anatomy of ge junction

1. Anatomy of Gastroesophageal
Junction with special reference
to hiatus hernia and anatomical
basis of therapeutic intervention
Dr. Rana Pratap Singh
JRII Surgery
M.L.B. Medical College, Jhansi

2. Introduction
• From mouth to stomach, the food conduit
consists of the oral cavity, pharynx, and
esophagus.
• The esophagus serves as a dynamic tube,
pushing food toward the stomach.
• Active peristaltic contractions propel residual
material from the esophagus into the
stomach.

3. Anatomical Division
The esophagus is a midline structure lying on
the anterior surface of the spine.
It descends through three compartments: the
neck, the chest, and the abdomen.
This progression has led to its classic anatomic
division into cervical, thoracic, and abdominal
segments.

4. Two new subdivisions
One is functional aspects and makes a distinction
between the esophageal body and the upper and
lower sphincters.
The other is oncosurgery aspects and
distinguishes between the proximal and the distal
esophagus, with the tracheal bifurcation used as
dividing part.

6. Constrictions of esophagus
• It is the narrowest part of the alimentary tract (except for
the vermiform appendix).
• 1. at the beginning (15 cm from the incisor teeth),
• 2.crossed by the aortic arch (22.5 cm from the incisor
teeth)
• 3. crossed by the left bronchus (27.5 cm from the incisors)
• 4. as it passes through the diaphragm (40 cm from the
incisors).

7. • These are important clinically with regard to
the passage of instruments .

9. Cervical esophagus
• approximately 5 cm long
• descends between the trachea and the vertebral
column.
• C6 to the level of the interspace between the T1 and
T2 vert posteriorly, and suprasternal notch
anteriorly.

10. Thoracic esophagus
• approximately 20 cm long.
• It starts at the thoracic inlet.
• In thorax, it is in close relationship
with the posterior wall of the
trachea and the prevertebral fascia.

11. • Just above the tracheal bifurcation, the
esophagus passes to the right of the
aorta. This anatomic positioning can
cause a notch indentation in its left
lateral wall on a barium swallow
radiogram.

12. abdominal esophagus
• 2 cm long and includes a portion of the lower
esophageal sphincter (LES) .
• It starts as the esophagus passes through the
diaphragmatic hiatus and is surrounded by the
phrenoesophageal membrane.

13. • The musculature divided into an outer
longitudinal and an inner circular layer.
• The upper 2 to 6 cm of the esophagus
contains only striated muscle fibers.
From there on, smooth muscle fibers
gradually become more abundant.

14. Arterial supply
• Cervical Oesophagus: Right & Left superior &
inferior thyroid arteries.
• Thoracic Oesophagus: Up to tracheal bifurcation
Right & Left inferior thyroid Artery
direct supply from aorta (tracheo-bronchial tree)
• Abdominal Oesophagus: ascending branch of the left
gastric artery and from inferior phrenic arteries

17. Gastroesophageal Junction
• 4 anatomical points that identify the
gastroesophageal junction (GEJ): two endoscopic
and two external.
• Endoscopically-
1. The squamocolumnar epithelial junction (Z-line)
may mark the GEJ provided the patient does not
have a distal esophagus replaced by columnar-
lined epithelium as seen with Barrett's
esophagus.
2. The transition from the smooth esophageal lining
to the rugal folds of the stomach.

18. • Externally-
1.the collar of Helvetius (or loop of Willis)-
where the circular muscular fibers of the
esophagus join the oblique fibers of the
stomach
2.the gastroesophageal fat pad

20. • Two to three centimeters above the hiatus of
the diaphragm it is anchored at its lower end
by the insertion of a tough, skirt-like
prolongation of the endoabdominal fascia
from the undersurface of the diaphragm, the
ascending leaf of the phrenoesophageal
ligament.

22. • 2 to 5cm below the insertion of the
phrenoesophageal ligament. squamous
changes to columnar epithelium.
• The point of transition is marked by ora
serrata or "z" line
• Two cm of the esophagus immediately above
the epithelial junction are contained within
the sling of the right diaphragmatic crus as it
forms the hiatus.

23. PHRENOESOPHAGEAL LIGAMENTS
• The phrenoesophageal ligament arises
primarily from the endoabdominal fascia.
• At the lower margin of the esophageal hiatus,
it decussates into an upper and a lower leaf.
• The upper leaf extends through the hiatus to
insert into the esophagus two to three
centimeters above it.

24. • The lower leaf, which exists as a loosely
defined collection of fibroelastic fibers,
descends to insert into the esophagus at or
below the epithelial junction.
• The upper leaf is strong, well-defined
membrane rather than a ligament

25. Diaphragm and esophageal hiatus viewed from the abdominal aspect.

26. • Physiology
–It has been shown by manometric
techniques that a sphincteric mechanism
exists at the gastroesophageal junction.
–This barrier we refer to as the lower
esophageal sphincter.

27. • Two conditions under which the gastroesophageal
junction must maintain competence.
1. First is at rest
2. Second raised intra abdominal pressure.

28.  At rest the sphincter normally maintains a
pressure barrier between positive intra gastric
and negative intrathoracic pressure.
 This pressure differential is approximately 10
cm. H2O .
 It is present in all phases of respiration and
may be maintained even when the GE
junction is displaced into the thorax, as in
sliding hernia.

29. • Raised intra abdominal pressure.
The phrenoesophageal ligament maintains the
esophagogastric junction within the abdomen,
and the increased intraabdominal pressure is
brought equally to bear on the abdominal
esophagus containing a portion of the
sphincter as well as on the stomach.
• The sphincter, reinforced by this pressure, is
able to maintain a pressure differential
between the stomach and thoracic esophagus.

30. • Pathophysiology
– In hiatal hernia of the sliding type, the clinical
manifestations are due to gastroesophageal reflux.
– hiatal hernia may exist and even attain mammoth
proportions without reflux.
– The mechanism which can prevent reflux under
these conditions is the sphincter .

31. • What then leads to the development of
gastroesophageal reflux?
– The answer is that the gastroesophageal sphincter
has become incompetent.

32. • The normal tension on the
A. Normally, the ascending limb
of the phrenoesophageal
ligament inserts into the
esophageal wall above the
lower esophageal sphincter
mechanism. Forces applied
to the ligament by the
contracting diaphragmatic
musculature serve only to
dilate the esophagus above
the sphincter. This may be
the origin of the
radiologically familiar
"Phrenic Ampulla."

33. B. If the ligamentous
insertion were to be
displaced inferiorly,
then tension
transmitted through the
ligament would serve to
dilate the sphincter
itself, allowing
gastroesophageal reflux
to to occur.

34. C. The same situation would
pertain in the patient with a
sliding hiatal hernia.
Normally, in the hiatal hernia
patient without reflux, the
ligament would insert above
the sphincter area, producing
the classic three radiologic
criteria of hiatal hernia: The
phrenic ampulla, the
esophageal vestibule
(corresponding to the
sphincter area which has
been displaced above the
diaphragm), and the supra-
diaphragmatic gastric
loculus.

35. D. If the ligamentous
insertion were to be
displaced inferiorly,
reflux would ensue. If
the patient still
possessed a
competent sphincter,
any operation which
would reduce
tension on the
ligaments would cure
the reflux.

36. Esophageal tissues
Wall structure at the esophagogastric junction. The tunica muscularis is composed of both a longitudinal (2a)
and a circular layer (2b). a, muscularis mucosae; b, lamina propria; c, epithelium; G1, esophageal glands; G2,
gastric glands; Ly,lymph vessels; N1, myenteric plexus; N2, submucous nerve plexus.

37. GIANT DIAPHRAGMATIC (HIATAL)
HERNIAS
A. The sliding hernia, type I,
characterized by an upward
dislocation of the cardia in
the posterior mediastinum.

38. B. The rolling or PEH, type
II, characterized by an
upward dislocation of
the gastric fundus
alongside a normally
positioned cardia.

39. C. The combined
sliding-rolling or
mixed hernia, type
III, characterized by
an upward
dislocation of
boththe cardia and
the gastric fundus

40. D. In some taxonomies,
a type IV hiatal
hernia is declared
when an additional
organ, usually the
colon, herniates as
well

41. • incidence of a sliding hiatal hernia is seven
times higher than that of a PEH. The PEH is
also known as the giant hiatal hernia.
• The median age of the PEHs is 61 years old; of
the sliding hiatal, 48 years old. PEHs are more
likely to occur in women by a ratio of 4:1.

42. Clinical Manifestations
• The clinical presentation of a giant hiatal
(paraesophageal) hernia differs from that of a
sliding hernia.
• symptoms of dysphagia and postprandial
fullness with PEHs, but the typical symptoms
of heartburn and regurgitation present in
sliding hiatal hernias can also occur.

43. Diagnosis
1. A radiogram of the chest with the
patient in the upright position can
diagnose a hiatal hernia if it shows
an air-fluid level behind the cardiac
shadow.

44. 2. Fiber-optic esophagoscopy is useful in
the diagnosis and classification of a hiatal
hernia because the scope can be
retroflexed.

45. • Sliding hiatal hernia can be identified by
1. Rugal folds extending above the
impression caused by the crura of the
diaphragm.
2. Measuring at least 2 cm between the
crura and the squamocolumnar
junction.

46. • PEH is identified on retroversion
of the scope by noting a separate
orifice adjacent to the GEJ into
which gastric rugal folds ascend.

47. Treatment
A. Indications for repair
B. Surgical approach
C. Role of fundoplication

48. INDICATIONS & SURGICAL APPROACH
• This recommendation is based upon two
clinical observations.
• First, retrospective studies have shown a
significant incidence of life-threatening
complications of bleeding, infarction, and
perforation in patients being followed with
known paraesophageal herniation.

49. • Second, emergency repair carries a high
mortality.
• If surgery is delayed and repair is done on an
emergency basis, operative mortality is high,
compared to <1% for an elective repair

50. SURGICAL APPROACH
• A transthoracic approach facilitates complete
esophageal mobilization but is rarely used
because the access trauma and postoperative
pain are significantly greater than a
laparoscopic approach.

51.  The transabdominal approach facilitates reduction of
the volvulus that is often associated with PEHs.
 Although some degree of esophageal mobilization
can be accomplished transhiatally, complete
mobilization to the aortic arch is difficult or
impossible without risk of injury to the vagal nerves.

52. ROLE OF FUNDOPLICATION IN HIATAL
HERNIA REPAIR
• Most advocate the routine addition of an
antireflux procedure following repair of the
hernia defect.
• The main reasons for this.
1. Physiologic testing with 24-hour esophageal pH
monitoring has shown increased esophageal
exposure to gastric juice in 60 to 70% of patients
with a PEHs,
2.71% incidence in patients with a sliding hiatal
hernia

53. PREOPERATIVE EVALUATION
1. First, the propulsive force of the body of the
esophagus should be evaluated by esophageal
manometry to determine if it has sufficient
power to propel a bolus of food through a
newly reconstructed valve.

54. • Patients with normal peristaltic contractions
do well with a 360° Nissen fundoplication.
• When peristalsis is absent a
partialfundoplication may be the procedure of
choice, but only if achalasia has been ruled
out.

55. 2. Second, shortening of the esophagus can
compromise the ability to do an adequate repair
without tension, and lead to an increased
incidence of breakdown or thoracic displacement
of the repair.
• Esophageal shortening is identified on a barium
swallow roentgenogram by a sliding hiatal hernia
that will not reduce in the upright position, or that
measures larger than 5 cm between the
diaphragmatic crura and GEJ on endoscopy.

56. PRINCIPLES OF SURGICAL THERAPY
• Operation should restore the LES
pressure twice the resting gastric
pressure.
• The length of the intraabdominal
oesophagus should be maintained 2 or
more cm.
• Apposition of diaphragmatic crurae,
reduction of hiatus hernia done when
present.

57. • Repaired OG junction should relax during
swallowing adequately. To ensure this
only fundus of the stomach should be
used to buttress the sphincter and avoid
damage to vagal nerve.
• Tension free short and flopy
fundoplication should be done.

58. Fundoplications
• Nissen’s – total 3600 posterior fundoplication.
• Toupet’s – partial 1800 posterior fundal.
• Dor – anterior partial.
• Rosetti Hell – total anterior fundal
• Watson’s – anterolateral 1200 partial.
• Lind – posterior and anterior

59. a. Laparoscopic Nissen
fundoplication is performed with
a five-trocar technique.

60. b. The liver retractor is affixed to a
mechanical arm to hold it in place
throughout the operation.

61. c. After division of the gastrohepatic
omentum above the hepatic branch of
the vagus (pars flaccida), the surgeon
places a blunt atraumatic grasper
beneath the phrenoesophageal ligament.

62. d. After completion of the crural
closure, an atraumatic grasper is
placed right to left behind the
gastroesophageal junction. The
grasper is withdrawn, pulling the
posterior aspect of the gastric fundus
behind the esophagus

63. e. Once the suture positions are chosen,
the first stitch (2-0 silk, 20 cm long) is
introduced through the 10-mm trocar,
and the needle is passed first through the
left limb of the fundus, then the
esophagus (2.5 cm above the
gastroesophageal junction), then through
the right limb of the fundus.

64. f. Final position of the fundoplication