ESOPHAGUS
anatomy
physiology
pathology
treatment
Anatomy of esophagus
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length 23-25 cm
esophagus begins at the level of the sixth cervical
vertebra and it enters into the superior
mediastinum through the upper thoracic outlet then
it descends into the posterior mediastinum and
exits the thorax through esophageal hiatus of the
diaphragm and enters the abdominal cavity
there are three parts of the esophagus: cervical,
thoracic and abdominal esophagus
esophagus has three physiological constrictions
Anatomy of esophagus
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It consists of three layers :
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arterial blood supply from:
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mucosa,
submucosa
muscular layer (circular and longitudinal layer)
inferior thyroid artery
descending aorta
left gastric artery
inferior phrenic artery
venous drainage into the superior caval vein
portal vein
Anatomy of esophagus

Esophagus has an extensive lymphatic drainage into
cervical, posterior mediastinal, paraesophageal and
celiac axis lymph nodes
Anatomy of esophagus
Carcinoma of the esophagus

most common neoplasm of the esophagus is
carcinoma
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its incidence is very differentiated worldwide and
depends on geographical localization that proves
its dependency on environmental factors
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90% of patients with esophageal carcinoma die
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incidence of esophageal carcinoma is 8-12/100000
men per year in Europe and 6/100000 in the
United States
Carcinoma of the esophagus
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risk to develop carcinoma of the esophagus
increases along with the age and is the highest
between the sixth and the seventh decade of life
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more frequent in males
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main risk factors: smoking, alcohol
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incidence of esophageal adenocarcinoma raises
Carcinoma of the esophagus
Premalignant states
Plummer-Vinson syndrome
caustic burns
achalasia
Barrett’s esophagus
leukoplakia
Carcinoma of the esophagus
Screening

screening exfoliative cytology in endemic
areas
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Barrett’s esophagus- endoscopic biopsy
Carcinoma of the esophagus
Clinical presentation
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dysphagia in 95% of cases
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regurgitation
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weight loss
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chest pain

cough
Carcinoma of the esophagus
Diagnosis

barium esophagogram

flexible fiberoptic
esophagoscopy with
biopsy
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Computed Tomography
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endoscopic ultrasound –
diagnostic accuracy 80–
90%

Bronchoscopy
Carcinoma of the esophagus
Staging

Primary tumor (size of tumor and depth of
infiltration)–T
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regional lymph node involvement - N
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distal metastasis–M
Carcinoma of the esophagus
Staging
Primary tumor - T
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T1 – tumor invades lamina propria or
submucosa
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T2 – tumor invades muscularis propria
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T3 – tumor invades adventitia
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T4 - tumor invades adjacent structures
Carcinoma of the esophagus
Staging
Regional lymph nodes – N
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N0 – no regional node metastasis
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N1 – regional node metastasis
Distant metastasis – M
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M0 – no distant metastasis
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M1 – distal metastasis
Carcinoma of the esophagus
Surgical management
radical – resection of a tumor with adequate
oncological margins and regional lymph
nodes
palliative - to restore oral intake of food
Carcinoma of the esophagus
Most common surgical
procedures
1.
Thoracoabdominal Ivor–Lewis esophagectomy
with high intrathoracic esophagogastric
anastomosis and gastric drainage procedure
2.
Thoracoabdominal McKeown esophagectomy
with esophagogastric anastomosis in the neck
3.
transhiatal Orringer esophagectomy with
esophagogastric anastomosis in the neck
4.
esophagectomy throuh left
thoracophrenolaparotomy
Carcinoma of the esophagus
How to replace the esophagus?

stomach- the best organ to replace the
esophagus
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colon- the second organ for reconstruction
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small intestine (pedicle or free graft)- least
appropriate
Carcinoma of the esophagus
Complications

Postoperative complications from 20 to 40%
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perioperative mortality 3–10%, 20% was also
reported
Carcinoma of the esophagus
Radiation therapy
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patients with advanced disease
patients refusing to undergo surgery
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irradiation with a dose of 55–60 Gy
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usually used as a palliative treatment,
unusually as a radical treatment
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has no influence on survival
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5-year survival rate less than 6%
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Carcinoma of the esophagus
Chemotherapy

Effective for a short time

recently advocated regimen is cisplatin with
vindesine, bleomycin and 5-fluorouracil

complete and partial response rates are
reported for 25-50 %
Carcinoma of the esophagus
Combination therapy

Results of monotherapy are bad

5-year survival rate after surgery alone is 10–
15 %
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most patients die due to distant metastases,
hence local treatment is combined with
systemic treatment
Carcinoma of the esophagus
Combination therapy - benefits

decrease in tumor size
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early therapy for micrometastases
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enables the assessment of response to a used
treatment and reassessment of staging after
induction therapy

surgery 3-6 weeks after induction therapy

some authors question the role of surgery in
improving survival
Carcinoma of the esophagus
Palliative therapy

50% of patients have distant metastases at the
time of diagnosis

main problem reported by a patient – dysphagia

radiation therapy combined or not with
chemotherapy offers immediate clinical
improvement in dysphagia
Carcinoma of the esophagus
Palliative endoscopic treatment
dilatation
 self-expanding stents
 stents
 laser ablation
 endoluminal brachytherapy
 photodynamic therapy

Palliative resection, bypass procedures and
gastrectomy are presently not advocated
Self-expanding stents
Carcinoma of the esophagus
Prevention

cessation of smoking and alcohol
consumption

treatment of Barrett’s esophagus

detection of p53 gene mutation
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screening programs
Rare esophageal malignancies
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Epithelial
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carcinoma planoepithelialae partim fusocellularae
adenocarcinoma
carcinoma basocellularae
carcinoma microcellularae
Non-epithelial
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leiomyosarcoma
melanoma
rhabdomyosarcoma
fibrosarcoma
Benign esophageal tumors
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Deriving from submucosa
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adenoma
haemangioma
papilloma
fibrolipoma
neurofibroma
Deriving from muscular layer (intraparietal)
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leiomyoma
lipoma
fibroma
Chemical burns of the esophagus
Necrosis occurs directly
after burn and is
irreversible!
Chemical burns of the esophagus
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Acids - they produce coagulative necrosis
that is rarely full-thickness one. Similar injury
should be expected in the stomach and
duodenum.
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Caustic agents - they produce colliquative
full-thickness necrosis including perforation.
Classification of chemical
burns of the esophagus
I.
Erythema, superficial exfoliation of
esophageal epithelium
shallow ulcerations not penetrating
beyond submucosa, whitish discolorations
II.
A.
superficial erosions and ulcerations
B.
deep, circumferential ulcerations
III. deep ulcerations penetrating into the
muscularis propria or producing perforation
Chemical burns of the esophagus
Clinical presentation
a)
severe retrosternal pain
b)
dysphagia
c)
shock
d)
respiratory disturbances
e)
subcutaneous emphysema in the necksometimes
f)
stridor and peritonitis- rarely
Chemical burns of the esophagus
First-aid treatment
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Oral administration of small amount of water
administration of antidotes, advocated in the
past, can trigger exothermic reaction and
compound injury
vomits shouldn’t be induced
administration of antibiotics, steroids and
analgesic agents.
in a case of acute airway obstruction
tracheostomy should be performed
intravenous access
Chemical burns of the esophagus
First-aid treatment
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cessation of oral food intake
chest x-ray examination
esophagoscopy performed within 12-24 hours after
burn preceded by laryngoscopy
part of surgeons is of the opinion that endoscopy
mustn’t be done and they advocate esophagogram
using a water-soluble contrast medium if
esophageal perforation is suspected, if not
esophagoscopy can be done 2-3 days after burn
and then 3 weeks after burn.
Chemical burns of the esophagus
Perforation of the
esophagus occurs usually
between 2 and 8 days after
burn.
Stricture of the esophagus
after burn - treatment
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dilatation of stricture
resection of the narrowed fragment of the
esophagus and esophagoesophageal
anastomosis- short strictures only
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esophagectomy and reconstruction using the
stomach, colon or small bowel (possible malignant
degeneration)- extensive esophageal strictures
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Thal or Collis gastroplasty- stenosis of
gastroesophageal junction
Perforation of the esophagus
Esophageal perforation is a serious diagnostic
problem.
Incidence:1case per 8000 hospitalized patients
per year and still increases due to growing
number of diagnostic and therapeutic endoscopies.
Perforation of the esophagus
Etiology
Iatrogenic
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from inside

endoscopy
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dilatations
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variceral sclerosis
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esophageal intubation
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laser
Perforation of the esophagus
Etiology
from outside
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mediastinoscopy
intraoperative injuries (thyroid resection,
enucleation of esophageal myoma, vagotomy,
pneumonectomy)
radiation therapy
Traumatic
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blunt trauma
penetrating trauma
caustic injury
Perforation of the esophagus
Etiology
Spontaneous perforation
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postemetic
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others e.g. childbirth
Foreign body
Neoplasms
Paraesophageal infections
Perforation of the esophagus
Bacteria in
saliva
Infection
Abscess,
empyema
, sepsis
Air
Emphyse
ma
Gastric juice
Chemical
burn
Disturbances in
Tension
water and
pneumothorax
electrolyte balance
shock
mediastinum
Perforation of the esophagus
Clinical presentation
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Cervical esophagus
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neck ache increased on swallowing
hemoptysis or hematemesis
subcutaneous emphysema
fever
local tenderness
change in the timbre of voice
hydropneumothorax
pneumothorax
neck abscess
Perforation of the esophagus
Clinical presentation.
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Thoracic esophagus
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chest pain
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dyspnea
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subcutaneous emphysema
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pneumo- and hydrothorax
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tachycardia and tachypnea

cyanosis

fever
Perforation of the esophagus
Clinical presentation

Abdominal esophagus
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peritonitis
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retrosternal pain radiating to the arms
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tachycardia and tachypnea
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fever
Perforation of the esophagus
Differential diagnosis

Chronic gastric and duodenal
ulcer disease

myocardial infarction
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acute pancreatitis

dissecting aortic aneurysm

pneumonia

pneumothorax
Perforation of the esophagus
Crucial aims of surgical treatment

Elimination of sources of bacterial infection
and chemical injury

drainage of infected areas

secure food intake
Perforation of the esophagus
Surgical management
1.
2.
3.
4.
5.
primary repair of the perforation
primary repair of the perforation buttressed
with well-vascularized autologous tissue
temporary exclusion of the perforated
esophagus
drainage procedures (T-tube drainage,
washing drainage, intraesophageal
drainage)
partial or total esophageal resection
Perforation of the esophagus
Surgical management
The earlier esophageal perforation is
diagnosed the easier is a treatment.
The later it is diagnosed the more
aggressive should be a surgical
management.
Disorders of esophageal motility
Disorders of esophageal motility can result both
from its increased and decreased neuromotor
activity .
Cricopharyngeal achalasia
Clinical presentation
 Cervical dysphagia
 Barium esophagogram demonstrates hypertonicity
of the upper esophageal sphincter (narrowing of
esophageal lumen)
 Presence of Zenker's diverticulum in some patients
Treatment
 Cervical esophagomyotomy from the level of the
superior cornu of the thyroid cartilage iferiorly to 1-2
cm behind the clavicle
Neuromotor diturbances of esophageal
motility

Usually myotonic

Observed in diseases such as:

miasthenia gravis,

dystrophia myotonica

Pathologies of the peripheral and central nervous
system.
Diffuse esophageal spasm
Clinical presentation
 Dysphagia, chest pain (retrosternal)
 Anxiety, signs and symptoms appear
periodically
 x-ray examination and esophageal
manometry demonstrate hypermotility
Treatment
 Nitrates, calcium channel blockers
 Liquid, small-volume meals
 Long esophagomyotomy
Achalasia
Clinical presentation
 dysphagia
 regurgitation
 Lack of primary esophageal peristalsis,
dilatation of the esophagus and the distal
bird-beak taper of the esophagogastric
junction on barium swallowing examination
 Luck of primary esophageal peristatlsis on
manometry
Achalasia

Alteration of the central or peripheral vagal
innervation.

In many cases the lack or disintegration of
ganglion cells in the myenteric (Auerbach's)
plexus is observed.

Etiology of achalasia is unknown.
Achalasia
Treatment

Myorelaxants have weak or no therapeutic
effect

Dilatation of the lower esophageal sphincter

Esophagomyotomy (Heller procedure) – 15%
of cases
Uchyłki przełyku
Podział
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wrodzone
nabyte
prawdziwe
rzekome
Typ z uwypuklenia - uwypuklenia błony śluzowej i
podśluzowej przez osłabiona mięśniówkę.
Typ z pociągania - pociąganiu ściany od zewnątrz
przełyku przez zapalnie lub bliznowato zmienione
okołooskrzelowe i śródpiersiowe węzły chłonne.
Diverticula of the esophagus
Clinical presentation
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Dysphagia
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Regurgitation
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Bad breath
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Chest pain
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Typical roentgenographic picture
Diverticula of the esophagus
Complications

Often asymptomatic clinical course
Diverticulitis

Fistula
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Abscess
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Bleeding

Symptomatic patients or patients in whom
complications occured should undergo surgical
treatment.