The document describes the anatomy and physiology of the esophagus. It details the different segments of the esophagus from the pharyngoesophageal junction to the gastroesophageal junction. Key structures like the lower esophageal sphincter are described. Motility disorders, diseases, cancers and treatments related to the esophagus are summarized. Evaluation methods for esophageal conditions are also outlined.

1. THE OESOPHAGUS
Dr. D.W. Daugherty
Department of Surgery

2. Anatomy
I. Pharyngoesophageal Segment
The segment between the laryngopharynx and
the cervical esophagus.
Includes the superior, middle, and inferior
constrictors.
Ends at the cricopharyngeal muscle (which is
where the cervial esophagus begins).

3. Anatomy
II. Cervical Esophagus
Begins below the cricopharyngeus muscle.
The cricopharyngeus muscle is continuous
with the more superior inferior constrictor of
the pharyngoesophagus.
* It is the potential space between these
muscles that is the site where Zenker’s
diverticulum develops.

4. Anatomy
II. Cervical Esophagus
Approximately 5cm in length and begins at
C-6 and extends to T-1.
Anteriorly, lie the trachea and the lobes of the
thyroid.
Posteriorly is the retropharyngeal space.
Laterally are the carotid sheaths.

5. Anatomy
II. Cervical Esophagus
The recurrent laryngeal nerves lie in grooves
between the esophagus and trachea.
The right recurrent laryngeal nerve runs an
oblique course and is most prone to anatomic
variation.
* Incisional approach from the left side of
the neck, along the anterior border of the
SCM muscle, is chosen if possible.

7. Anatomy
III. Thoracic Esophagus
Above the level of the tracheal bifurcation, the
esophagus courses to the right of the descending
aorta and is in close relation to the posterior tracheal
wall.
It then courses left, behind the tracheal bifurcation
and left main bronchus.
The lower third then courses anteriorly and to the
left to pass through the diaphragmatic hiatus at the
level of T-10.

8. Anatomy
III. Thoracic Esophagus
The lower esophagus is covered only by the flimsy
mediastinal pleura on the left. This is the weakest
portion and is most commonly the site of perforation
in Boerhaave’s syndrome.
* Boerhaave’s syndrome: increased intra-esophageal
pressure secondary to emesis or retching ultimately
leading to a rupture/perforation.

10. Anatomy
IV.Abdominal Esophagus
Begins where the esophagus enters the abdomen
through the diaphragmatic hiatus, at T-10.
It is surrounded by a fibroelastic membrane, the
phrenoesophageal ligament, which arises from the
sub-diaphragmatic fascia.
The lower limit of the phrenoesophageal ligament
anteriorly is marked by a prominent fat pad, which
corresponds to the gastro-esophageal junction.

11. Anatomy
The Lower Esophageal Sphincter (LES)
Zone of high pressure measuring 3-5 cm long at the
lower end of the esophagus.
The LES is a physiologic sphincter. NOT an
anatomic sphincter. Therefore, it does not
correspond to any gross anatomical structure.
* Incompetence of this physiologic sphincter results
in gastro-esohpageal reflux disease (GERD) and
could unltimately lead to Barrett’s esophagitis.

12. Anatomy
Histology
The wall is composed of two muscular layers.
- Inner Circular and Outer Longitudinal
Upper 2/3 is striated muscle
Lower 1/3 is smooth muscle
No surrounding Serosal covering
Prominent Submucosa

13. Anatomy
Histology
The mucosal Lining is made up of squamous
epithelium
Exception is the distal 1-3 cm of the esophagus,
which are composed of columnar epithelium
** Barrett’s esophagous the metaplasia of the
esophageal squamous epithelium to columnar
epithelium.
It is a result of severe reflux disease and is a risk
factor for esophageal adenocarcinoma.

14. Anatomy
Arterial Supply
Cervical Esophagus: The Inferior Thyroid Arteries
Thoracic Esophagus:
Proximal: Branches from two or three
bronchial Arteries
Distal: Branches directly from the Aorta. The
most proximal arise between the 6th
and 7th
thoracic vertebrae; the most distal arise
between the 8th
and 9th
vertebrae

15. Anatomy
Arterial Supply
Abdominal Esophagus:
Branches of the Left Gastric Artery
Branches of the Inferior Phrenic Artery
Intramuscular:
Once the vessels have entered the muscular
wall of the esophagus, branching occurs at
right angles to provide a longitudinal plexus
* Important in that this allows mobilization of
the esophagus without ischemic injury

17. Anatomy
Venous Drainage
Extensive venous plexus in the submucosa
Then drains to into the peri-esophageal plexus
Proximal 1/3: drains to the inferior thyroid vein
Middle 1/3: drains into the bronchial, azygos, or
hemiazygos veins in the thorax

18. Anatomy
Venous Drainage
Distal 1/3: drains into the left gastric vein or
coronary vein. This provides the principle collateral
circulation to the portal system.
* Esophageal verices develop in these vessels
secondary to increased portal pressure in portal
hypertension.
** Submucosal veins in the distal 1-2 cm of
the esophagus become very superficial and are
consequently the most common site of
bleeding in portal hypertension.

20. Anatomy
Lymphatics
Upper 2/3 of Esophagus:
Cervical esophagus drains to the internal
jugular nodes
Dorsal Thoracic esophagus drains to the
posterior mediastinal nodes
Anterior Thoracic esophagus drains to the
tracheal nodes superiorly and subcarinal and
paraesophageal nodes inferiorly

21. Anatomy
Lymphatics
Lower 2/3 of Esophagus:
Abdominal esophagus drains to the cardiac
and celiac nodes
Eventually, this drains to the cisterna chyli or
the thoracic

22. Anatomy
Lymphatics
Cancer – Lymphatic Spread
Tumor limited to the mucosa: the incidence of
lymphatic spread is low.
Tumor invades the submucosa: the incidence of
nodal metastasis is 60% due to the rich
submucosal lymphatics
A three field lymph node dissection provides the
best evidence for staging

24. Anatomy
Innervation
Right and left recurrent laryngeal nerves, arising from
the Vagus (X), provide the innervation to the
cricopharyngeal sphincter and cervical portion of the
esophagus
* Injury to one or both of these nerves results in
vocal cord dysfunction, cricopharyngeal
dysfunction, motility dysfunction, and inability
to properly close the glottis.
** These dysfunctions all contribute to the risk of
aspiration.

25. Anatomy
Innervation
The esophageal plexus on the anterior and posterior
walls of the esophagus innervate the lower esophagus.
This plexus also receives fibers from the thoracic
sympathetic chain.
The single trunks distally contain fibers from both the
original vagus nerves

26. Anatomy
Innervation
Efferents:
Preganglionic sympathetic fibers arise from the
spinal segments 4-6
Terminate in the cervical and thoracic
sympathetic ganglia
Postganglionic fibers reach the esophagus from
the cervical and thoracic sympathetic chain
Distal esophagus receives sympathetic fibers
directly from the celiac ganglion

27. Anatomy
Innervation
Afferents:
Visceral sensory pain fibers from the esophagus
terminate without synapses in segments 1-4 of
the thoracic cord
Follows both sympathetic and vagal pathways
* Vagal fibers from the heart also travel in the
same pathway, explaining the similarity of
symptoms in many esophageal and cardiac
diseases

29. Physiology – Swallowing
• Food bolus enters the esophagus and the cricopharyngeus
muscle constricts causing an increase in pressure to
60mmHg (twice the resting pressure of 30mmHg)
• Smooth muscle activation is initiated and a peristaltic
wave is generated.
• A pressure gradient of 10mmHg exists between the
thorax and abdomen. This is overcome by peristaltic
pressure.
• The Lower Esophageal Sphincter (LES) relaxes and
allows the bolus to be passed to the stomach.

30. Physiology – LES
• Provides the pressure barrier between the esophagus and the
stomach.
• A physiologic sphincter, not an anatomic sphincter.
• Is an area approximately 3-5cm in length and normal resting
pressures range from 10-20 mm Hg.
• Has intrinsic myogenic tone, modulated by neural and
hormonal mechanisms.
• The vagus nerve carries both excitatory and inhibitory fibers to
the esophagus and the LES.

31. Physiology – LES
• Increase LES pressure: Gastrin, Motilin, Beta-blockers, Alpha-
adrenergic agonists, Antacids, Cholinergics, Metocloprimide.
• Decrease LES pressure: Cholecystokinin, Estrogen, Glucagon,
Progesterone, Secretin, Anti-cholinergics, Barbituates, Ca-
Channel blockers, Diazepam, Meperidine.
• Dietary contribution to decreased LES tone: Caffiene, Coffee,
Alcohol, Peppermint, Chocolate, and Fat.
• LES pressures of less than 6 mm Hg (equal to that of intra-
abdominal pressure) or a length of less than 2cm are associated
with LES incompetence and GERD.

32. Evaluation of the Esophagus
• Endoscopy
• CT Scan
• Barium Swallow
• Endoscopic Ultrasound (EUS)
• Manometry
• pH Monitoring

38. Motility Disorders
• Four Categories:
• Inadequate relaxation of the LES – Achalasia
• Uncoordinated contractions – Diffuse Esophageal
Spasm (DES)
• Hypercontraction – Nutcracker esophagus
•Hypocontraction – Ineffective motility

39. Esophageal Diverticula
• Pulsion Diverticula
• Traction Diverticula
• Pharyngoesophageal (Zenker) Diverticulum

40. Esophageal Perforation

41. Esophageal Caustic Injury

43. Esophageal Reflux Disease

44. Esophageal Reflux Disease
• Barrett’s Esophagitis
Metaplasia of the squamous cells in the lower
esophageal lining to columnar cells
Caused by chronic GERD
Predisposing condition for dysplasia and thus
transformation into esophageal adenocarcinoma

46. Esophageal Reflux Disease

47. Esophageal Reflux Disease

48. Esophageal Cancer
• Risk Factors:
- Tobacco use
- Heavy alcohol use
- Barretts esophagitis
- Age
- Men
- Race: African-Americans, Asians

49. Esophageal Cancer
• Symptoms:
- Dysphagia
- Odynophagia
- Weight loss
- Sub-sternal chest pain
- Hoarseness
- Cough
- Indigestion / Heartburn

50. Esophageal Cancer
• Work Up
- Bronchoscopy
- Laryngoscopy
- Endoscopic Ultrasound
- CT Scan
- PET Scan

51. Esophageal Cancer
• Squamous cell carcinoma:
Most often found in the upper and middle part of the
esophagus, but can occur anywhere along the
esophagus. This is also called epidermoid
carcinoma.
Associated with smoking and alcohol use.
• Adenocarcinoma:
Most often form in the lower part of the esophagus,
near the stomach.
Associated with Barrett’s esophagitis.

52. Esophageal Cancer

53. Esophageal Cancer - Treatment

54. Esophageal Cancer - Treatment

55. Esophageal Cancer - Survival

56. Esophageal Cancer - Survival

57. Esophageal Cancer - Esophagectomy

58. Esophageal Stenting

59. Esophageal Stenting