3. Anatomy
the esophagus is a fibromuscular tube,
approximately 25cm in length that
transports food from the pharynx to
the stomach. It originates at the inferior
border of the cricoid cartilage, C6,
extending to the cardiac orifice of
the stomach, T11. Anatomically, the
oesophagus can be divided into two parts:
thoracic and abdominal.
4. Anatomical Location and Structure
The oesophagus originates in the neck, at the level of the sixth cervical vertebrae. It is continuous
with the laryngeal part of the pharynx.
It descends downward into superior mediastinum of the thorax. Here, it is situated between the
trachea and the vertebral bodies T1 to T4. It then enters the abdomen by piercing the muscular right
crus of the diaphragm, through the oesophageal hiatus (simply, a hole in the diaphragm) at the T10
level.
The phrenicoesophageal ligament connects the oesophagus to the border of the oesophageal
hiatus. This permits independent movement of the oesophagus and diaphragm during respiration
and swallowing.
The abdominal part of oesophagus is approximately 2cm long – it terminates by joining the cardiac
orifice of the stomach at level of T11.
5. Muscular layers
The oesophagus consists of an internal
circular and external longitudinal layer of muscle.
Furthermore, the external longitudinal layer is
comprised of different muscle types in each third of
the oesophagus:
•Superior third – voluntary striated muscle.
•Middle third – voluntary striated and smooth muscle.
•Inferior third – smooth muscle.
Food is transported through the oesophagus
by peristalsis – a rhythmic contractions of the
muscles, which propagates down the oesophagus.
7. Oesophageal Sphincters
Upper Oesophageal Sphincter
The upper sphincter is an anatomical, striated muscle sphincter at the junction between the
pharynx and oesophagus. It is produced by the cricopharyngeus muscle. Normally, it is
constricted to prevent the entrance of air into the oesophagus.
Lower Oesophageal Sphincter
The lower oesophageal sphincter is a physiological sphincter located in the gastro-
oesophageal junction (junction between the stomach and oesophagus). The gastro-
oesophageal junction is situated to the left of the T11 vertebra, and is marked by the change
from oesophageal to gastric mucosa.
8. Vasculature
Thoracic
The thoracic part of the oesophagus receives its arterial supply from the
branches of the thoracic aorta and the inferior thyroid artery (a branch
of the thyrocervical trunk). Venous drainage into the systemic
circulation occurs via branches of the azygous veins and the inferior
thyroid vein.
Abdominal
The abdominal oesophagus is supplied by the left gastric artery(a
branch of the coeliac trunk) and left inferior phrenic artery. This part of
the oesophagus has a mixed venous drainage via two routes: To the
portal circulation via left gastric vein To the systemic circulation via the
azygous vein. These two routes form a porto-systemic anastomosis, a
connection between the portal and systemic venous systems.
9. Incidence
4% of GIT tumors
Age >>>>> 45-60 years old.
Sex >>>>> Male (5% of all carcinomas) except in cervical esophagus may be more
common in females.
It has geographical distribution showing higher incidence in some countries as China and
Japan.
10. Predisposing factor
Chronic lrritation:
Spicy food, smoking & spirits.
Food contamination by fungi
Nirosamine used in food preservation.
Barrett's esophaqus which is lined by columnar epithelium in reflux ) adenocarcinoma.
Achalasia of esophagus.
Tylosis type A (A.D, characterized by hyperkeratosis of palm and sole, 100% esophagus carcinoma at
age of 40 years).
Decrease beta carotene, selenium, vitamin E in diet.
Plummer-vinson syndrome
postcoroosive
Scleroderma.
Benign tumors: Papilloma or adenoma.
11. pathology
Site
Upper 1/3: 20% Middle 1/3: 30% Lower1/3 : 50%
Macroscopic
Proliferative. infiltrating. Ulcerative.
Microscopic
• Squamous cell carcinoma (40% upper 2/3 "rare").
• Adenocarcinoma (60% lower 1/3): from;
Lower 3 cm (lined by columnar epithelium)
On top of Barrett's esophagus.
Upward spread from gastric carcinoma
Recently incidence of adenocarcinoma
• Anaplastic: the cells show malignant criteria
12. Spread
Direct spread
1. Spreads transversely then lonqitudinallv
(extensive submucosal lymphatic spread,
proximal line of resection should be '10 cm
proximal to the upper limit of the tumor).
2. Neighboring structures: .
Cervical esophaqus:
Trachea >> fistula.
Recurrent laryngeal nerve ) vocal cord
paralysis.
Thyroid.
Thoracic esophageal:
Trachea >> fistula
Aorta ) fatal hematemesis.
Left recurrent laryngeal nerve.
Lung.
Thoracic vertebrae.
. Abdominal esophaqus:
Liver.
Stomach.
Diaphragm.
15. Clinical picture
Symptoms Male > 50 years old with.
Dysphagia : rapidly progressive to solids > fluids, but later the patient cannot swallow his
own saliva leading to continuous driplling of saliva.
Regurgitation (blood stained) leads to pulmonary symptoms.
Excessive salivation.
Loss of Appetite.
Symptoms due to infiltration of adjacent structures e.g. change of voice due to infiltration
of RLN.
16. Signs
General>>>> Cachexia, dehydration & chest infection.
Local>>>> Neck: for presence of lymph nodes or mass.
Abdominal for palpable hard nodular liver & ascites.
17. Complication
Mediastinits: due to esophageal perforation.
Fatal hematemesis: due to aortic invasion.
Paralysis of diaphragm and vocal cords.
Pulmonary complications: (pneumonia, lung abscess
etc.) (cause of death)
18. Investigation
for-diagnosis:
Esophagoscope "early endoscopy is the key for good result" + biopsy + cytology
Barium swallow:
Rat tail appearance: Narrow lumen at site of Lesion with mild proximal dilatation due to
short duration (unlike achalasia)
Shoulderings.
lrregular filling defect in cauliflower mass.
Prestaltic wave may be absent above the lesion due to infiltration of the wall .
19. for-staging,
- Endoluminal sonar: show extent of tumor(the most important for local staging and assessing
operability)
- Chest X-Ray: elevated copula of diaphragm due toaffection of phrenic nerve, pleural
effusion.
- U/S ) liver metastasis.
- CT scan.
- Bone Scan.
- Bronchoscope >>> before barium swallow
- indirect Laryngoscope ) invasion of recurrent laryngeal nerve.
20. For preoperative preparation
CBC. anemia & leucocytosis in chest infection.
LFTs: for metastasis.
Serum electrolytes & serum protein
- KFTs.
22. Treatment:
bypass
Gastric bypass with a cervical esophagogastrostomy.
Colon bypass.
Major operation with high mortality for a patient with short life span
radiotherapy
The dose of X-Ray should be between 4000 and 4500 rads / 4 wks
Patients treated with high doses complicated with; pulmonary fibrosis,
esophageal bleeding or esophageal perforation.
Suitable for upper esophagus
23. intubation
The idea is to insert a rigid tube through the stenosed segment to keep a patent lumen.
The tube is inserted by :
o Gastrostomy (e.9. Celestin tube)
o Esophagoscopy (e.9. Souttar tube).
Laser photocoagulation
Dysphagia can be relieved by endoscopic laser therapy.
A core of tumor is vaporized, opening the lumen without perforating
the esophagus.
Treatment needs to be repeated every 6-8 weeks.
gastrotomy
Obsolete nowadays as the patient remains unable to swallow his saliva
>> aspiration pneumonia
Chemotherapv: s FU.
24. Preoperative Preparation
Surgery:
1) Tumors below the carina (tracheal bifurcation):
lvor Lewis operation (2 phases) for middle 1/3 tumors.
1st phase: Laparotomy & mobilization of stomach.
2nd phase: Rt thoracotomy through the 5th intercostal space,
resection of the tumor, LNs and 1Ocm of the esophagus above the
tumor & GE anastomosis.
2) Tumors above the carina:
Mc Keown operation (3 phases)
1st phase: Laparotomy & mobilization of stomach.
2nd phase: Rt thoracotomy through the 5* intercostal space and
oesphageal mobilization.
3rd phase: Neck incision, the esophagus & stomach are delivered
to the neck where resection is done and anastomosis of the
stomach & cervical esophagus is carried out.
25. 3) Tumors below the diaphragm (1 phase) for lower 1/3 tumours
• Lt thracoabdominal incision, the stomach & lower esophagus are removed with Roux-en-Y
esophagojujenostomy.
4) Nowadays many surgeons prefer to do:
TranshiataI totaI esophagectomy
Chemotherapy Can be effective with surgery especially with squamous cell carcinoma
26. Barrett’s esophageal
10% of cases of GERD.
Metaplasia of the lower end of the esophageal mucosa into columnar type.
A precursor for ulcers, dysplasia, cancer in situ and adenocarcinoma.
Regular endoscopic monitoring with multiple biopsies is essential
Endoscopic mucosa resection (EMR) using photodynamic therapy or argon beam
coagulation may be used before progression to cancer.
The best line of TTT of it is large dose of PPls
