The esophagus (esophagus) is a 25-centimeter long muscle tube that connects the pharynx with the stomach. In the area of the larynx, the upper part of the esophagus begins, which at this point has an important sphincter, as the backflow of chyme upwards must be prevented, because this is in close proximity to the entrance to the trachea. The areas of the esophageal sphincters on the one hand have a protective function, on the other hand they also form a significant constriction due to the phase-wise higher muscle pressure.
In the further course down the esophagus lies behind the trachea; This in turn is well protected behind the breastbone. After about nine centimeters, the trachea lying in front of the esophagus forks into two main branches (bronchi), flanking the front and left of the heart from behind. At this point, the main artery from the heart also passes over the left bronchus. The esophagus passes behind this, even surgically demanding point straight down and passes after a total of 20 to 24 centimeters through a special opening in the diaphragm (hiatus) in the abdominal cavity. Shortly before the esophagus goes into the stomach, there is another sphincter muscle in the wall to prevent the gastric acid from rising to the lower part of the esophagus. Because of this danger, this site is a critical transition zone of the esophagus, which is why the wall structure of the esophagus must be explained.
The mucous membrane consists of a nonkeratinizing squamous epithelium, which slowly merges into the columnar epithelium of the stomach in the lower part of the esophagus. If gastric juice permanently flows back into the lower esophagus, the mucous membrane in this zone (reflux disease), occasionally also so strong that here the squamous epithelium converts to the columnar epithelium and thus can become a precursor of a carcinoma. In the next shift, the wall of the esophagus consists of a transverse and longitudinal musculature, which ensures that the chyme is transported quickly. An outer, tight and smooth envelope (serosa), as it is also present in the stomach and intestine, is missing from the esophagus and due to the high demands placed on each suture in this area, as thus precipitates another, strengthening layer of the wall.
The process of swallowing, in which the esophagus is involved, is subject to a very complicated neurogenic control. When swallowing, a peristaltic wave is triggered, and upper and lower sphincters must relax one after another at a certain interval to allow the food to pass. Outside of the act of swallowing, the areas of the sphincter muscles are part of a high-pressure zone, which ensures that the food does not enter the trachea and that the gastric acid rises back into the lower esophagus. The latter phenomenon is the most common "occlusive disorder" of the lower sphincter and is due to a relaxation of the muscles in this zone. It causes the reflux disease, which, however, can be treated predominantly with acid-inhibiting drugs.
The benign diseases of the esophagus include cavities in the area of the esophageal wall, the so-called diverticula, which differ from one another by their place of origin. They typically occur in front of the upper or lower sphincter, when it comes to diseased pressure spikes in the esophagus during swallowing due to dysfunction. The most common (70%) is a wall protuberance in front of the upper sphincter, called the "Zenker diverticulum" or "cervical pulsatile diverticulum". During swallowing, the upper sphincter closes too early, so that there is an acute overpressure, which over time leads to a protrusion of the mucous membrane through a gap in the muscles.
With nine new cases per year per 100,000 inhabitants, esophageal carcinoma is the most common surgical disease of the esophagus, with men being five times more likely to be affected than women. Typically, these tumors emanate from the squamous cells of the oesophageal mucosa and arise in fifty percent of cases in the middle of the third half of the esophagus. The main risk factor to develop such a tumor is probably chronic alcohol and nicotine abuse. There are also tumors that emanate from the mucus-forming cells (adenocarcinomas). They occur predominantly in the transition region from the esophagus to the stomach, because they are based on a long-term damage to the mucous membrane with pre-existing acid reflux from the stomach.
Both patients suffering from a Zenker's diverticulum and those with an oesophageal tumor will first notice dysphagia or difficulty swallowing. These can be in the form of a pressure sensation behind the sternum, as if the food were getting stuck in one place. Sometimes even the already swallowed food rises again into the oral cavity. Occasionally, patients also describe discomfort such as a stinging sensation when swallowing. Especially the Zenker diverticulum can also cause coughing, hoarseness and bad breath. The diverticulum may also be felt as a small, crunchy tumor around the neck, usually left-sided.
As soon as a patient notices dysphagia, he / she should go to specialist care, because various diseases of the esophagus can cause these symptoms. For this reason, the medical doctor takes particular interest in the patient's medical history, because in three quarters of the cases alone a diagnosis can be made on the basis of precise questioning: Are the dysphagia dependent on the nutritional consistency? What is the timing of swallowing after food intake - intermittent, slowly increasing? In which temporal context are food intake and the resurgence of food? Are there any signs of premature withdrawal, such as a reflux disease or a stroke? Has the patient noticed a severe weight loss? Thereafter, a close inspection of the mouth and throat of the patient should be made and the neck scanned for enlarged lymph nodes or soft tissue changes.
Depending on the suspected diagnosis, a reflection of the esophagus is performed and at the same time a tissue sample is taken in the area of conspicuous mucous membrane areas. In addition, especially in diverticula, an x-ray examination of the esophagus with liquid contrast agent is performed, which can also show movement disorders of the esophageal wall. If the disease is a tumor, it may be necessary to perform an additional CT or MRI scan to see its extent and location in the thorax. Under certain circumstances, a preliminary examination by an ear, nose and throat doctor is necessary, which must check the functioning of an important nerve in the larynx. Depending on the pre-existing conditions and the age of the patient, ultrasound examinations on the heart as well as a lung function test are also carried out.
In a Zenker diverticulum, the indication for surgery is given, no matter how severe the complaints of the patient, because the complication rate is low.
For the operation, the patient is supine and covered so that the neck area on the left side is easily accessible. The skin incision takes place longitudinally to the side and left of the larynx to a length of six centimeters. Thereafter, the preparation is carefully prepared until the left thyroid lobe can be mobilized and folded up and one clearly sees a very important nerve running here. Now the diverticulum is dissected, presented and ablated and the esophagus is closed again at this point. Finally, in the region of the upper sphincter of the esophagus, in which the pressure peaks occur during swallowing, a special muscle transection is performed, so that the resistance in this area decreases when swallowing and a recurrence of a diverticulum can be prevented.
The indication for operation in esophageal carcinoma depends on the one hand on the tumor stage, on the other hand on its localization. Since 50% of the tumors develop in the middle third, it must always be carefully determined which positional relationship a tumor has to the bronchial system, since this is in close proximity. There is therefore the danger that the tumor grows into the bronchi or into the main artery. Depending on the location of the carcinoma, the therapy may be different:
- Upper third of the throat: Cooperation with ear, nose and throat doctors
- Mid-third: combination of surgery through the chest and through the abdomen
- Lower third: surgery only from the abdomen
- Special case: tumor of the lower esophageal third with spreading to the stomach (cardia carcinoma)
Fundamental is the difference between a two-cavity operation (chest and abdomen) and a so-called "transhiatal esophageal resection" (Einhöhlenresektion), in which only the abdominal cavity is opened and the esophagus in the thorax blunt, detached from the abdominal cavity. The upper end of the esophagus is then separated via an access at the neck. The thorax is thus not opened in this method.
Subtotal esophagectomy involves partial removal of the esophagus and stomach entrance including major lymph nodes. This is always a two-cavity operation, which means that the abdominal cavity and chest must be opened.
In the two-cavity operation, the patient is stored supine. The incision is made first from the lower end of the sternum to the belly button. Thereafter, the abdominal wall is severed layer by layer and subsequently the abdominal cavity is carefully scanned by the surgeon's hand. He pays attention to enlarged lymph nodes in the area of the main artery, to the surface of the liver and, if possible, to the extent of the tumor. Now the dissection and extensive mobilization of the stomach, lower esophagus and duodenum takes place.
In a second step, the right front chest, about three transverse fingers below the areola, opens and the pleura is severed to expose the tumor in the esophagus. After further preparation, the tumor including lymph nodes and surrounding fatty tissue is removed, which means that the esophagus above the tumor is also removed with sufficient safety distance. The tissue is examined by a pathologist while the surgery is in progress to see if the esophagus is healthy.
Now follows the design of the gastric tube, which is later pulled up into the chest to bridge the defect of the esophagus. For this purpose, first the transition from the esophagus to the stomach is removed over a length of about eight centimeters in the region of the stomach entrance with a cutting and suture apparatus, so that here a narrow tube is formed. The gastric outlet (pylorus) is surgically enlarged, as it becomes the bottleneck after unavoidable transection of an important nerve. The stomach entrance is placed in a plastic bag and later pulled up into the chest. In order to enable the new suture connection between the stump of the esophagus and the gastric tube, another incision of the skin on the left side of the neck is necessary to give the surgeon the greatest possible overview. The patient receives at this stage a large stomach tube, which is advanced over the nose and throat and ensures better splinting of the soft esophageal stump. The stump of the esophagus is marked with two strong retaining threads, which are then pulled through the prepared gastric tube in the plastic sheath and pulled up into the chest with manual support. There, the plastic sheath is removed, and the new gastric tube receives in the back wall still an opening, so here the new seam (anastomosis) can be created to the esophagus. This is finally sewn by hand in two rows. The most important suture is the suture of the esophageal mucosa, since only it is strong enough for anchoring the suture.
Finally, a drainage in the area of the anastomosis is inserted and all skin sections are closed layer by layer. It may be necessary to put on a chest drainage because during surgery the lungs may be injured on one side. The most important postoperative complication is the leakage in the area of the new anastomosis between the esophagus and the new gastric tube. Therefore, the patient has to abstain from eating and drinking for several days after surgery. Recent methods combine surgery with a minimally invasive procedure for the thorax and minimally invasive abdominal surgery, as well as a suture on the neck. If the tumor over-strikes the stomach, the stomach must be removed, and part of the colon must serve as a gastric and oesophageal replacement.
Often a patient in the intensive care unit still has to be ventilated for several hours after the end of the operation. As a rule, a differentiated infusion and pain therapy is performed in the intensive care unit, and the laboratory values are monitored regularly. First, the patient must not eat and drink over several days in order not to endanger the new suture connection.
After about four days, the tightness of the suture may be checked by means of a contrast agent examination. Thereafter, the patient may first drink swallowed tea and bouillon. It is followed by a careful diet on pureed food and finally a light diet. With the help of nutritional counseling, every patient in the hospital learns that he first has to eat a lot of small meals a day until the process of swallowing via the new "esophageal passage" works well. Relatively late, namely only when the surgeon is quite sure that the new suture is completely dense, the drainage is pulled. Finally, the skin clips of the abdomen are removed on the tenth day.
All patients can subsequently participate in a close-knit follow-up program. Above all, this has the aim to recognize a recurrence of the tumor at an early stage by the regular removal of tissue samples. Collaboration between surgeons, oncologists and gastroenterologists remains very important.
As a late consequence of esophageal removal, a constriction may occur in the area of the new interface that results in disruption of the food passage. To dilate this constriction, if necessary, under sedation or narcosis, a stepwise stretching of the tissue is performed by tapered rubber catheter of different sizes, until a good passage of the food is guaranteed again.
The esophagus, which for the most part lies in the posterior midfield of the thorax, passes with its lower portion into the abdomen. In the transition from the esophagus to the stomach is the lower esophageal sphincter. This prevents acidic stomach contents from running back into the esophagus. The esophagus has its own movement (peristalsis), which on the one hand transports the food to the stomach and on the other hand serves as a self-cleaning process.
In achalism, the increased pressure of the lower esophageal sphincter muscle causes difficulty in swallowing, since the food does not or hardly gets into the stomach. This causes permanent enlargement of the esophagus with changes in the mucous membrane.
Symptoms and diagnosis
Patients with achalasia complain of pain behind the sternum, belching, bad breath and repeated vomiting of undigested food. Diagnosis The physical examination shows in most cases no special finding. The most important examination to confirm the diagnosis is the x-ray examination of the esophagus, esophageal and gastric mirroring (esophagoscopy, gastroscopy and pressure measurement of the sphincter of the lower esophagus (manometry)). This is a significant narrowing of the lower esophagus. The therapy of achalasia is initially conservative, i. without surgery. Medications are prescribed that affect the lower oesophageal muscle. This medication may improve the difficulty swallowing. Another approach is the endoscopic extension by means of pressure balloon. For this purpose, a balloon is inserted into the esophagus during gastroscopy and widened the sphincter. In addition, by injecting medication (Botox) into the sphincter during gastroscopy, the symptoms can be alleviated. However, this procedure must be repeated several times in many patients.
Surgery is only necessary if the drug or endoscopic therapy does not show lasting success. The surgery leads to a permanent enlargement of the sphincter. The food can pass unhindered back into the stomach. Under intraoperative endoscopic control, the sphincter muscle without mucous membrane is split with the ultrasound scissors. By 4 -5 trocars (working sleeves) adhesions, which pull from the stomach to the spleen, are released by means of a special ultrasonic scissors. With this ultrasonic scissors, it is possible to safely cut through vessels up to 4mm in size. Subsequently, the mobilization of the esophagus takes place over a length of 5-6 cm into the abdomen. Then the formation of a cuff from the upper, mobilized gastric portion (fundus). This cuff lies on the lower split esophageal muscle. The cuff is fixed to the esophagus with sutures. After completion of the cuff, all trocars are removed again, the wounds sewn in depth and glued to the surface.
Course and aftercare
Already on the day of the operation, you can drink tea and water. An intravenous gastric tube is removed about 6 hours later. You can move freely on the ward and take a shower in the evening by bonding the wounds. On the first postoperative day, an imaging of the lower esophagus is performed using X-ray contrast media. This serves on the one hand the exclusion of a leak and on the other hand the control of the passage. If you find inconspicuous conditions here, the first thing to do is to have a diet that is both liquid and mushy. On the fourth postoperative day, you can leave the clinic. Your family doctor will check the wounds in the following days. A physical protection is advised in the first week. From the second week you can feed yourself again with normal diet.
Mostly, the first stage of cancer reveals no symptoms, including pain. At this stage of development, a neoplasm, as a rule, does not exceed 3 cm and does not affect adjacent organs and tissues. Endoscopic surgery on the esophagus is the most effective method to curecancer in early forms.
Surgery on the esophagus effectively eliminates the first metastases with an endoscopic laser. This type of operations on the esophagus includesusing optical devices, which enables surgeons to monitor each stepcarefully. Laser energy precisely burns the affected areas. Laser surgery on the esophagus perfectly eases covering wounds, and prevents blood loss and relapse of cancerous cells.
In the later stages of the spread of cancer cells, the doctors of the Schwarzwald Baar Clinic use radical methods of therapy that are aimed to save as many healthy segments of the esophagus as possible.
Surgery on the esophagus is performed after a course of chemotherapy that is done for preliminary weakening of the tumor, decreasing its size and preventing itfrom further progression. Chemotherapy is often used as an independent treatment, which is capable to defeat even squamous cell carcinoma.
Radical surgery on the esophagus starts from getting to the affected area in the abdominal and thoracic cavity. The entire esophagus is accurately separated from the adjacent tissues. Then, surgery on the esophagus includes its replacement with a portion of the colon or segment of the intestine. Resection operations on the esophagus can last up to 5 hours. The rehabilitation period will take approximately 1 month.
Benign neoplasms of the esophagus have the risk of being transformed into cancerous ones, so it is better not to delay their treatment. Optimal results are achieved with the help of laparoscopy on the esophagus. During laparoscopic surgery on the esophagus several punctures a few millimeters wide are made to introduce an optical device and tiny surgical tools. Then a surgeon removes a tumor, which is encapsulated and has not yet penetrated into the mucous tissuesof the esophageal tube. This type of surgery on the esophagus does not damagethe soft tissues of the body, significantly reduces blood loss, contributes to aesthetic appearance (there are no visible scars), and also prevent the reссurence of cancer.
In the environment of the innovative spirit of the Schwarzwald Baar Clinic, surgery on the esophagus is performed in accordance with the latest European regulations and standards. To ensure the safety and effectiveness of surgery isthe main goal of the multidisciplinary clinic.