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Hiatus Hernia

Hiatus Hernia Repair

We have two large cavity in our body, one is thoracic cavity containing lung, esophagus, heart other is abdominal cavity containing stomach, liver, spleen and other important organs; These are separated by a membranous structure called diaphragam; The opening in diaphragam where esophagus enter from thoracic cavity into abdomen is called hiatus and just below it esophagus join the stomach this point is called gastro-esophageal junction (GE Junction); Hiatus hernia occur when either GE junction is displaced upward into thorax called as sliding hiatus hernia or abdominal organs such as stomach, spleen moves through hiatus into thorax and GE junction remain stable called as paraesophageal hernia

Sliding hernia is more common and less symptomatic, most of symptoms are of gastro-esophageal reflux disease; Para-esophageal hernia is less common but patient present with vomitting, dysphagia; Barium swallow and upper GI endoscopy can make the diagnosis;CECT chest and abdomen is done in case of large para-esophageal hernia

Only symptomatic patients require surgery, Surgery done is Laparoscopic hiatus hernia repair

GERD (Reflux Disease)

Fundoplicaion

Gastro-esophageal reflux disease as the name indicates, it is reflux of gastric contents into an esophagus; It is often associated with a hiatus hernia; Most common presentation is heart burn; other symptoms include regurgitation, dysphagia and sometimes extraesophageal symptoms like a cough, wheezing.

When patients present with symptoms of GERD first thing to be done is Upper GI Endoscopy; it will exclude other disease and will show erosions, ulcers at lower end of esophagus, signs of acid injury and can grade disease severity; 20-30% of patients have normal upper GI endoscopy a condition termed as non-erosive esophagitis; however the gold standard test for diagnosis is 24-hour pH test; other investigations include Manometery, Esophagogram

Today most patients are managed medically with proton pump inhibitor; These drugs should be taken on empty stomach for better action, However as these drugs inhibit the acid formation and do not prevent reflux, patients can still have symptoms of regurgitation and can develop its complication such as cancer

Indications for Surgery are severe esoph­ageal injury on endoscopy like ulcer, stricture, Barrett’s mucosa and regurgitative symptoms despite medical therapy; The Surgery done is Laparoscopic Nissen Fundoplication; In this surgery a hiatus hernia is repaired if present and gastric fundus is wrapped over the lower end of esophagus to tighten the lower esophageal sphincter; Patient can start oral diet next day of surgery and can do his normal routine activity.

Corrosive Stricture

 

Gastric/Colonic pull up

Corrosive ingestion is either acid or alkali and it can be either accidental or suicidal, in children it is mainly accidental whereas it is suicidal in adults; Patient can present in the acute stage just after ingestion or after weeks when complications develop

In acute stage means when patient present immediately after ingestion, Patient should be monitored for vitals (Pulse rate and Blood Pressure) and should be admitted preferably in ICU; Immediate upper GI endoscopy is not required, it can do harm rather than any benefit, Patient oral intake should be stopped even liquids also; X-ray Neck, chest and abdomen done to look for any evidence of perforation ; Patient should be started orally once there is no difficulty in swallowing saliva; if the patient condition is stable for 48-72 hrs then patient can be shifted toward and can be discharged next day, if the patient is stable otherwise but has difficulty in swallowing for a week or so, feeding jejunostomy should be done and patient can be discharged, later on patient should be investigated by Upper GI Endoscopy and Barium swallow for cause of dysphagia

If the patient condition deteriorate CECT chest and Abdomen should be done which can show wall enhancement of esophagus and stomach and can predict transmural necrosis or perforation; in this case, damage control surgery should be done, all the necrosed part involved should be removed and Feeding jejunostomy can be done, reconstruction is done later on.

In later stage patient may develop either esophagus or antral stricture and present with either dysphagia or vomitting; sometimes patient may have both esophagus and antral stricture; so it is important to evaluate both esophagus and stomach before any reconstructive procedure is planned; Esophagus is replaced with stomach if it is normal, if the stomach is also involved then colon is used to replaced scarred esophagus; Gastro-jejunostomy is done for antral stricture

Achalasia Cardia

Hellers Cardiomyotomy

Normally when we swallow anything by the peristalsis movement of esophagus it is propelled further lower down and the lower esophageal sphincter muscle relax so that food bolus can enter into the stomach; Achalasia Cardia is one of the common cause of dysphagia and is basically a motility disorder characterized by primary peristalsis failure of esophagus and absence of lower esophageal sphincter muscle relaxation in response to swallowing; As it is a motility disorder patient will have dysphagia to both solid and liquid from initial stage, patient may complain of chest pain and regurgitation of undigested food material; Upper GI endoscopy is done to rule out other disorders, Manometery is gold standard for the diagnosis; Surgery done is Laparoscopic Hellers Myotomy

 

 

 

Cancer Esophagus

Minimally invasive esophagectomy

Esophagus cancer is one of the leading cause of cancer related mortality; These patients have poor outcome as these tumor have propensity for metastases even when tumours are superficial; Risk factors for Esophagus cancer include Smoking, Alcohol, Tobacco, Obesity; Incidence of esophagus cancer is rising as the incidence of obesity

 

Histologically esophagus cancer is of two types one is squamous cell carcinoma and another is adenocarcinoma; Smoking is risk factor for squamous cell carcinoma, seen in the upper part and most commonly seen in male patients and in smokers, another type is adenocarcinoma seen mostly in lower part, obesity is a risk factor and seen mostly in female patients

Most common symptom is dysphagia, initially to solid food and later on even to liquid also, other symptoms are loss of appetite, weight loss, cough, bony pain

Upper GI Endoscopy if the first step in patients who present with dysphagia, Endoscopy can show mass/stricture in the esophagus as the cause of dysphagia and biopsy from the mass can be taken;Biopsy will confirm the diagnosis, CECT chest and upper abdomen is done for locoregional spread and distant metastases ; Endoscopic ultrasound and PET Scan are done when indicated

If the CT Scan show tumor is locally advanced or there is regional lymph node involvement neo-adjuvant chemo-radiotherapy is given; after neo-adjuvant therapy patient is again evaluated and if tumor is resectable surgery is done

If the tumor is resectable initially, surgery is the best option; As mostly these patients are chronic smokers and chest condition is poor surgery is done with minimally invasive approach; Minimally Invasive Radical Esophagectomy is done in which esophagus is mobilized by thoracoscopic approach and abdomen part is done laparoscopically