Download MBBS Surgery Presentations 20 Esophagus Surgical Anatomy Lecture Notes

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Relations...

? Right side- mediastinal pleura &

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terminal part of azygous vein

? Left side- left subclavian artery,

aortic arch, thoracic duct,

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mediastinal pleura

? When esophagus pierces the

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diaphragm, it is accompanied by

two vagi, branches of left gastric

artery & lymphatic vessels.

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? In abdomen ? left lobe of liver

anteriorly & left crus of diaphragm

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posteriorly.
Constrictions

I ? Pharyngo-esophageal junction

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-15cm from incisor teeth.

I - Aortic arch and left bronchus

crosses esophagus

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anteriorly- 25cm from

incisor teeth.

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Clinical importance of constrictions of

esophagus
? Common site for lodgment of foreign body
? Common site for stricture formation after corrosive ingestion

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? Common site for carcinoma of esophagus
? Difficult sites for passage of esophagoscope.
Length of the Esophagus

? The distance between the cricoid cartilage and the gastric orifice.

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? In adults, it ranges from 22 to 28 cm, 3 to 6 cm of which is located in

the abdomen.

? length of the esophagus is related to the subject's height rather than

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sex.

? Cervical ? 5cm
? Thoracic -18-20cm

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? Abdomen ? 2-4cm

Blood supply

? Upper 1/3 ? inferior thyroid

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artery

? Middle 1/3 ? direct branches

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from aorta.

? Lower 1/3 ? left gastric artery
Venous drainage

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? Upper 1/3 ? inferior thyroid vein
? Middle 1/3 ? Azygous and hemi-

azygous vein.

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? Lower 1/3- left gastric vein

Nerve supply (Extrinsic)

? Esophageal plexus ? formed by

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vagus nerves by joining with

sympathetic nerves below the

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root of lungs.

? LARP- left vagus anteriorly

? Right vagus posteriorly

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Nerve suply

? Extrinsic ?vagus
? Intrinsic ?

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? Auerbach /myentric plexus - between longitudinal and circular muscle

? Peristalsis

? Meissner's plexus-

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at submucosal level ?

for secretion

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? Meissner's submucosal plexus is sparse in the esophagus.

? The parasympathetic nerve supply is mediated by branches of the

vagus nerve

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? that has synaptic connections to the myenteric (Auerbach's) plexus.

Lymphatic drainage

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? Upper 1/3-

? deep cervical nodes.

? Middle 1/3-

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? superior & posterior mediastinal

nodes

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? Lower 1/3-

? celiac nodes
Diameter of the Esophagus

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? The esophagus is the narrowest tube in the intestinal tract.

? At rest, the esophagus is collapsed; it forms a soft muscular tube .

? Flat in its upper and middle parts, with a diameter of 1.6 cm.

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? The lower esophagus is rounded, and its diameter is 2.4 cm.

Musculature

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? The musculature of the upper

esophagus & UES is striated.

? This is fol owed by a transitional

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zone of both striated and smooth

muscle.

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? proportion of the smooth muscle.

progressively increasing.

? In the lower half of the esophagus,

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there is only smooth muscle.

? It is lined throughout with

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squamous epithelium.
Layers

1. Mucosa ?

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? epithelium

? Basement membrane

? Lamina Propria

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2. Submucosa- strongest layer
3. Muscular propria-

? Inner circular

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? Outer longitudinal

4. Adventitia ?visceral peritoneum

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Periesophageal Tissue, Compartments, and

Fascial Planes
? Unlike the general structure of the digestive tract, the esophageal

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tube has neither mesentery nor serosal coating.

? Its position within the mediastinum and a complete envelope of

loose connective tissue allow the esophagus extensive transverse

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and longitudinal mobility.

? The esophagus may be subjected to easy blunt stripping from the

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mediastinum.
Clinical relevance

? The connective tissues in which the esophagus and trachea are

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embedded are bounded by fascial planes,

? the pretracheal fascia anteriorly and

? the prevertebral fascia posteriorly.

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? In the upper part of the chest, both fascia unite to form the carotid

sheath.

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Tunica Adventitia

? This thin coat of loose

connective tissue envelops the

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esophagus.

? connects it to adjacent

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structures,

? contains small vessels, lymphatic

channels, and nerves.

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Tunica Muscularis

? The tunica muscularis coats the

lumen of the esophagus in two

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layers :

? the external muscle layer paral els

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the longitudinal axis of the tube,

? the muscle fibers of the inner layer

are arranged in the horizontal axis.

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? For this reason, these muscle layers

are classical y cal ed longitudinal

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and circular, respectively.

Tela Submucosa

? The submucosa is the connective tissue layer that lies between the

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muscular coat and the mucosa.

? It contains a meshwork of small blood and lymph vessels, nerves, and

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mucous glands.

? The duct of deep esophageal glands pierce the muscularis mucosae.
Tunica Mucosa

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? The mucous layer is composed of three components:

? the muscularis mucosae,

? the tunica / lamina propria, and

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? the inner lining of nonkeratinizing stratified squamous epithelium .

Physiology of the Esophagus and Its

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Sphincters
Physiology

? The musculature of the esophagus = predominantly striated at the

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level of the UES and proximal 1 to 2 cm of the esophagus.

? mixed striated = smooth muscle transition zone spanning 4 to 5 cm

? Entirely smooth muscle structure = in the distal 50% to 60% of the

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esophagus, including the LES

SWALLOWING PROCESS

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? Normal human subjects swallow on average 500 times a day.
? The act of swallowing can be divided into three stages:

1. the oral (voluntary) stage,

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2. the pharyngeal (involuntary) stage, and

3. the esophageal stage.

? These stages are a continuous process closely coordinated through

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the medullary swallowing centers.
Esophageal Stage

? The esophageal stage of swallowing starts once the food is

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transferred from the oral cavity through the UES into the esophagus.

? This active process is achieved by contractions of the circular and

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longitudinal muscles of the tubular esophagus and coordinated

relaxation of the LES.

? Esophageal peristalsis is controlled by afferent and efferent

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connections of the medullary swallowing center via the vagus nerve

(cranial nerve X).

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? The vagus nerve carries both stimulating (cholinergic) and inhibitory

(noncholinergic, nonadrenergic) information to the esophageal

musculature.

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? In addition to the central nervous system control, the myenteric

(Auerbach) plexus

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? plays a major role in coordinating peristalsis in the smooth muscle portion of

the distal esophagus.
Esophageal peristalsis

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? Esophageal peristalsis is the result of sequential contraction of the

circular esophageal muscle.

? Three distinct patters of esophageal contractions have been

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described:

1. Primary peristalsis

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2. Secondary peristalsis

3. Tertiary contractions.

Primary peristalsis

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? Primary peristaltic contractions are the usual form of the contraction

waves of circular muscles that progress down the esophagus;

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? they are initiated by the central mechanisms that follow the

voluntary act of swallowing.

? During primary peristalsis, the LES is relaxed, starting at the initiation

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of swallowing and lasting until the peristalsis reaches the LES.
Secondary peristalsis

? Secondary peristaltic contractions are the contraction waves of the

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circular esophageal muscle occurring in response to esophageal

distention.

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? They are not a result of central mechanisms.
? The role of secondary peristaltic contractions is to clear the

esophageal lumen of ingested material not cleared by primary

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peristalsis or material that is refluxed from the stomach.

? Tertiary contractions are primarily identified during barium x-ray

studies and represent non-peristaltic contraction waves that leave

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segmental indentations on the barium column.

LES

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? Normal LES resting pressure ranges from 10 to 45 mm Hg above the

gastric baseline level.

? The function of the LES is to

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? prevent gastroesophageal reflux and

? to relax with swallowing to allow movement of ingested food into the

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stomach.
Perforation of the oesophagus

? Causes -

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1. usually iatrogenic (at therapeutic endoscopy) or

2. due to `barotrauma' (spontaneous perforation).

3. Pathological perforation- rare

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4. Penetrating injury

Barotrauma (spontaneous perforation, Boerhaave syndrome)

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? This 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

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stream of material into the mediastinum and often the pleural cavity

as well.

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? The condition was first reported by Boerhaave , who reported the

case of a grand admiral of the Dutch fleet who was a glutton and

practised auto emesis.

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Boerhaave syndrome...

? Most serious type of perforation

? because of the large volume of material that is released under pressure.

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? mediastinitis

? Barotrauma has also been described in relation to other pressure

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events when the patient strains against a closed glottis (e.g.

defaecation, labour, weight-lifting).

Diagnosis of spontaneous perforation

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? history

? severe pain in the chest or upper abdomen following a meal or a bout of drinking.

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? shortness of breath

? O/E-

? rigidity on examination of the upper abdomen, even in the absence of any peritoneal

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contamination.

? D/D

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? myocardial infarction,

? perforated peptic ulcer or

? pancreatitis if the pain is confined to the upper abdomen.

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Boerhaave syndrome...

1. Chest x-ray - confirmatory

? air in the mediastinum, pleura or peritoneum.

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2. A contrast swallow or
3. CT scan

Pathological perforation

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? Free perforation of ulcers or tumors of the oesophagus into the

pleural space is rare.

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? Erosion into an adjacent structure with fistula formation is more

common.

? Aerodigestive fistula is most common and usually encountered in

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primary malignant disease of the oesophagus or bronchus.

? Covering the communication with a self-expanding metal stent is the

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usual solution.
Penetrating injury

? Perforation by knives and bullets is uncommon

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Instrumental perforation

? Instrumentation is by far the most common cause of perforation.
? Incidence - 1:4000 examinations /UGIE
Diagnosis of instrumental perforation

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? History and physical signs may be useful pointers to the site of

perforation.

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1. Cervical perforation:

? pain localised to the neck,

? hoarseness,

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? painful neck movements and

? subcutaneous emphysema.

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2. Intrathoracic and intra-abdominal perforations,

(more common),

? Immediate symptoms and signs

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? chest pain,

? haemodynamic instability,

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? oxygen desaturation .

? evidence

of

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subcutaneous

emphysema,

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pneumothorax

or

hydropneumothorax.

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Treatment of oesophageal perforations

? Perforation of the oesophagus usually leads to mediastinitis.
? The loose areolar tissues of the posterior mediastinum allow a rapid

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spread of gastrointestinal contents.

? Aim of treatment

? limit mediastinal contamination and

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? prevent or deal with infection.

Decision between operative and non-

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operative management rests on four factors
1. the site of the perforation (cervical versus thoraco-abdominal

oesophagus);

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2. the event causing the perforation (spontaneous versus

instrumental);

3. underlying pathology (benign or malignant);

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

empty versus obstructed with a stagnant residue).
Non-operative treatment of Instrumental

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perforations
? Cervical oesophagus - are usually small perforation and can nearly

always be managed conservatively.

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? The development of a local abscess is an indication for cervical

drainage preventing the extension of sepsis into the mediastinum.

Indication for non-operative management

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(thoraco-abdominal perforation)
? when the perforation is detected early and prior to oral alimentation.

? absence of

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? crepitus,

? diffuse mediastinal gas,

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? Hydro-pneumothorax or pneumo-peritoneum;

? mediastinal containment of the perforation with no evidence of widespread

extravasation of contrast material;

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? no evidence of ongoing luminal obstruction or a retained foreign body.

? patients who have remained clinically stable despite diagnostic delay.
Principles of non-interventional management

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? nasogastric suction and
? broad-spectrum intravenous antibiotics

Indication of Surgical management

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? unstable with sepsis or shock;

? have evidence of a heavily contaminated mediastinum, pleural space

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or peritoneum;

? have widespread intra-pleural or intra-peritoneal extravasation of

contrast material.

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Surgery

? direct repair,
? the deliberate creation of an external fistula or,
? rarely, oesophageal resection with a view to delayed reconstruction.

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? Direct repair

? if the perforation is recognised early (within the first 4?6 hours) and the

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extent of mediastinal and pleural contamination is small.

? After 12 hours, the tissues become swollen and friable , primary

repair not possible.

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MALLORY?WEISS SYNDROME

? Forceful vomiting may produce a mucosal tear at the cardia rather

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than a full perforation.

? In Boerhaave's syndrome, vomiting occurs against a closed glottis,

and pressure builds up in the oesophagus.

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? In Mallory? Weiss syndrome, vigorous vomiting produces a vertical

split in the gastric mucosa, immediately below the squamo-columnar

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junction at the cardia in 90 per cent of cases.

? In only 10 per cent is the tear in the oesophagus.
MALLORY?WEISS SYNDROME...

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? Clinical feature

? Haematemesis

? Surgery is rarely required.

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