This presentation is for post graduate surgery residents. Anatomy with pictorial representation and management of carcinoma esophagus is being explained. Barretts esophagus, diagnosis and management is being explained. This presentation is subjected to errors and mistakes. I have consulted 2, 3 books to make this presentation.

1. MALIGNANT
DISEASES OF
ESOPHAGUS
DR. SAJAD NAZIR

2. CONTENTS
• Anatomy
• Carcinoma oesophagus
• Management

3. ANATOMY
• The esophagus is a muscular tube that starts as
the continuation of the pharynx and ends as the
cardia of the stomach.
• In a normal anatomic position, the transition from
pharynx to esophagus occurs at the lower border
of the sixth cervical vertebra.
• Topographically this corresponds to the cricoid
cartilage anteriorly and the palpable transverse
process of the sixth cervical vertebra laterally .
• It pierces the diaphragm at the level of 10th
thoracic vertebra to join the stomach.

4. •The uppermost narrowing is located at the Beginning of the
esophagus and is caused by the cricopharyngeal muscle.
•Its luminal diameter is 1.5 cm, and it is the narrowest point of
the esophagus
•The middle narrowing is due to an indentation of the anterior
and left lateral esophageal wall caused by the crossing of the left
main stem bronchus and aortic arch. The luminal diameter at this
point is 1.6 cm.
•The lowermost narrowing is at the hiatus of the diaphragm and
is caused by the gastroesophageal sphincter mechanism. The
luminal diameter at this point varies somewhat, depending on the
distention of the esophagus by the passage of food, but has
been measured at 1.6 to 1.9 cm.

5. DIVISIONS OF ESOPHAGUS
ANATOMICAL
• Cervical esophagus
• Thoracic oesophagus
• Abdominal part
FUNCTIONAL
• Upper esophageal sphincter.
• Body
• Lower oesophageal sphincter.

6. CERVICAL
ESOPHAGUS
•The cervical portion of the esophagus is approximately 5 cm
long and descends between the trachea and the vertebral
column, from the level of the sixth cervical vertebra to the level of
the interspace between the first and second thoracic vertebrae
posteriorly, or the level of the suprasternal notch anteriorly.

7. THORAIC ESOPHAGUS
• The thoracic portion of the esophagus is
approximately 20 cm long. It starts at the thoracic
inlet. In the upper portion of the thorax, it is in
intimate relationship with the posterior wall of the
trachea and the prevertebral fascia. 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.
• From there down, the esophagus passes over the
posterior surface of the subcarinal lymph nodes
(LNs), and then descends over the pericardium of
the left atrium to reach the diaphragmatic hiatus .

8. ABDOMINAL PART
• The abdominal portion of the esophagus is
approximately 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, a fibroelastic ligament
arising from the subdiaphragmatic fascia as a
continuation of the transversalis fascia lining the
abdomen .
• The upper leaf of the membrane attaches itself in a
circumferential fashion around the esophagus, about
1 to 2 cm above the level of the hiatus. These fibers
blend in with the elastic-containing adventitia of the
abdominal esophagus and the cardia of the stomach.
This portion of the esophagus is subjected to the
positive-pressure environment of the abdomen.

9. ANATOMIC LAYERS OF
ESOPHAGUS
• Innermost layer
(hyperechoic): superficial mucosal layer
corresponding to the interface of the
esophageal lumen and the mucosa
• second layer (hypoechoic): mucosa
• third layer (hyperechoic): submucosa
• fourth layer (hypoechoic): muscularis
propria
• fifth layer (hyperechoic): esophageal
adventitia.

10. • The mucosa is the innermost layer and consists of squamous epithelium for
most of its course. The distal 1 to 2 cm of esophageal mucosa transitions to
cardiac mucosa or junctional columnar epithelium at a point known as the Z-line .
Within the mucosa, there are four distinct layers: the epithelium, basement
membrane, lamina propria, and muscularis mucosae.
• Deep to the muscularis mucosae lays the submucosa . Wi thin it is a plush
network of lymphatic and vascular structures, as well as mucous glands and
Meissner neural plexus.
• Enveloping the mucosa, is the muscularis propria. Below the cricopharyngeus
muscle, the esophagus is composed of two concentric muscle bundles: an inner
circular and outer longitudinal . Both layers of the upper third of the esophagus
are striated, whereas the layers of the lower two-thirds are smooth muscle.
• The circular muscles are an extension of the cricopharyngeus muscle and
traverse through the thoracic cavity into the abdomen, where they become the
middle circular muscles of the lesser curvature of the stomach.
• Between the layers of esophageal muscle is a thin septum comprised of
connective tissue, blood vessels, and an interconnected network of ganglia known
as Auerbach plexus.. Enshrouding the inner circular layer, the longitudinal
muscles of the esophagus begin at the cricoid cartilage and extend into the
abdomen, where they join the longitudinal musculature of the cardia of the
stomach. The esophagus is then wrapped by a layer of adventitia.

11. BLOOD SUPPLY
• The cervical portion of the esophagus receives its main
blood supply from the inferior thyroid artery.
• The thoracic portion receives its blood supply from the
bronchial arteries, with 75% of individuals having one
right-sided and two left-sided branches.
• Two esophageal branches arise directly from the aorta.
• The abdominal portion of the esophagus receives its
blood supply from the ascending branch of the left
gastric artery and from inferior phrenic arteries

12. • Blood from the capillaries of the esophagus flows into
a submucosal venous plexus, and then into a
periesophageal venous plexus from which the
esophageal veins originate.
• In the cervical region, the esophageal veins empty into
the inferior thyroid vein; in the thoracic region, they
empty into the bronchial, azygos, or hemiazygos veins;
and in the abdominal region, they empty into the
coronary vein.
• The submucosal venous networks of the esophagus
and stomach are in continuity with each other, and, in
patients with portal venous obstruction,
• this communication functions as a collateral pathway for
portal blood to enter the superior vena cava via the
azygos vein

13. INNERVATION
• The cervical sympathetic trunk arises from the superior ganglion
in the neck. It extends next to the esophagus into the thoracic
cavity, where it terminates in the cervicothoracic (stellate)
ganglion. Along the way, it gives off branches to the cervical
esophagus.
• The thoracic sympathetic trunk continues on from the stellate
ganglion, giving off branches to the esophageal plexus, which
envelops the thoracic esophagus anteriorly and posteriorly.
• Inferiorly, the greater and lesser splanchnic nerves innervate the
distal thoracic esophagus. In the abdomen, the sympathetic
fibers lay posteriorly alongside the left gastric artery
• The parasympathetic innervation of the pharynx and esophagus
is provided mainly by the vagus nerves.
• The cricopharyngeal sphincter and the cervical portion of the
esophagus receive branches from both recurrent laryngeal
nerves, which originate from the vagus nerves—the right
recurrent nerve at the lower margin of the subclavian artery and
the left at the lower margin of the aortic arch.

14. • The lymphatics located in the submucosa of the esophagus are dense and
interconnected that they constitute a single plexus .
• In the upper two-thirds of the esophagus, the lymphatic flow is mostly cephalad,
and, in the lower third, caudad. In the thoracic portion of the esophagus, the
submucosal lymph plexus extends over a long distance in a longitudinal direction
before penetrating the muscle layer to enter lymph vessels in the adventitia.
• The efferent lymphatics from the cervical esophagus drain into the paratracheal
and deep cervical LNs, and those from the upper thoracic esophagus empty
mainly into the paratracheal LNs.
• Efferent lymphatics from the lower thoracic esophagus drain into the subcarinal
nodes and nodes in the inferior pulmonary ligaments..
• The superior gastric nodes receive lymph not only from the abdominal portion of
the esophagus, but also from the adjacent lower thoracic segment

15. E P I D E M I O L O G Y
DR. SAJAD NAZIR MALLA

16. • Esophageal cancer is the eighth most common cancer worldwide and the sixth most common
cause of death from cancer.
• There is significant variation of incidence among different geographic regions and various
ethnic Groups.
• The disease is common in countries of the so-called Asian esophageal cancer belt.
• In high incidence areas, the occurrence of esophageal cancer is 50- to 100-fold higher than
that in the rest of the world.
• It is the fourth most common cancer in China.
• The crude age-adjusted mortality is up to 140 per 100,000, and esophageal cancer is the one
of the most common causes of cancer death in China.
• Esophageal cancer most commonly presents in the sixth and seventh decades of life.
• Over the past three decades, there has been an epidemiologic shift from squamous cell
cancers to adenocarcinoma of the lower esophagus and cardia in the white populations in
Western countries.
• The incidence of adenocarcinoma has surpassed that of squamous cell cancers since the
1990s.In Eastern countries, however, squamous cell cancer remains the predominant type and
is mostly located in the mid esophagus

17. CLASSIFICATION
EPITHELIAL
• Squamous cell carcinoma
• Adenocarcinoma
• Adenosquamous carcinoma.
• Adenoid cystic carcinoma.
• Small cell carcinoma.
• Undifferentiated.
NON EPITHELIAL
• Leiomyosarcoma
• Malignant melanoma.
• Rhabdomyosarcoma
• Malignant lymphoma.

18. ETIOLOGY

19. SCC VS
ADENOCARCINOMA

20. INCIDENCE
OF
CARCINOMA
OF THE
ESOPHAGUS
AND CARDIA
BASED ON
TUMOR
LOCATION

21. CLINICAL
MANIFESTATIONS
• Nonspecific upper GI
symptoms (vomiting,
regurgitation).
• Dysphagia
• stridor, tracheoesophageal
fistula.
• coughing, choking, and
aspiration pneumonia.
• Rarely, severe bleeding.
• jaundice or bone pain.
• Weight loss.

22. GRADES OF
DYSPHAGIA

23. EVALUATION

24. PATIENT
EVALUATION
• Barium esophagogram
• Upper GI endoscopy.
• Endoscopic ultrasound
• CECT abdomen pelvis chest.
• Bronchoscopy
• MRI & PET scanning.
• Minimally invasive surgical
staging:
• Laparoscopy or thoracoscopy

25. BARIUM CONTRAST STUDIES
• Features indicative of presence of
malignancy include mucosal irregularity,
shouldering, stenotic lumen, and dilatation
of proximal esophagus.
• Signs that are suggestive of advanced
stage disease include tortuosity,
angulation, axis deviation from the
midline, sinus formation, and fistulation to
the tracheobronchial tree.

26. ENDOSCOPY
• Allows direct visualization of the tumor
and biopsy.
• Visual staining on endoscopy for early
detection of tumor.
• Disadvantages:
• May miss early mucosal &submucosal
tumors.
• No information on radial extension.

27. SQUAMOUS CELL DYSPLASIA

28. BARRETT'S ESOPHAGUS
SALMON-PINK COLORED EXTENSIONS OR TONGUES OF MUCOSA

29. COMPUTED TOMOGRAPHY SCAN
• The main value of CT scan in the staging of
esophageal cancer is its ability to detect distant
metastasis, such as that in liver, lung, bone, and
kidneys.
• The sensitivity for liver metastases larger than
2 cm is approximately 70% to 80%, but
sensitivity is reduced to 50% if the lesion is <1
cm.
• In evaluation of the primary esophageal tumor,
the precision of CT scan is inferior to EUS. In
the diagnosis of T4 disease by CT scan,
obliteration of the fat plane between the
esophagus and the aorta, trachea and bronchi,
and pericardium is suggestive of invasion.

30. ENDOSCOPIC ULTRASOUND
• EUS is the only imaging modality able to distinguish
the various layers of the esophageal wall, usually
seen as 5 alternating hyper- and hypoechoic layers.
• The accuracy of EUS for tumor and nodal staging
averages 85%and 75%, respectively, compared to
58% and 54% for CT scanning.
• Echo features of lymph nodes that suggest malignant
involvement include echo-poor (hypoechoic)
structure, sharply demarcated borders, rounded
contour, and size greater than 10 mm, in increasing
order of importance.
• The ability to perform EUS-guided FNA cytology of
suspicious nodes (such as celiac nodes) is another
factor that makes EUS superior to CT scanning

31. FDG-PET SCANS
• PET is gaining popularity in esophageal cancer staging and is
commonly used in conjunction with CT scans for better
anatomic definition.
• For detecting the primary tumor, the sensitivity of PET
ranges from 78% to 95%, with most false-negative tests
occurring in patients with T1 or small T2 tumors.
• PET does not provide definition of the esophageal wall and
thus has no value in determining T stage

32. BRONCHOSCOPY

33. STAGING
SYSTEM

34. DEFINITIONS OF TNM FOR ESOPHAGEAL CANCER

35. SIEWERT CLASSIFICATION
• type I: adenocarcinoma of the distal esophagus
(epicenter of lesion 1-5 cm above gastro-
esophageal junction)
• type II: adenocarcinoma of the cardia
(epicenter of lesion up to 1 cm above or 2 cm
below gastro-esophageal junction)
• type III: sub-cardial type adenocarcinoma
(epicenter of lesion 2-5 cm below gastro-
esophageal junction)

37. E S O P H A G E C T O M Y

38. C H O I C E O F S U R G I C A L
A P P R O A C H E S

44. INTRATHORACIC ESOPHAGEAL
CANCER AND CARDIA CANCERS
• For upper third tumors, a 3-phase esophagectomy (McKeown approach) is
an appropriate choice with the purpose of gaining adequate proximal
margin.
• For mid-third: Many surgeons prefer 2-phase esophagectomy (Lewis Tanner
approach).
• For lower third or GEJ tumors, mid and lower third tumors: The transhiatal
approach is more suitable for distally located tumors with anastomosis in
the neck.

45. MINIMALLY INVASIVE TRANSHIATAL
ESOPHAGECTOMY
• This operation combines the advantages of transhiatal esophagectomy
at minimizing pulmonary complications with the advantages of
laparoscopy (less pain, quicker rehabilitation).

46. E X T E N T O F LY M P H A D E N E C T O M Y

47. STATIONS OF REGIONAL LYMPH NODES
FROM EGJ CANCER

48. STATIONS OF REGIONAL LYMPH NODES FROM EGJ CANCER

49. STANDARD 2-FIELD
LYMPHADENECTOMY
• Standard mediastinal lymphadenectomy
includes removing the paraesophageal
nodes and subcarinal and right and left
bronchial nodes below the tracheal
bifurcation.

50. EXTENDED 2-FIELD
LYMPHADENECTOMY.
• standard lymphadenectomy plus right
apical nodes, right recurrent laryngeal
nerve nodes, and right paratracheal nodes.

51. COMPLETE 2-FIELD
LYMPHADENECTOMY
• . If the lymphatic chain along the left
recurrent laryngeal nerve is also resected,
it is regarded as complete 2-field
lymphadenectomy

52. 3-FIELD LYMPHADENECTOMY
• The addition of bilateral cervical lymph
node dissection is regarded as 3-field
lymphadenectomy

53. R E C O N S T R U C T I O N A F T E R
E S O P H A G E C T O M Y
DR. SAJAD NAZIR

54. GASTRIC TUBE
• The most commonly used conduit is the gastric tube, and of the
many configurations, an isoperistaltic tube based on the greater
curvature with preservation of the right gastric and right
gastroepiploic vessels is most reliable.
• The simplicity of preparation, adequate length, and robust blood
supply make it the first choice as the esophageal substitute.
• Disadvantages of the gastric conduit include:
• the fact that patients who have an intrathoracic stomach often
experience postprandial discomfort and early satiety related to
loss of normal gastric functions such as receptive relaxation.
• Patients can also suffer from acid reflux, possible gastric
ulceration, and dysfunctional propulsion.
• The level of the esophagogastric anastomosis has a bearing on
the severity of reflux.
• Patients who have a low intrathoracic anastomosis tend to have
more severe reflux and esophagitis compared with the high
intrathoracic or cervical anastomosis.

55. COLONIC CONDUIT
There are instances when the stomach cannot be used, such as
after:
• previous gastric resection.
• tumor involvement of a substantial part of the stomach
dictating its removal..
• For most, colonic interposition remains an infrequently
performed procedure and has the potential for more
complications.
• Mobilization of the colonic loop is more complex; its blood
supply is less reliable than the gastric conduit.
• 3 anastomoses are required; and when the colon becomes
ischemic, the choice of alternative conduit is restricted.
• A colonic conduit provides good long-term swallowing
function; it seems to have active peristalsis, and this is cited as
an explanation for its superior function as an esophageal
substitute when compared with a passive gastric conduit.

58. SUMMARY

59. BARRETT’S ESOPHAGUS
• Barrett’s esophagus (BE) is
defined as metaplastic change
of the epithelial lining of the
distal esophagus from normal
stratified squamous epithelium
to intestinal columnar
epithelium containing goblet
cells.

60. ETIOLOGY
• chronic injury to the
esophageal mucosa secondary
to long-standing
gastroesophageal reflux disease
(GERD).
• BE is the major risk factor for
esophageal adenocarcinoma
(EAC).

61. DIAGNOSIS
• The diagnosis of BE must be made
endoscopically with a visible change in the
lining of the distal esophagus and biopsy
demonstrating columnar epithelium with
goblet cells

62. MANAGEMENT
OF BARRETT’S
ESOPHAGUS
• The objectives of treatment are
to treat the underlying reflux
disease, prevent progression of
BE, and treat BE with
dysplasia before progression to
EAC.

63. • Progression from BE to EAC generally takes place in a stepwise manner over time from normal
squamous epithelium to non-dysplastic BE, low-grade dysplasia (LGD), high-grade dysplasia (HGD),
and finally EAC.

64. SCREENING
• The American College of
Gastroenterology (ACG) Clinical
Guidelines support screening for
males :
• with chronic GERD, defined as
symptoms for 5 or more years with
at least weekly symptoms and two
or more additional risk factors (age
>50, white race, central obesity,
current or past smoking, family
history in a first-degree relative).

65. EVALUATION
• white light endoscopy:
salmon pink mucosa is
identified proximal to the
gastroesophageal junction
(GEJ).
• Biopsies should be taken of the
distal esophagus in four
quadrants from the GEJ at 1- to
2-cm intervals through the
proximal extent of suspected
BE (the Seattle protocol).

66. PRAGUE CLASSIFICATION
• The Prague classification is the most
commonly used standardized reporting
mechanism which identifies the proximal
extent of circumferential BE as well as the
maximal extent of any tongues of BE.
• The presence and size of any hiatal hernia
should also be noted.

67. MANAGEMENT

70. THERE IS NO MAYBE IN SURGERY-------- STEVEN
STRASBERG