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Oesophagus is a fibro-muscular tube, measuringabout 25cm in adults. It extends from lower end of pharynx (C6) tocardiac end of stomach (C11). There are three normal constrictions which are atfollowing levels- a. At pharyngo-oesophageal junction (C6) – 15cmfrom the upper incisors.b. At crossing the Arch of Aorta and left mainbronchus (T4) – 25cm from upper incisors.c. Where it pierces the diaphragm (T10) – 40cm fromupper incisors.
It runsvertically butinclines to theleft from itsorigin tothoracic inletand from T7 tooesophagealopening in thediaphragm.
Wall of OesophagusThe wall of oesophagus consist of 4 layers from within outwards - Mucosa- lines by non keratinised stratified squamous epithelium. Submucous- contains mucous secreting oesophageal glands. Muscular layer- made of inner circular and outer longitudinal fibres. Upper third – striated muscle fibres. Middle third – both striated and smooth muscle fibres. Lower third – smooth muscle fibres.
NERVE SUPPLYo Parasympathetic – Vagus Nerveo Sympathetic – Sympathetic trunk LYMPHATIC DRAINAGEo Cervical part – Deep cervical lymph nodeso Thoracic part – posterior mediastinal LNo Abdominal part – gastric(coeliac) LN
ARTERIAL SUPPLYBlood supply –o Cervical part (segment including up to arch of aorta) – Inferior thyroid arteries.o Thoracic part – Oesophageal branches of Aortao Abdominal part – Oesophageal branches of Left gastric artery.Venous drainage –o Upper part – Brachiocephalic veino Middle part – Azygous veino Lower end – Left gastric vein
APPLIED PHYSIOLOGY Manometric studies have shown 2 high pressure zones in oesophagus and they form the physiological sphincters-1. Upper oesophageal sphincter- starts at the upper border of oesophagus and is about 3-5cm in length and functions during the act of swallowing.2. Lower oesophageal sphincter- is situated at lower portion of oesophagus. It is also 3-5cm in length and functions to prevent oesophageal reflux.
ACHALASIA CARDIAIt is failure of relaxationof Cardia (oesophago-gastric junction) due todisorganizedoesophageal peristalsis,as a result of failure ofintegration of theparasympatheticimpulse causingFunctional Obstructionand high restingpressure in LES. LESdoes not relax duringswallowing.
CLINICAL FEATURES More common in females of age group 20-40yrs. Dysphagia more to liquids than solids. Regurgitation of swallowed food particularly at night. Odynophagia and weight loss. Malnutrition and general ill health.
DIAGNOSIS Radiography Barium swallow shows- 1. pencil like smooth narrowing of lower oesophagus (Rat Tail appearance). 2. dilatation of proximal oesophagus. 3. absence of fundic gas bubble. 4. sigmoid oesophagus or mega- oesophagus
Manometric studies Shows low pressure in body of oesophagus and high pressure at lower sphincter and failure of the sphincter to relax. Oesophagoscopy is done to confirm the diagnosis and rule out benign strictures or carcinoma of oesophagus.
TREATMENTSurgeries1. Modified Heller’s operation (myotomy of narrowed lower portion of the oesophagus).2. Negus hydrostatic dilatation (rarely).3. Laparoscopic/ thoracoscopic cardiomyotomy.4. Resection only when failure of myotomes occurs or when mega-oesophagus or metaplasia is present.Drugsa. Endoscopic injection of botulinum toxin to sphincter – high recurrence rate.b. Calcium channel blocker, nitroglycerine sublingually.
CARCINOMA OESOPHAGUS It is the 6th most common cancer in world.More common in China, Japan, USSR, South Africa and Asian countries. Five year survival is not more than 5 – 10%.
Smoking Excessive alcohol consumption Tobacco chewing Age > 45yrs More common in MenAETIOLOGY Pre-existing pathological lesions as benign strictures etc. Plummer-Vinson syndrome
PATHOLOGY Squamous cell carcinoma is the most common(93%) in India and other Asian countries. Adenocarcinoma (3%) is also seen, but in the lower oesophagus.Involvement of –Middle third (50%)Lower third (33%)Upper third (17%)
SPREAD OF THE DISEASE• The lesion may fill • Depending on site • Metastases may the lumen and involved, cervical, develop in the liver, infiltrate the wall of mediastinal or lungs, bone and oesophagus. coeliac LNs may be brain.• It may spread to involved. adjoining spaces. Recurrent laryngeal nerve causes aspiration problems. Direct Lymphatic Blood borne
CLINICAL FEATURES • Substernal discomfort.Early symptoms • Preference for soft or liquid food. Progressive • Dysphagia first to solids and then to liquids.dysphagia and • Weight loss leading to emaciation. emaciation • Usually signifies extension of tumor beyond the Pain walls of oesophagus. • It is referred to the back Aspiration • Spread of cancer may cause laryngeal paralysis or fistulae formation leading to cough, hoarseness of problem voice, aspiration pneumonia and mediastinitis
Barium swallow X-Ray showingirregular filling defect which is afeature of Carcinoma ofOesophagus
DIAGNOSIS Barium swallow – shows narrow and irregular oesophageal lumen, without proximal dilatation of the oesophagus. Oesophagoscopy – to see the site and the extent of lesion and take the biopsy, done under GA. Bronchoscopy – helps to exclude extension of growth into the trachea and bronchi. CT scan – useful to assess the extent of disease and nodal metastases.
TREATMENTUpper 2/3rd – Surgery- difficult due to great vessels and involvement of mediastinal nodes. Thus radiotherapy is the treatment of choice.Lower 1/3rd – Surgery is preferred. Affected segment with a wide margin of oesophagus proximally, and the fundus of stomach distally, can be excised with primary reconstruction of the food channel.Advanced lesion – Only palliation is possible. Chemotherapy is used only as a palliative measure in the locally advanced or disseminated disease.
AN ALTERNATIVE FOOD CHANNEL CAN BE PROVIDE BY:A. A by-pass operation.B. Oesophageal intubation with Celestin or Mousseau-Barbin or a similar tube.C. Permanent gastrostomy or a feeding jejunostomy.D. Laser surgery- oesophageal gwoth is burnt with Nd:YAG laser to provide food channel.