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Upper GI Surgery

ACHALASIA CARDIA

WHAT IS ACHALASIA CARDIA

Achalasia cardia (Cardio spasm) a chronic disease of the neuromuscular system of the esophagus, characterized by impaired opening of the lower esophageal sphincter at the entrance to the stomach during swallowing. This is accompanied by decrease peristaltic movements of the esophagus leads to difficult passage of food into the stomach.

CAUSES OF ACHALASIA

Causes of Achalasia cardia have not been fully established. It believes that Achalasia cardia arises from the mismatch of neural regulatory mechanisms responsible for the peristaltic movements of the esophagus and the relaxation of the lower sphincter in response to food.


Clinical feature


The classic triad of presenting symptoms consists of dysphasia, regurgitation, and weight loss. However, heartburn, postprandial choking, and nocturnal coughing are associated common problems. Eating of solid is difficult and laborious and patient need water to gulp the food. With disease progression regurgitation of undigested, foul-smelling foods is not an uncommon phenomenon.


DIAGNOSIS OF ACHALASIA CARDIA

Diagnosis of Achalasia cardia can be obtained by Contrast study, Upper GI Scopy and Manometery. On radiographs show a level of fluid in the enlarged esophagus, changes in the lungs. With the help of a contrast study (barium passage) – note the delay of contrast medium in the esophagus, With esophagogastroscopy make inspection of the walls of the esophagus and esophageal cancer, and exclude other diseases. Manometery is the gold standard for the diagnosis as well as for prognostication.


TREATMENT OF ACHALASIA CARDIA

Endoscopic balloon dilatation (expansion) of the lower openings of the esophagus (the cardia) is usually considered as initial treatment. However effect of dilation lasts only for few months and patients need repeated dilation. The most effective modality is laparoscopic (keyhole) Heller’s myotomy which has most sustainable results. In few very advance cases removal of the esophagus (esophagectomy) may be needed.



Esophageal diverticulum

What is an esophageal diverticulum?

An esophageal diverticulum is a pouch that protrudes outward in a weak portion of the esophageal lining. This pocket-like structure can appear anywhere in the esophageal lining between the throat and stomach.

Esophageal diverticula (pleural of diverticulum) are classified by their location within the esophagus:


Zenker’s diverticula (pharyngoesophageal) is the most common type of diverticula of the esophagus. Zenker’s diverticula are usually located in the back of the throat, just above the esophagus
Midthoracic diverticula, in the mid-chest
Epiphrenic diverticula, above the diaphragm


Who is affected by esophageal diverticula?

Esophageal diverticula can affect people of all ages, although most cases occur in middle-aged and elderly individuals. Overall, esophageal diverticula are rare, showing up in less than 1 percent of upper gastrointestinal X-rays and occurring in less than 5 percent of patients who complain of dysphagia (difficulty in swallowing).


Are esophageal diverticula serious?

Typically, esophageal diverticula are nuisances that enlarge slowly over many years, gradually producing increasing symptoms, such as dysphagia, regurgitation and aspiration pneumonia, caused by breathing in regurgitated diverticula content.
When symptoms of esophageal diverticula worsen, a person may be unable to swallow due to an obstruction near the diverticulum; rarely, the esophagus may rupture. An obstruction or rupture caused by an esophageal diverticulum is dangerous, and both complications require immediate attention. Regurgitation caused by a diverticulum often occurs at night when lying down, which can lead to choking, aspiration pneumonia (a lung infection caused by pulmonary aspiration, the entry of secretions or foreign material into the trachea and lungs), and lung abscesses.
Although rare, squamous cell carcinoma can develop in 0.5 percent of those with diverticula. This is thought to be caused by chronic irritation of the diverticula by prolonged food retention. It is important to note that the fear of cancer is not a reason to surgically treat diverticula.


What causes esophageal diverticula?

While the first case of an esophageal diverticulum was reported nearly 250 years ago, little is still known about this condition. It is believed that the internal pressure produced by the esophagus to move food into the stomach can herniate the esophageal lining through a weakened wall, creating a pouch or a diverticulum. There is usually distal end obstruction.
Esophageal diverticula are more common in people who have motility disorders of the esophagus, such as achalasia, that cause difficulty in swallowing, regurgitation of food, and, in some people, a spasm-type pain.


What are the symptoms of esophageal diverticula?

The symptoms of esophageal diverticula include:


Dysphagia (difficulty swallowing, characterized by a feeling of food caught in the throat)
Pulmonary aspiration (the entry of secretions or foreign material into the trachea and lungs)
Aspiration pneumonia (a lung infection caused by pulmonary aspiration)
Regurgitation of swallowed food and saliva
Pain when swallowing
Cough
Neck pain
Weight loss
Bad breath (halitosis)

Some people may experience a gurgling sound as air passes through the diverticulum. This is known as Boyce's sign.


How is esophageal diverticulum diagnosed?

The tests most commonly used to diagnose and evaluate esophageal diverticulum include:


Barium swallow: The patient swallows a barium preparation (liquid or other form) and its movement through the esophagus is evaluated using X-ray technology.

Gastrointestinal endoscopy:

A flexible, narrow tube called an endoscope is passed through the gastrointestinal tract and projects images of the inside onto a screen.

Esophageal manometry:

This test measures the timing and strength of esophagus contractions and muscular valve relaxations. 24-h pHmetry: A test to check for the presence of gastroesophageal reflux disease (GERD).


How is esophageal diverticulum treated?

Cases of esophageal diverticulum that cause minor symptoms can be treated through lifestyle changes, such as eating a bland diet, chewing food thoroughly, and drinking plenty of water after meals.
If symptoms become severe, several types of surgery are available to remove the diverticula, repair the defects and relieve a patient’s symptoms and improve their quality of life.


Treatment of diverticula require:

An examination of the diverticula;
Repair of the weakened wall; and
Relief of obstruction

The type of surgical treatment recommended depends on the size and location of diverticula, and include:


Cricopharyngeal myotomy: Used in the removal of small diverticula, this surgical treatment can be completed using an open or trans oral approach. Diverticulopexy with cricopharyngeal myotomy: Used to remove larger diverticula, this procedure involves turning the diverticular sac upside down and suspending it by suturing it to the esophageal wall.
Diverticulectomy and cricopharyngeal myotomy: Diverticulectomy for the treatment of Zenker's diverticula has been performed for almost a century. The procedure involves complete excision of the diverticular sac.
Recently, Cleveland Clinic surgeons have improved the outcome of this procedure by adding the Heller myotomy laparoscopic approach to ensure the movement of food through the lower esophageal sphincter.
Endoscopic diverticulotomy (Dohlman procedure): This procedure divides the septum between the cervical esophagus and the diverticular pouch. By dividing the septum, food can freely drain from the pouch to the esophagus. Cleveland Clinic surgeons complete this division by using a Zenker’s diverticuloscope and a minimally invasive stapling technique to treat Zenker’s diverticulum.


Esophageal leiomyoma

What is an esophageal diverticulum?

Although leiomyoma is the most common benign esophageal neoplasm, it is a rare condition. Resection of the tumor is recommended in symptomatic patients, and observation is recommended in asymptomatic patients with small lesions. We discussed here a patient admitted to our hospital for dyspepsia in whom a calcified mediastinal neoplasm was diagnosised preoperatively and esophageal leiomyoma was diagnosised postoperatively. Enucleation of a leiomyoma of the esophagus is recommended and the optimal approaches should be tailored based on the location and size of the tumor.

Introduction

Benign tumors of the esophagus are rare and leiomyoma is the most common benign tumor of the esophagus. It is reported that most leiomyomas originate the inner circular muscle layer of the distal and midthoracic esophagus, particularly at the esophagogastric junction. Middle-aged men are most frequently affected. The main symptoms usually are dysphagia and epigastric pain, but they are not specific for the disease. The size of the esophageal leiomyoma may change, a size of 1 to 29 cm has been defined in the literature. But most of them was samller than 5 cm in diameter. Tumor that size lager than 5cm are rare. It was easily misdiagnosised as mediastinal mass, esophageal cancer and esophageal stromal tumor. Its clinical feature and management are differente with other smaller esophageal leiomyoma. Here, a patient with large calcified esophageal leiomyoma who was treated in our institute is presented, initial discuss its diagnosis and management against the background of previously published cases and series.


Discussion

Leiomyomas are benign tumors descending from smooth muscle cells of the esophagus. They are the most common benign tumors of the esophagus and they may occur in all parts of the esophagus, but 60% occur in the distal third, 30% in the middle, and 10% in the proximal esophagus. Although gastrointestinal bleeding is a common finding in gastric leiomyomas, esophageal leiomyomas rarely bleed, which may be because they do not ulcerate. Leiomyomas grow slowly, and half of the patients are asymptomatic and the symptoms are not specific. Dysphagia with concomitant epigastric pain or retrosternal burning usually appears when the tumor's diameter becomes larger than the critical point of 4.5-5 cm. It seemed that the size of tumor correlates with the severity of the symptoms, but larger leiomyoma usually grow toward outside of esophageal lumen. So dysphagia don't always proportionate to the size of tumor in larger leiomyoma. In our report, the symptoms were dyspepsia and esophageal reflux.
The diagnosis of esophageal leiomyoma is mostly not clear preoperatively. It may present as a mediastinal mass on chest radiograph and may be seen as an incidental radiologic finding. Differential diagnoses include foreign oppressed desease of esophagus, malignant esophageal tumors such as squamous or adenomatous carcinomas or leiomyosarcoma and other benign tumors. Barium swallow is the most commonly used radiologic test for esophageal lesions. The finding on barium swallow is a smooth filling defect in esophageal lumen without a mucosal abnormality. More esophagus was involved in large esophageal leiomyoma, the mucosa of diseased region become thinnings, and show hyperaemia. So it can be regarded as mucosa destroy when barium swallow examination, that misdiagnosis as esophageal cancer or esophageal stromal tumor. Computed Tomography scans of the chest show in most cases a mass originating from esophagus without mediastinal lymphadenopathy, but in giant leiomyoma, tumor usually grow toward outside of esophageal lumen. To form soft tissue shadow in mediastinum, it can be misdiagnosised as mediastinal mass. The diagnosis is difficault to do and may cause diagnostic confusion. So to posterior mediastinum mass that close neighbor esophagus, it maybe a esophageal leiomyoma, this is worthy think highly.

Esophagoscopy is also used for the diagnosis of esophageal leiomyoma, but it only shows submucosal lesions and will not lead to an accurate diagnosis. The use of the EUS can clearly reveal the structure of the esophageal wall. On EUS, leiomyoma presents as a homogeneous and hypoechoic lesion with clear margins, surrounded by a hyperechoic area, which can easily be differentiated from a lipoma, cyst, or hemangioma in the esophageal wall. Preoperative biopsy of the tumor is a debating issue. Our policy is not to recommend it, because the tumor is easily adhesive to the mucosa and the mucosal damage occurs accidentally during enucleation. Moreover, in many cases biopsy could not provide enough material to establish an accurate histopathological diagnosis. Once the clinical diagnosis of leiomyoma is established, many factors must be considered for the optimal treatment. Tumor size and location are important, but also the patient’s symptoms, general condition, and comorbidities should be taken into account. The surgical indications of these tumors include unremitting symptoms, increased tumor size, mucosal ulceration, histopathologic diagnosis, and facilitation of other surgical procedures. Because malignant transformation in leiomyomas is rare, some authors recommend regular follow-up with barium swallow and endoscopy for asymptomatic patients with lesions smaller than 5 cm and when the preoperative workup has excluded malignancy. We suggest that a leiomyoma should be removed when diagnosed even when asymptomatic, because there is always the possibility, rarely though, of malignant transformation.
For leiomyoma, the location and size of the tumor are important factors in determining the appropriate surgical approach. Endoscopic approaches appear possible in case of small pedunculated tumors of 2–4 cm originating from the muscularis mucosae. Usually to execute endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). Symptomatic small leiomyomas < 5 cm can be enucleated either by open surgery or by means of videoassisted thoracoscopy (VATS). Transthoracic extramucosal blunt enucleation via a left- or right-sided thoracotomy is the most common procedure for small- to midsized esophageal leiomyoma, which is easier, faster, and safer compared to resection. Low tumors and tumors of the esophago-gastric junction can be approached via upper midline laparotomy. After nucleation, the muscular wall should be closed to avoid diverticular-like mucosal bulging and for the preservation of the muscular propulsing activity. The larger the tumor that diameter >5 cm, associated with muscle atrophy and more muscular defects. The muscular wall should be repaied with pedunculated pleural film, diaphragm valve, or omentum, lung, pericardium. Postoperation feeding time should be delayed to avoid fistula, diverticula. Strengthen the lower esophageal mucosa, esophageal mucosa even weak are protected, and can effectively prevent to form postoperative gastric acid reflux and esophageal diverticulum. For giant esophageal leiomyoma should be preferred esophageal resection and reconstruction surgery, not the same as conventional enucleation of tumor. Because: (i) It was technically difficult to only enucleate giant leiomyoma, and the defect of esophageal muscle can’t ensure wound healing; (ii) esophageal muscle was pressed by giant leiomyoma that expansive growth, became thinning and membranous. So lower esophageal sphincter dysfunction or loss. Iterature has reported that patients after removal of giant leiomyoma prone to symptoms of reflux esophagitis ; (iii) For giant esophageal leiomyoma, it may have leiomyosarcoma-like transformation or with small leiomyosarcoma-like lesions; Meanwhile, the huge tumor endangered the physical health of patients by dysphagia. Or may be combined esophageal cancer, so as soon as possible surgery. To perform partial or subtotal resection of the esophagus, and esophagogastric anastomosis, the results are satisfactory. In our patient, because of the size, the location and the confusion diagnosis of the tumor, it was extramucosal blunt enucleated using thoracotomic approach.
IIn conclusion, diagnosis of esophageal leiomyomas requires both endoscopic and radiologic examinations. Once the clinical diagnosis of leiomyoma is established, the operation should be performed to remove the tumor.


Symptoms

Often there are no symptoms
Difficulty eating Vomiting
Food regurgitation Heartburn Weight Loss
Cough Painful Swallowing
others


Diagnosis

Biopsy and Endoscopy are essential to ensure the tumor is benign


Ways of treatment

Wait and Watch
Removal by Endoscopy
Surgery


Esophagus Cancer

Esophagus

Esophagus

is the food pipe which serves the purpose of carrying food from mouth to stomach and its cancer is 6th most common cancer worldwide. Usually occurs in elderly patients. Symptoms often include difficulty in swallowing (dysphasia) and weight loss. Other symptoms may include pain when swallowing (retro sternal pain), a hoarse voice, enlarged lymph nodes (glands) around the collarbone, a dry cough, and possibly coughing up or vomiting blood.

The most common causes are: tobacco, alcohol, very hot drinks, poor nutrition and hyperacidity (acid reflux). The disease is diagnosed by biopsy done by an endoscope (a fiber optic camera). However CECT chest and abdomen is important to plan the treatment. Treatment is based on the cancer's stage and location, together with the person's general condition and individual preferences. Surgery is the mainstay of treatment in patients with operable disease. Small localized squamous-cell cancers may be treated with surgery alone with the hope of a cure. In most other cases, chemotherapy with or without radiation therapy is used along with surgery. Larger tumors may have their growth slowed with chemotherapy and radiation therapy followed by surgery. Usually surgical procedure needs complete removal of esophagus along with all nodes related to disease and replacement of esophagus by stomach In the presence of extensive disease or if the affected person is not fit enough to undergo surgery, palliative care is often recommend.


Eventration of Diaphragm (Diaphragm Repair)

What is the diaphragm?

The diaphragm is the major muscle of respiration and separates the thoracic and abdominal cavities. The phrenic nerve is responsible for the contraction of the diaphragm.


What is diaphragmatic eventration?

This is a condition in which the diaphragm is placed at a much higher level than it normally is because it is paralyzed and fails to contract. It most commonly is congenital (present at birth) and may result from a phrenic nerve problem or an abnormally thin diaphragm at birth. Rarely it may affects adults or cause symptoms in adults.


What causes diaphragmatic eventration in adults?

In adults this condition is caused by an injury to the phrenic nerve or an infection or a cancer in the chest that causesthe phrenic nerve to function poorly. Often a viral infection that results in an eventration may go unnoticed and the results may become apparent several years later. One half of the diaphragm, commonly the left side, is affected. As the lower half of the lung fails to expand properly as the diaphragm does not contract it does not take part in the breathing process effectively.


What symptoms do patients with an eventration experience?

This condition is often asymptomatic. The patients may experience respiratory symptoms such as breathlessness, cough or chest pain particularly on exertion. In addition, patients may suffer from recurrent pneumonia, bronchitis, or cardiac arrhythmias. They may also experience gastrointestinal complaints resulting from compression of the stomach.


How is the diaphragmatic eventration diagnosed?

In the majority of cases, the condition is picked up on a chest x-ray performed for assessment of some other problem demonstrates a raised diaphragm on one side. This is further confirmed by a fluoroscopic examination in which the movement of the diaphragmis observed by continuous x-ray as the patient is asked to breathe in and out deeply. A CT scan may be ordered to rule out a cancer or a tumor inside the chest as a cause for the paralyzed diaphragm. The function of the lungs is assessed by performing pulmonary function tests.