importantly, it is not necessary to dilate the oesophagus to beyond 8 mm to insert the unexpanded stent through the tumour, so there is a lower risk of injury to the oesophagus.  Palliation Endoscopic laser treatment may be used to core a channel through the tumour. It is based on thermal tumour destruction It produces a worthwhile improvement in swallowing, but has the disadvantage that it has to be repeated every few weeks. Lasers may also be used to unblock a stent that has become occluded by tumour overgrowth  Palliation Brachytherapy A method of delivering intraluminal radiation with a short penetration distance (hence the term brachy) to a tumour. An introduction system is inserted through the tumour, and the treatment is then delivered in a single session lasting approximately 20 minutes. The equipment is expensive to purchase  THANKS QUESTIONS