Of The Esophagus

For cervical esophageal carcinoma, radiation is the treatment of choice, not surgery. If radiation therapy fails with erosion of the tumor, for example into the larynx, then a laryngopharyngoesophagectomy is the operation of choice.

Squamous cell carcinoma of the esophagus is least common in this surgical region. Its management is difficult since it may involve larynx and trachea. It may metastasize to cervical lymph nodes as well. The evaluation in a patient with carcinoma of the cervical esophagus includes careful examination of the neck as well as barium x-ray films and CT scans of the neck and mediastinum, as well as the upper abdomen. Careful endoscopy of the larynx, trachea and esophagus are essential. Particular attention must be paid to laryngeal function and the distance between the cricopharyngeus and the tumor.

The likelihood of obtaining prolonged palliation in patients with extensive disease is minimal. In these advanced cases, radiation with or without chemotherapy may be used but without much chance of cure. Placement of an endoesophageal prosthesis is usually impossible at this level. More limited lesions are categorized into those involving the larynx and those that do not. For more limited lesions, if the carcinoma does invade the cricoid or larynx, it is not possible to salvage a functional larynx, and the resection must include larynx and enough trachea to provide a margin below the tumor, as well as removal of the entire cervical esophagus. A mediastinal tracheostomy is required. In this procedure, a collar incision provides access to both sides of the esophagus. A flap is raised and the extent of involvement is completely assessed before definitive resection is performed. The isthmus of the thyroid is transected and the trachea is dissected to a point low enough to define a margin of normal tissue. Intubation is carried out across the operative field into the transected distal trachea. The esophagus is transected in the mediastinum. If total esophagectomy is undertaken, the dissection can be carried down to the carina from the cervical approach, and the transhiatal esophagectomy completed from the abdominal approach.

Fig 17.4. CT scan of a patient with adenocarcinoma at the junction of the proximal and mid-portions of the esophagus (arrow). The lesion is seen abutting the membranous portion of the trachea. Bronchoscopy did not reveal tracheal invasion. A right thoracotomy was done to mobilize the tumor and esophagus. The patient was repositioned supine and a transhiatal esophagectomy with gastric pull-up into the neck was performed.

The specimen with the esophageal tumor is elevated and the lateral attachments of the larynx on either side are divided. The pharynx is entered through an incision above the hyoid bone and carried laterally. The epiglottis is removed at the hyoid bone. If total esophagectomy is performed, it is simplest to mobilize the stomach for replacement and bring it up for a direct pharyngeal-gastric anastomosis. If metastatic lymph nodes are found in the neck, cervical lymph node dissection may be done at the same time.

For cervical lesions not involving the larynx, initial dissection and exploration of the lesion are more difficult. The esophagus is encircled below the lesion at a reasonable point that will provide a satisfactory distal margin. This is done through a collar incision, since then each side of the esophagus can be dissected. In the event a laryngectomy is needed, this can be done through the collar incision. Again, a total esophagectomy is performed and a pharyngeal-to-stomach anastomosis is performed in the cervical region.

Ivor-Lewis Technique

All of the above treatment modalities for tumors in the cervical, mid-thoracic and lower esophageal regions are acceptable surgical positions. These are not the only choices and many other procedures exist. One popular method of treatment, for example, for lower esophageal carcinoma is the Ivor-Lewis procedure. In this procedure, the stomach is brought up into the right chest and a thoracic esoph-ageal-to-stomach anastomosis is performed. This leaves the proximal esophagus intact. The disadvantage of this is that there still may be multicentricity of tumor which could involve the proximal esophagus. This is partially obviated by the fact that most lower esophageal carcinomas are adenocarcinoma in histology and are therefore probably of gastric origin and do not have the same incidence of multi-centricity seen with squamous cell carcinoma. The second major reason that an Ivor-Lewis procedure may be more fraught with complications than a transhiatal esophagectomy is the fact that a thoracic anastomotic leak is a much more disastrous situation than a cervical esophageal anastomotic leak. The intrathoracic leak can lead to empyema and can rapidly progress to death, whereas a cervical esophageal anastomotic leak can be managed simply with a drain for weeks if need be.

An anastomosis may be technically perfect, however if the region becomes devascularized for any reason, the chance of healing properly is diminished and a leak may be inevitable. Therefore, it is not a trivial problem even in the best of hands.

In the Ivor-Lewis procedure, there again are several options available. One is to have the patient laying at a 45 degree angle and perform a thoraco-abdominal incision through the seventh intercostal space, mobilize the stomach, mobilize the esophagus, transect the esophagus and bring the stomach up into the chest to perform the intrathoracic esophagogastrostomy. A drainage procedure is necessary and this usually involves a pyloroplasty, either as a finger fracture pyloro-plasty or a myotomy incision in the seromuscular layer down to the mucosa.

The other option is to perform separate laparotomy and thoracotomy. In this case, the patient is supine and an upper midline incision is made and the stomach mobilized and brought up through the diaphragm. The patient is placed in the lateral decubitus position with the right side up and the thoracotomy performed. The stomach is further brought up into the chest, the esophagus mobilized, and an esophagogastric anastomosis performed.

Herbal Remedies For Acid Reflux

Herbal Remedies For Acid Reflux

Gastroesophageal reflux disease is the medical term for what we know as acid reflux. Acid reflux occurs when the stomach releases its liquid back into the esophagus, causing inflammation and damage to the esophageal lining. The regurgitated acid most often consists of a few compoundsbr acid, bile, and pepsin.

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