– . II. For undergraduate. Staff Members of Cardio-thoracic Surgery Departments. Egypt. HIATUS HERNIA. Definition. :. Protrusion of any part of the stomach through the esophageal hiatus into the thorax. . ID: 615547
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Surgery of the Esophagus – IIFor undergraduate
Staff Members of Cardio-thoracic Surgery DepartmentsEgyptSlide2
Protrusion of any part of the stomach through the esophageal hiatus into the thorax.
junction lies above the diaphragm, associated with
Type II (
: The stomach
through an enlarged hiatus , adjacent to the esophagus into the
junction is not displaced and there is no reflux, its
Type III (combination)
: A combination of sliding and
Type IV (complex)
of other abdominal viscera with the stomach (colon,
fatty infiltration with obesity
Increased intra-abdominal pressure
Space occupying lesions
Increased intra-gastric pressure
of hiatus hernia
: GERD and its complications
, bleeding, stricture, aspiration, Barrett’s mucosa
: Results in obstruction of lower
(dysphagia), gastric outlet (postprandial fullness).
: Results from rotation of herniated stomach along a longitudinal (
) or transverse (
) axis. This results in bleeding (congestion of gastric mucosa, peptic ulceration), perforation (strangulation and gangrene), pulmonary impairment (space occupation, aspiration).Slide6
Nonspecific upper abdominal or respiratory symptoms.
Symptoms of GERD.
Reflux: gastric juice reach mouth with acid taste
Heart burn: burning pain,
Blenching ( wind from mouth)
Symptoms related to complications of reflux
, dysphagia due to fibrosis, acute chest pain , inability to vomit , postprandial fullness, chronic iron deficiency anemia due to chronic blood loss)
Symptoms related to
hernia (stomach at chest)
Dyspepsia, fullness and abdominal distension
Severe abdominal painSlide7
Barium study of upper GIT
: Defines foregut anatomy, position of the stomach and its ability to empty.
: Used to assess level of
ulcers, stricture or
, taking biopsy if there doubt for
or malignant transformation.
function studies (
: anemia due to blood loss.Slide8
Sliding Hiatal HerniaSlide9
Mixed Hiatal HerniaSlide10
Organo axial volvulusSlide11Slide12
treatment of GERD.
on failure of medical treatment or presence of complications.
Type II, III, IV:
Reduce the hernia
and Excise the sac (abdominal or left thoracic approach).
Close the hiatus
(posterior to the esophagus).
Correct associated pathology (
bleeding ulcer, excise gangrenous viscera).
Fix the stomach in the abdomen (
Perform an anti-reflux procedure
IV repair, Hill’s repair.
Indications of surgery in H.H:
hernia to avoid complications e.g. strangulation, obstruction.
Failure of medical conservative treatment in sliding H.H for 3-6 month.
Complicated sliding H.H e.g. hemorrhage, ulcers, short esophagus, recurrent pulmonary infection, cancer.Slide14
Comparison between sliding & paraeoophageal herniaSlide15
Gastresophageal Reflux (GERD)
usually occur with
hernia, but it may be independent of it.
and malignant transformation,
, stricture formation and short
Preventive mechanism against reflux
I- First line defenses:
Presence of intra-
part of the
which has higher pressure than thoracic
action of circular muscle fibers of the lower esophagus (inferior
Valve like effect of the angulation of the
junction (Angle of His).
The “pinch cock” action of the right crus of the diaphragm maintaining the forward bent of the
The rosette like fold of gastric mucosa at the cardia.Slide17
Preventive mechanism against reflux esophagitis: (Cont.)
II- Second line
Clearing effect of reflux by:
Swallowing saliva (alkaline)
Erect position & gravity,
Elevate the head of the bed on 15 cm blocks: Gravity helps
Weight loss in obese
bedtime (2hrs): Avoid
food. Food rich in proteins increases gastric acidity.
which decrease lower esophageal sphincter (LES)
(nonsteroidal anti-inflammatory drugs, calcium channel
increasing intra abdominal pressure by staining, lifting heavy weights and tight belts.Slide19
, a basic aluminum salt, exerts a generalized
effect in acidic environment by enhancing
mucosal defense mechanisms, acting as a barrier to the diffusion of acid, pepsin and bile salts.
: Act by increasing LES pressure and by enhancing gastric and esophageal emptying. Examples:
: Reduce gastric
: Silicates, H2-blockers (
, ranitidine), Proton-pump inhibitors (
of anti-reflux surgery for GERD:
Failure of maximal medical therapy for at least 6 months.
Complications of GERD :
Recurrent aspiration and/or pneumonia.
(to correct GERD-related symptoms).
Associated lesions e.g. gall bladder stone.Slide21
of surgery for
Reduction of the
, with: Creation
segment of esophagus (5 cm
Prevention of herniation of
junction into the chest (
Narrowing of the hiatus
by approximation of 2 halves of right
of the diaphragm
of anti-reflux mechanism
). Creation of acute angle of entry of
to the stomach.Slide22
Operative approaches for GERD (anti-reflux surgery
: Effective with normal length abdominal
: For re-operation.
After reduction of the stomach and bringing
-gastric junction below the diaphragm.
The hiatus is narrowed by one or two
sutures approximate the
posteriorly to prevent migration of the fundoplication.
Wrapping the fundus of the stomach around
(360°) over wide bored stomach tube to avoid narrowing
Mark IV (270
A transthoracic approach through bed of 7
Restoring cardio-esophageal angle by suturing the fundus of the stomach to the lower esophagus utilizing 2 - 3 rows of horizontal mattress sutures.
Tightening diaphragmatic hiatus, reduction of the stomach to abdomen
Belsey IV fundoplicationSlide27
Suturing fundus to the median arcuate ligament overlying aorta.
Suturing the posteriorly sited fundus to the right and left
to create 180
In the presence of
shortening due to reflux
as gastric tube from the greater curve.
Then a partial (Collis-
) or total (Collis-
) fundoplication is performed around the
which is reduced below the diaphragm.Slide29
complications of anti-reflux surgery :
Related to the extent of
(too long, too tight) or presence of associated motility disorder.
Gas bloat syndrome
Inability to belch and postprandial fullness. (
,delayed gastric emptying , extent of
”, breakdown of
, herniation into mediastinum,
or gastric perforation.Slide32
containing all layers of the
containing mucosa only).
are secondary to an inflammatory process.
are the end-result of
True (traction) diverticula.& False (pulsion) diverticula.Slide34
Pharyngo-esophageal ( Zenker’s diverticulum )
is an acquired
arising from a triangular weakening (
) in the posterior midline of the lower pharynx, between the oblique and transverse (
) muscle fibers of the inferior pharyngeal constrictor.
results secondary to dysfunction of
aspiration with alteration of the voice and
Large diverticulum may present a neck mass
and closed transversely through a left neck approach. If left
, suspension of the apex of the
) to the
fascia or pharyngeal musculature may be done.
and extending the
2-3 cm onto the proximal esophagus) is
traction type due to mediastinal fibrosis.Slide40
Foreign bodies of the esophagus
may be coins, meat or dental prosthesis.
usually obstruct the upper part of the esophagus at the level of
muscle being the narrowest part all-over the gastrointestinal tract.
2- On top of
Levels of physiological narrowing of the
narrowing: at 15cm from the upper incisor teeth.
narrowing: at 25cm from UIT.
: 40cm from UIT.Slide46
esophageal Foreign Bodies at the three physiological levels of esophageal narrowingSlide48
There is sudden onset of dysphagia.
CXR in coins.
Extraction of the foreign body using the rigid
and a crocodile forceps.Slide49
Foreign body in the upper esophagusSlide50
Mediastinal abscess complicating esophageal Foreign BodiesSlide51
Female 2y old, swallowed fish bone with esophageal perforation and mediastinal abscess when first seen.Slide52Slide53Slide54
Coin Extraction by Foley’ catheterSlide58
Boerhaave’s syndrome (Effort rupture of the esophagus)
Spontaneous perforation of esophagus.
Results from a full-thickness tear in the esophageal wall due to a sudden increase in
pressure combined with relatively negative
pressure caused by straining or vomiting.Slide59
In most cases of
syndrome, the tear occurs at the left
-lateral aspect of the distal esophagus and extends for several centimeters.
The condition is associated with high morbidity and mortality and is fatal without treatment.
esophageal disease is not a prerequisite for esophageal perforation but it contributes to increased mortality.Slide60
Suggested on the plain chest radiography
and confirmed by chest CT scan. Usually reveals mediastinal or free peritoneal air. Pleural effusion(s) with or without pneumothorax, widened mediastinum, and subcutaneous emphysema are typically seen.
may show esophageal wall edema and thickening,
fluid with or without gas bubbles, mediastinal widening, and air and fluid in the pleural spaces,
or lesser sac.Slide61
which reveals the location and extent of
of contrast material. Although barium is superior in demonstrating small perforations, the spillage of barium sulfate into the mediastinal and pleural cavities can cause an inflammatory response and subsequent fibrosis and is therefore not used as the primary diagnostic study. If, however, the water-soluble study is negative, a barium study should be performed for better definition.
Endoscopy has no role in the diagnosis
high in amylase (from saliva), low pH, and may contain particles of food.Slide62
Mortality of untreated Boerhaave syndrome is nearly 100%. Even with early surgical intervention (within 24 hours) the risk of death is 25%.
Its treatment includes:
Antibiotic therapy (prevent mediastinitis and sepsis).
Surgical repair of the perforation.
IV fluid therapy.Slide63
Malory Weis Syndrome (Gastro-esophageal laceration syndrome)
Bleeding from a laceration in the mucosa at the junction of the stomach and esophagus.
This is usually caused by severe vomiting.
Presents with painful hematemesis.
The laceration is sometimes referred to as a
The tear involves mucosa and
but not the muscular layer (contrast to Boerhaave syndrome which involves all the layers).Slide64
after violent retching or vomiting (alcoholic, food poisoning).
after 24–48 hours.
Rarely the condition is fatal.
Definitive diagnosis is by
as persistent bleeding is uncommon.
Cauterization or injection of epinephrine to stop the bleeding may be undertaken during
of the arteries supplying the region may be required to stop the bleeding.
If all other methods fail, high
can be used to ligate the bleeding vessel.Slide65
Mallory–Weiss tear affecting the esophageal side of the gastresophageal junctionSlide66
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