Download MBBS Surgery Presentations 19 Esophagus Lecture Notes

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OBJECTIVES

? By the end of this lecture the student should be able to
? Describe the anatomy of the esophagus: extent, length,

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parts, strictures, relations, blood supply, innervation

and lymphatics.

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ESOPHAGUS

? Tubular structure about 25

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cm long.

Cervical

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? Begins at the level of C6.
? Pierces the diaphragm atT10.
? It is divided into 3 parts:

? 1- Cervical.

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? 2- Thoracic.

? 3- Abdominal.

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? Proximal and distal- oncosurgery

thoracic

Abdominal

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RELATIONS

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CERVICAL PART

? Posteriorly
? Post: Vertebral column.
? Lateral y:

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? Lat: Lobes of the

thyroid gland.

? Anteriorly:

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? Ant: Trachea and the

recurrent laryngeal

nerves.

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THORACIC PART

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? In the thorax, it passes

downward and to the left

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through superior then to

posterior mediastinum

? At the level of the sternal angle,

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the aortic arch pushes the

esophagus again to the midline.

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Thoracic part

ANTERIOR

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RELATIONS

? Trachea
? Left recurrent

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laryngeal nerve

? Left principal

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bronchus

? Pericardium
? Left atrium

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POSTERIOR RELATIONS ? Thoracic duct

? Bodies of the thoracic vertebrae
? Thoracic duct

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? Azygos vein
? Right posterior intercostal arteries
? Descending thoracic aorta (at the

lower end)

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LATERAL RELATION

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? On the Right side:
? Right mediastinal pleura
? Terminal part of the azygos vein.
? On the Left side:
? Left mediastinal pleura

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? Left subclavian artery
? Aortic arch
? Thoracic duct

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ESOPHAGUS AND LEFT ATRIUM

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? close relationship
? What is the clinical

application?

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? A barium swallow will

help the physician to

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assess the size of the

left atrium (dilation).

RELATIONS IN THE ABDOMEN

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? In the Abdomen, the esophagus

? Fibers from the right crus of the

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descends for 1.3 cm and joins the

diaphragm form a sling around the

stomach.

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esophagus.

? At the opening of the diaphragm, the

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? Anteriorly, left lobe of the liver.

esophagus is accompanied by:

? Posteriorly, left crus of the

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? The two vagi

? Branches of the left gastric vessels

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diaphragm.

? Lymphatic vessels.

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ESOPHAGEAL

CONSTRICTIONS

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? The esophagus has 3 anatomic

constrictions.

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? The first is at the junction with the

pharynx(pharyngeoesophageal

junction).

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? The second is at the crossing with

the aortic arch and the left main

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bronchus.

? The third is at the junction with the

stomach.

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? They have a considerable clinical

importance.

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? Why?

1. They may cause difficulties in

passing an endoscope.

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2. In case of swallowing of caustic

liquids (mostly in children), this

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is where the burning is the

worst and strictures develop.

3. The esophageal strictures are a

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common sites of the

development of esophageal

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carcinoma.

4. In this picture what is the

importance of the scale?

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ARTERIAL SUPPLY

? Upper third by the

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inferior thyroid

artery.

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? The middle third by

the thoracic aorta.

? The lower third by the

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left gastric artery.

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VENOUS

DRAINAGE

? The upper third drains

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in into the inferior

thyroid veins.

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? The middle third into

the azygos veins.

? The lower third into

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the left gastric vein,

which is a tributary of

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the portal vein.

? NB. Esophageal varices.

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LYMPH DRAINAGE

? The upper third is drained into the

deep cervical nodes.

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? The middle third is drained into the

superior and inferior mediastinal

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nodes.

? The lower third is drained in the celiac

lymph nodes in the abdomen.

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NERVE SUPPLY

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? It is supplied by sympathetic fibers from the

sympathetic trunks.

? The parasympathetic supply comes form the

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vagus nerves.

? Inferior to the roots of the lungs, the vagus

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nerves join the sympathetic nerves to form

the esophageal plexus.

? The left vagus lies anterior to the esophagus.

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? The right vagus lies posterior to it.

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CARDIAC ORIFICE

? It is the site of the gastro-

esophageal sphincter.

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? It is a physiological rather

than an anatomical,

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sphincter.

? Consists of a circular layer of

smooth muscle (under vagal

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and hormonal control).

? Function:
? Prevents (GER)

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regurgitation (reflux)

? NB. Notice the abrupt

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mucosal transition from

esophagus to stomach (Z-

line)

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Microscopic anatomy

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? 2 layers of muscles- longitudinal and circular.
? Lined by non keratinizing stratified squamous epithelium.
? Squamocolumnar jn.
Recap

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? Length ?
? Parts?
? Arterial supply?
? Venous drainage?
? Constrictions ?

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? Relation with lt atrium?
? Barett's esophagus?

Stricture
? Causes can be grouped into:

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? Intrinsic ? due to inflammation, fibrosis or neoplasia

? Extrinsic ? due to external compression

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? Disruption of peristalsis

Proximal and mid esophagus

? Caustic ingestion (acid or alkali)

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? Malignancy

? Radiation therapy

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? Infectious esophagitis - Candida, herpes simplex virus (HSV),

cytomegalovirus (CMV), human immunodeficiency virus (HIV)

? AIDS and immunosuppressed patients

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? Diseases of the skin - Pemphigus vulgaris, benign mucous membrane

(cicatricial) pemphigoid, epidermolysis bullosa dystrophica

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? Idiopathic eosinophilic esophagitis

? Extrinsic compression

? Squamous cel carcinoma

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Distal esophagus

? Peptic stricture
? Adenocarcinoma
? Collagen vascular disease - Scleroderma, systemic lupus

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erythematosus (SLE), rheumatoid arthritis

? Extrinsic compression
? Alkaline reflux following gastric resection

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? Sclerotherapy and prolonged nasogastric intubation

? Heartburn

? Dysphagia, odynophagia

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? Food impaction

? Weight loss

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? Chest pain

? Poor nutritional status

? Patients with collagen vascular diseases -- joint abnormalities,

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calcinosis, telangiectasias, sclerodactyly, or rashes

? Virchow node
Corrosive injury

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? Accidental or suicidal.
? The type of agent, its concentration and the volume ingested

determine the extent of damage.

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? Pathophysiology:

? Alkalis cause liquefaction that leads to fibrous scarring.

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? Acids cause coagulative necrosis with eschar formation, and this coagulum

limit penetration to deeper layers.

? Acids cause more gastric damage because of intense pylorospasm with

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pooling in the antrum.

Treatment

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? Supportive
? Feeding jejunostomy until patient starts swallowing saliva.
? Repeated endoscopy and dilation.
? Esophageal replacement for very long or multiple strictures. Why not

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resection?
Corrosive injury- Key points

Skil ed early endoscopy is mandatory

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Esophageal perforation
? Usually iatrogenic or due to `barotrauma'.
? Spontaneous perforation is a life-threatening condition.
? Iatrogenic perforation can be managed conservatively.
? Can be pathological

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? Due to penetrating injury or foreign body

Barotrauma (spontaneous perforation,

Boerhaave syndrome)

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? occurs classically when a person vomits against a closed glottis.
? The pressure in the oesophagus increases rapidly, and the
? oesophagus bursts at its weakest point in the lower third, sending
? a stream of material into the mediastinum and often the
? pleural cavity as well. The condition was first reported by

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? Boerhaave, who reported the case of a grand admiral of the
? Dutch fleet who was a glutton and practised autoemesis.
? Boerhaave syndrome is the most serious type of perforation
Pathophysiology

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Vomitting

Pressure in

Perforates at

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against

esophagus

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its weakest

Mediastinitis

closed glottis

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increases

point

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Clinical presentation

? Severe pain in the chest or upper abdomen following a meal or a bout

of drinking

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? SOB
? Sometimes misdiagnosed as MI, perforated peptic ulcer or

pancreatitis

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? Rigidity of the upper abdomen
? Dec. breath sounds
? Dullness on percussion, subcutaneous emphysema
? In late cases sepsis is present

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Investigations

? CXR - air in the mediastinum, pleura or peritoneum.
? Pleural effusion
? A barium swallow

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? CECT

Iatrogenic injury

? Most common cause of esophageal perforation.

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? Most common site is the cricopharyngeus.
? Factors associated with increased risk are including large anterior

cervical osteophytes, the presence of a pharyngeal pouch and

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mechanical causes of obstruction

? It may follow biopsy
? Patients undergoing therapeutic endoscopy have a 10 times greater

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perforation risk than those undergoing diagnostic endoscopy.
Treatment

? Aim is to limit mediastinal contamination and infection
? The decision between operative and non-operative management

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rests on four factors:

1 the site of the perforation (cervical vs. thoracoabdominal oesophagus)

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2 the event causing the perforation (spontaneous vs. instrumental)

3 underlying pathology (benign or malignant)

4 the status of the oesophagus before the perforation (fasted and empty vs.

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obstructed with a stagnant residue).

? Indications for non-operative management include:

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? pain that is readily controlled with opiates;

? absence of crepitus, diffuse mediastinal gas, hydropneumothorax or

pneumoperitoneum;

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? no evidence of widespread extravasation of contrast material;

? no evidence of on-going luminal obstruction or a retained foreign body.

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? patients who have remained clinically stable despite diagnostic delay.

? The principles of non-operative management are hyperalimentation,

nasogastric suction and broad-spectrum intravenous antibiotics.

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? Surgical management is indicated when:
? Patients are unstable with sepsis or shock
? Have evidence of a heavily contaminated mediastinum, pleural space

or peritoneum.

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? Surgery can be a primary repair, creation of an external fistula or

resection.

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Key points

? Most perforations are iatrogenic.
? Surgical emphysema is pathognomonic.
? Complications are mediastinitis and sepsis.

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? Treatment is both conservative or surgical but requires specialised

care.