Best Hospital for Esophageal Cancer in Warangal

Best Hospital for Esophagal Cancer in Warangal

The esophagus is a muscular tube that connects the throat to the stomach. It is part of the digestive system and plays an important role in the process of swallowing. When we swallow food or liquids, the muscles in the esophagus contract and move the bolus (a small rounded mass of a substance, especially of chewed food) down toward the stomach.

The esophagus is about 10-13 inches (25-33 centimeters) long and is lined with moist pink tissue called mucosa. It has two muscular sphincters – the upper esophageal sphincter (UES) and the lower esophageal sphincter (LES) – which help to control the flow of food and prevent backflow of stomach acid and other contents into the esophagus.

1. Achalasia cardia

History and Clinical Examination

Dysphagia to both solids and liquids from the onset is the most common presenting feature of achalasia, as liquids require better neuromuscular co-ordination than solids for oesophageal emptying.
Postures like raising the arms in an erect position increase the intraoesophagael pressure and propel food in the aperistaltic oesophagus, Regurgitation of undigested food (occurs in 75–91% of patients) is the second most common presenting symptom.
Retrosternal chest pain and heartburn can be seen in 40–60% of patients, which often leads to misdiagnosis as GERD
Weight loss can occur
Cough and fever caused by aspiration pneumonia (8–10%) can be one of the presenting symptoms of achalasia.

Investigations

Upper GI endoscopy and timed barium oesophagogram are the initial investigations to rule out mechanical obstruction

High resolution manometry (HRM) is diagnostic and helps to classify achalasia

Upper Gastrointestinal Endoscopy

Endoscopy in achalasia shows a dilated and tortuous oesophagus and intermittent tertiary contractions

A pulsion-type oesophageal epiphrenic pseudodiverticulum can be seen

Timed Barium Oesophagogram

Timed barium oesophagogram (TBE) is the imaging of choice in achalasia

Delayed emptying of the barium from the oesophagus, tertiary contractions, and bird-beak appearance on the X-ray are the characteristic features

In late stages of achalasia, megaoesophagus (oesophageal diameter: >7 cm) and sigmoid oesophagus (dilated, tortuous oesophagus) can be seen

High-Resolution Manometry

Classifies achalasia cardia

Type I achalasia

no oesophageal contractility or pressurization
represents late-stage disease with a dilated, atonic oesophagus

Type II Achalasia

characterised by panoesophagael pressurisation (in >20% swallows) between the upper and lower oesophageal sphincter
Type II AC represents the early stage of disease
most responsive to pneumatic dilatation (PD)
Type II achalasia is also the most common subtype

Type III Achalasia

least common
least responsive to therapy

Management

In patients with low surgical risk, pneumatic dilatation, laparoscopic Heller’s myotomy (LHM), or POEM are the mainstays of treatment

Botulinum toxin (BT)/pharmacotherapy is reserved for patients with high surgical risk/limited life expectancy.

Botulinum Toxin

The effect of therapy is short lived
50% of patients require reinjection after 6–12 months
Repeat injections can be technically difficult because of fibrosis from prior injections.

Pharmacological Therapy

calcium channel blockers, nitrates, anticholinergics, phosphodiesterase inhibitors, and β agonists have been tested in achalasia

provide short-lived benefits at most

Pneumatic Dilatation

Rigiflex™ balloon dilator available in three sizes: 30, 35, and 40 mm, is used for performing PD

Initially, the 30 mm balloon is used, followed by progressively larger balloons (the graded approach)

After index dilatation by the graded approach, repeated dilatations on follow-up for recurrent symptoms is known as the ‘on demand approach’.

Peroral Endoscopic Myotomy

It is useful in treatment naïve, treatment failure, and Type III achalasia.

A contrast oesophagogram is carried out at postoperative Day 1 to exclude a possible leak and to evaluate the treatment response by seeing adequacy of barium emptying

Laparoscopic Heller’s Myotomy

LHM is the first-line surgical therapy for achalasia

a response rate of 90–97%

The minimally invasive, laparoscopic approach is associated with shorter hospital stays, reduced postoperative pain, and lower disability

2. Para esophageal Hernia/ Hiatal Hernia

A hiatal hernia is a medical condition in which the upper part of the stomach or other internal organ bulges through an opening in the diaphragm

Classification of hiatal hernias are divided into 4 types:

Type I (sliding type), which represents more than 95% of hiatal hernias, occurs when the GEJ is displaced upwards towards the hiatus.
Type II is a paraesophageal hiatal hernia, which occurs when part of the stomach migrates into the mediastinum parallel to the esophagus.
Type III is both a paraesophageal hernia and a sliding hernia, where both the GEJ and a portion of the stomach have migrated into the mediastinum.
Type IV is when the stomach, as well as an additional organ such as the colon, small intestine, or spleen, also herniate into the chest

Etiology and epidemiology

increased prevalence in older people

typically is a result of obesity, pregnancy, chronic constipation, and chronic obstructive pulmonary disease (COPD). Trauma, age, previous surgeries, and genetics can also play a role in the development of a hiatal hernia.

History and Physical

Patients typically complain of heartburn and sometimes regurgitation. While heartburn is the most common complaint, some patients will present with extra-esophageal symptoms such as a chronic cough or asthma

Evaluation

Endoscopy:This is an essential step in the evaluation of patients with GERD and a suspected hiatal hernia
Manometry:

to rule out primary motility disorders such as achalasia, which can mimic the symptoms of reflux

Patients with primary motility disorders often require a partial fundoplication as opposed to a Nissen.

pH monitoring: The 24-hour pH test is the gold standard for diagnosing acid reflux
Esophagography: The esophagogram provides valuable information in terms of the anatomy of the esophagus and proximal stomach. Anatomic abnormalities such as tumors or strictures may also be discovered during this study.

Treatment / Management

Initial management of a patient presenting with typical symptoms of GERD in an outpatient setting includes a double dose of a proton pump inhibitor (PPI).

Patients with evidence of severe esophageal injury such as ulcer, stricture, or Barrett’s mucosa should be considered for surgical treatment

Current recommendations

operative repair of all symptomatic paraesophageal hernias as well as completely asymptomatic large hernias in patients less than 60 years old and otherwise healthy

surgical procedures

Nissen fundoplication (360-degree wrap) and Partial fundoplication (Dor and Toupet)

3. Corrosive Injury Esophagus (Acid Ingestion)

Corrosive ingestion is a common form of poisoning

Corrosive agents cause severe damage to the gastrointestinal (GI) tract. The most severe forms of injury can lead to mortality

Upper GI endoscopy is the test of choice for assessing severity in the acute phase of the disease

The long-term management is based on the site, length, number, location, and tightness of the stricture

Acidic agents, frequently responsible, are the ones that are commonly available such as cleaning agents (hydrochloric acid) and a gold solvent, which is a mixture of hydrochloric and nitric acid

Alkalis commonly used are hydroxides of sodium and potassium.

The mechanism of acidic and alkaline injury is coagulation necrosis and liquefactive necrosis, respectively

Injuries due to corrosives can be restricted to the esophagus or stomach

Coexistent esophageal and gastric injuries are seen in 20%–62.5% cases

Clinical Features

The acute phase of corrosive injuries involves perforation of the esophagus, stomach, or duodenum.

Esophageal strictures cause dysphagia.

Imaging Features

1. Plain x ray

A plain chest x ray – may demonstrate pneumomediastinum suggesting esophageal perforation

free air under the diaphragm suggesting stomach perforation

upper GI endoscopy
barium esophagogram
CECT chest and abdomen

Management

Management of acute corrosive ingestion is focused on initial resuscitation, evaluation of the grade of injury, treatment of early complications, maintenance of nutrition, and prevention of stricture formation

Emergency surgery

Indication – transmural necrosis of the gastrointestinal tract

Aim- to remove all the necrotic tissue

the standard approach – laparotomy

Procedure – patients with combined esophageal and gastric injury, esophagogastrostomy with cervical esophagostomy is performed

for nutritional improvement before definitive procedure – A feeding jejunostomy

Endoscopic Management

Graded Approach – endoscopic esophageal dilatation

Surgical Management – colon pull up