Surgical Affection of Oesophagus

Dr. Bikash PuriAssist. Professor

Nepal Polytechnic Institute, Chitwan

Surgical Anatomy• Oesophagus is musculomembranous tube

connecting pharynx and the stomach.

• The whole length of oesophagus is divided

into cervical, thoracic and abdominal part

in monogastric animal but very small or

absence of abdominal part in polygastric

animal.

• The average diameter approximately one to

two inches

• Begins at the level of the first cervical vertebra.

• Occupies almost dorsal position at origin and passes gradually to

left side of the trachea at the level of about 4th cervical vertebrae.

• Thereafter it occupies the left position of trachea upto 3rd thoracic

vertebrae.

• In the thoracic region it is median in position and enters the

abdominal cavity through hiatus oesophagus and terminates at the

cardia of the stomach.

• As the oesophagus crosses to left side of the trachea it is

accompanied by—

– Dorsally: longus coli and longus capitis muscles

– Laterally: left carotid artery, vagosympathetic trunk, jugular vein and recurrent

laryngeal nerve

• Overlying the oesophagus, following structures are

encountered:

– Skin,

– Cervical fascia

– Cervical paniculus muscle

– Omohyoideus muscle crossing the jugular furrow obliquely form below

upward, forward and inward towards the median line.

Composition of Esophageal wall

Its wall is composed of

• fibrous sheath,

• the tunica adventitia (Outermost layer)

• the muscular coat, (Double layer but in cat single layer)

• the sub-mucous and mucous coat. It is the

strongest layer to place the suture.

• The Blood supply to oesophagus is by branches of

– carotid,

– brachio-oesophageal

– and gastric arteries.

• The nerve supply to oesophagus is by

– vagus,

– glosso-pharyngeal

– and sympathetic nerves.

Blood and nerve supply

Surgical disease of Oesophagus

• Osophageal obstruction

• Oesophageal diverticulum

• Oesophageal stenosis

• Oesophageal wounds and fistula

• Neoplastic growth underneath the oesophagus.

Oesophageal obstruction/ChokeDefination:

– Choke is the intraluminal blockage of oesophagus.

– This condition is frequent in pet animals but infrequent in ruminants.

– Its frequency is higher in cattle but occasionally recorded in buffalo, camels and small

ruminants.

Etiology:

– Intraluminal causes: Example: vegetable (Turnip), fruits (large size lemon and apple), meat ball,

tennis ball, woods, plastic etc.

– Extraluminal causes: Example: large perioesophageal abscess, enlarged mediastinal lymph

nodes and tumors.

– Nutritional deficiencies, Dry feed ,

– Greedy nature of feeding of ruminants

– Oesophageal stenosis.

Symptoms• Swelling in the ventral neck region

• Inability of the animal to swallow feed and water.

• Hyper –salivation

• Animals keeps the neck stretched.

• Severe tympany occurs in complete choke

• The patient remains thirsty and makes attempts to drink water which often

returns back through the nostrils caring food particles with it.

• If obstruction persist for longer duration than it leads to perforation of

oesophagus due to pressure necrosis.

• Regurgitation of swallowed food and water may cause cough and

aspiration pneumonia.

Diagnosis

• Based on history, clinical signs and physical examination

• Obstruction to cervical region can be easily palpated. For obstruction in

thoracic region or doubtful condition, a probang may be passed.

• By measuring the length of the probang inside helps to locate the

obstruction.

Confirmatory diagnosis

• Radiographic examination with contrast media like barium salt past or

• Endoscopic examination in case of perforation

Treatment

• Oesophageal obstruction is usually not life threatening as long

as care is taken to control development of ruminal tympany.

• All extraluminal obstruction needs surgical correction

• The treatment for intraluminal obstruction can be categorized

as conservative and surgical

Conservative Management1. First of all oesophageal spasm should be controlled by applying

neuromuscular blocking agent along with anesthesia or deep sedation.

2. In large animal cervical obstruction should be cleared by placing the thumb or

fingers distal to the foreign body and gradually forcing it upwards until

reaches to pharynx. Then inserting hand obstructing material is removed.

3. Retraction of obstructing materials by Folley Urethral Catheter.

• Here, the folley catheter with a stylet is passed across the foreign obstructing object

and inflating the catheter bulb . Radiograph ascertain the correct position of the

inflatted cuff.

• Gentle retraction of catheter dislodges blunt foreign bodies and pull them out in

4. Push the obstruction material into rumen or stomach using probang

5. Along with this conservative management the animal must be infused with

ringes’s lactate solution

Surgical treatment

• Oesophagotomy is performed.

• It is practical in proximal two-third of cervical

part where the organ is relatively accessible

• Exposure of the caudal cervical oesphagus

form C6 to T2 is more difficult

CONTROL AND ANAESTHESIA

1. The position of animal is right lateral

recumbency after proper sedation.

2. Anaesthesia is by general anaesthesia in small

animals or by local in filtration analgesia at the

site of operation.

SURGICAL TECHNIQUE

1. An incision about twice the length of foreign body should be made

on skin and subcutaneous tissue.

2. The omohyoideus muscle is separated from upper and lower

structure. The areolar tissue is bluntly dissected with the help of

fingers.

3. The trachea is recognized to locate the oesophagus on its lateral

surface.

4. The oesophagus is drawn out and fixed in position by placing

intestinal forceps proximally and distally to foreign body.

5. Operative field is now packed off to avoid any chance of

contamination

6. Make an incision on dorsal wall of oesophagus either anterior or posterior to

obstruction. The incision should be large enough to extract the

obstruction/foreign body.

7. The repair of oesophageal incision can be done in two layers. The mucous

membrane can be sutured with mattress sutures or continuous sutures using

round bodies swaged needle.. The muscularis layer is to be sutured with

continuous lock stitch pattern. The distance between two suture should not

exceed 2-3 mm in small animal and 5mm in large animal.

8. Irrigate the area well with sterile saline mixed with antibiotic solution before

routine skin closure

9. The oesophagus is replaced in its original position.

10. The skin wound is closed in routine manner or it is left as open wound.

Oesophageal stenosis

• Oesophageal lumen need to be enlarged for its

correction

• For this first give the longitudinal incision over

stenosed part to include the normal oesophagus

proximally and distally

• Apply the stay sutures one centimeter away on

either side of the middle of the line of incision

• Next, this incision should be changed into

transverse position by pulling the stay suture.

• Suture the oesophagus in transverse position.

POST OPERATIVE CARE• Do not allow solid food for few days and intravenous feeding

is done twice daily.

• A course of antibiotics is to be completed (4-5 days)

• Antiseptic dressing of the wound should be carried one till

healing is complete or when sutures are removed after 8-12

days.

IMPORTANT CONSIDERATION/ REMARKS

1. Check hemorrhage during surgery

2. If oesophagus is empty it is recognized by passing a stomach tube.

3. During dissection, prevent damage to recurrent laryngeal nerve.

4. Suturing only oesophagus and leaving the skin wound open is the

procedure of choice because

a) It favours early closure of oesophageal wound

b) It prevents escape of alimentary matter during swallowing.

c) It permits drainage of any material, if present.