Esophagus
Esophagus or food pipe is a long hollow muscular tube which begins in the throat. From throat it enters the chest, crosses the muscular partition between the chest and abdomen called diaphragm to enter the abdominal cavity. In the abdominal cavity esophagus joins the stomach.
The function of the oesophagus is to propel food down from the throat into the stomach by way of muscular contractions or peristalsis.
The entry and exit of the oesophagus have sphincters or special muscle valves that help prevent digestive juices, acid, and food in the stomach from entering the food pipe in a reverse direction.
Various diseases can affect the oesophagus, ranging from simple reflux to muscular disorders like Achalasia to malignancies or cancers. Some of the common ones are:
- Motility disorders – Achalasia Cardia, Diffuse Esophageal spasm
- Gastro-esophageal reflux disease (GERD)
- Corrosive injury – Acid or Alkali injuries
- Hiatus hernias
- Oesophageal malignancies or cancers
1. Achalasia
Achalasia is a disorder of the Oesophagus or food pipe, where there is difficulty in swallowing due to a failure in relaxation of muscles at its lower end.
Symptoms:
Patients usually present with difficulty in swallowing, especially liquids. They may also experience a sensation of food getting stuck in the chest. This problem often begins slowly but progresses gradually. Other symptoms include chest pain, regurgitation of swallowed food, heartburn, difficulty in burping, a sensation of fullness or a lump in the throat, hiccups, recurrent cough, and weight loss.
Diagnosis:
Upper GI endoscopy, Oesophageal manometry, Barium swallow, and CT scan chest and abdomen with oral contrast.
Treatment:
Options include medical, endoscopic, and surgical management. Though surgery remains the best modality, treatment depends on various factors which will be assessed before suggesting the most appropriate care.
Laparoscopic Heller’s Myotomy:
This is considered the gold standard treatment for achalasia and is also a definitive procedure. Here, 3-4 small keyholes are made in the abdomen, and laparoscopically, the muscle fibers in the lower end of the food pipe and upper end of the stomach are divided to relieve the tightness. The muscles are split precisely under vision to allow an easy passage of the food bolus. This is followed by wrapping the involved segment of the food pipe with the upper portion of the stomach (the fundus) to provide additional protection and migration.
2. Other oesophageal motility disorders – Diffuse esophageal spasm
Like any other motility disorders of the esophagus where there is lack of co-ordination of different segments of the oesophagus or food pipe. These are of different varieties including Diffuse oesophageal spasm, etc.
Symptoms:
Difficulty in swallowing, severe excruciating chest pain after consumption of food, regurgitation or vomiting of swallowed food, heartburn, difficulty in burping, a sensation of fullness or a lump in the throat, hiccups, recurrent cough, and weight loss.
Diagnosis:
Upper GI endoscopy, Oesophageal manometry, 24-hour pH study, Timed barium swallow, and CT scan chest and abdomen with oral contrast.
Treatment:
Medical management, Endoscopic management, Surgical management – Laparoscopic long cardiomyotomy with partial fundoplication.
Laparoscopic Long Cardiomyotomy with Partial Fundoplication:
Using 3-4 small keyholes in the abdomen, the muscle fibers in the mid and lower end of the food pipe along with the upper end of the stomach are divided to relieve the tightness or spasm. The muscles are split precisely under vision to allow an easy passage of the food bolus. This is followed by wrapping the involved segment of the food pipe with the upper portion of the stomach (the fundus) to provide additional protection and prevent migration.
3. Fundoplication for Gastro-esophageal Reflux Disease (GERD)
Acid reflux is when the digestive juices produced normally in the stomach inadvertently enter into the oesophagus or food pipe. Another term for acid reflux is “Gastroesophageal reflux disease,” or GERD.
Symptoms:
Heartburn, an acidic taste in the throat, difficulty in swallowing, change in voice, repeated belching and burping, sore throat, and unexplained cough.
Diagnosis:
Acid reflux is usually diagnosed based upon symptoms and response to treatment. In cases where the diagnosis is not clear, one or more of the following tests are helpful to detect the disease: Upper GI endoscopy, 24-hour pH study, Oesophageal manometry, and Barium swallow.
Treatment:
Treatment depends on the severity of symptoms, and the options are a mix of medications, lifestyle changes, and surgery. We suggest suitable options after thorough clinical evaluation.
Medical Management & Surgical Management – Laparoscopic Nissen’s Fundoplication:
This surgery strengthens the lower oesophageal sphincter mechanism (between the oesophagus and stomach) by tightening the diaphragmatic muscles and wrapping the upper portion of the stomach (fundus) around the lower oesophagus, which stops the acid from entering into the oesophagus.
4. Hiatal Hernia Repairs
This is a condition where a portion of the stomach migrates up into the chest through the diaphragm (a muscle separating the chest & abdomen). It is usually associated with gastro-esophageal reflux disease.
Symptoms:
Heartburn, acidic taste in the throat, difficulty in swallowing, sore throat, unexplained cough, and chest pain.
Diagnosis:
Upper GI endoscopy, 24-hour pH study, Barium swallow, and CT scan chest with oral contrast.
Treatment:
Surgical management: Laparoscopic hiatal repair along with Nissen’s fundoplication.
Laparoscopic Hiatal Repair along with Nissen’s Fundoplication:
This is again the gold standard treatment for hiatal hernia. Surgery involves strengthening the lower oesophageal sphincter (or valvular mechanism between the oesophagus and stomach) by tightening the diaphragmatic muscles (crura) and wrapping the upper portion of the stomach (fundus) around the lower oesophagus.
5. Barrett's Oesophagus
Barrett's oesophagus occurs when the normal lining (epithelium) of the oesophagus is replaced by tissue that is similar to that of intestines. It is usually caused by acid reflux. If left untreated, it can turn cancerous.
Symptoms:
Heartburn, acid taste in the mouth, vomiting after eating, and difficulty in swallowing.
Diagnosis of Barrett’s Oesophagus:
Upper GI endoscopy with or without biopsy is the best method to diagnose.
Treatment:
Treatment options include both medical and surgical management, which in turn depends on various factors that will be assessed before suggesting the most appropriate care.
Surgical Procedure – Endoscopic Mucosal Resection (EMR):
In this day care procedure, the abnormal lining is lifted and separated from the wall of the oesophagus endoscopically. The goal is to remove abnormal cells contained in the lining.
6. Esophagectomy for Cancers – Trans Hiatal and Transthoracic
Oesophageal cancer (OC) is the world’s sixth most common cancer. Its unique feature is rapid progression. Cancer can appear in any segment of the oesophagus.
Symptoms:
Difficulty in swallowing solids initially & later liquids also, weight loss, loss of appetite, hoarseness of voice, black stools, chest pain, cough, and intractable hiccups.
Diagnosis:
Upper GI endoscopy with biopsy, CT scan - chest, abdomen and pelvis, and PET CT scan.
Treatment:
The treatment is complex and requires interdisciplinary planning. The main factors for selecting treatment are the site, histological type, stage, and medical condition of the patient.
- Chemo-Radiotherapy
- Neo-adjuvant therapy – Sandwich surgery between cycles of chemo-radiation
- Surgical resections
Surgical Procedures
i. Esophagectomy with Gastric or Colonic Pull Up
When the cancer is in the mid or upper portion of the esophagus, the food pipe needs to be removed completely and continuity established by pulling the stomach or colon up into the chest or neck. This procedure can be done by open technique or by keyhole surgery (thoraco-laparoscopy).
ii. Esophagectomy with Partial/Total Gastrectomy and Colonic Interposition
Oesophageal cancers at the esophago-gastric junction (EGJ) or lower end of the food pipe are traditionally managed surgically with either an esophagectomy with partial gastrectomy or an extended gastrectomy, with or without thoracotomy (approaching the esophagus through the thoracic or rib cage).
7. Corrosive Injury Esophagus
Consumption of acids or alkali agents may cause severe and permanent damage to the food pipe. Throat, windpipe, stomach, and small intestines may also be involved depending on the type of agent consumed and the quantity. It can affect the mouth, food pipe, stomach, and beyond. The scarring that these agents leave behind can affect the normal swallowing mechanism, compromising the quality of life.
Symptoms:
Early: Burning sensation in mouth, throat, stomach, chest pain, abdominal pain, fevers, difficulty in breathing, difficulty in swallowing, inability to speak, bleeding, etc.
Late or Delayed: Difficulty in swallowing food and even saliva, repeated cough and vomiting, loss of weight, aspiration of ingested food, etc.
Diagnosis:
Upper GI endoscopy, CT scan chest and abdomen with intravenous contrast.
Treatment:
Medical management, Endoscopic management, and Surgical management – Emergency / Elective, Staged or Single sitting.
Surgical Procedures:
- Laparoscopic Feeding Jejunostomy: This is done solely for the purpose of feeding and improving nutrition. Through keyholes, a tube is passed into the initial part of the small intestine and hitched to the stomach. Feeds in liquid forms are given through this tube at frequent intervals.
- Gastric or Colonic Pull Up, with / without Esophagectomy: When the entire food pipe is damaged, an alternate passage needs to be provided for consumed food to pass down. Either the stomach, if it is normal, or a portion of the large intestine (colon) is pulled up into the neck and joined to the normal portion of the upper food pipe. This procedure can be done by open technique or by keyhole surgery (thoraco-laparoscopy).
