This document provides an overview of the anatomy, physiology, pathology, clinical features, investigations, staging, and treatment of oesophageal disease. It describes the layers of the oesophageal wall and its blood supply. Common causes of oesophageal cancer are discussed, including genetic, environmental, and pre-existing conditions. Symptoms, investigations such as endoscopy and imaging, and TNM staging of oesophageal cancer are outlined. Both palliative and curative options for managing oesophageal cancer are summarized.

1. Management Of Oesophageal
Pathology
Dr Chizoma G

2. Introduction/anatomy
• Is a hollow muscular tube
• Length: 25cm long & 2cm is
below the diaphragm
• Begins at lower edge of
cricoid cartilage C-6
• Ends at oesophagogastric
junction T-12
• Upper end is closed by
cricopharyngeus muscle
and forms UES

3. • It lies anterior to vertebral column
• It lies posterior to trachea
• Is surrounded by loose fibroareolar adventitia
– lacks serosa
• Lined by squamous epithelium
• Terminal 3cm lined by columnar epithelium
• Submucosa is thick and strongest part

4. • Mucosa - Lining epithelium with:
– Lamina propria, connective tissue, capillaries,
muscularis mucosae – a thin double layer of
smooth muscles
• Submucosa
– Loose connective layer, capillaries & lymphatics

5. Muscularis Propria
• 2 layers of smooth muscles
• circular & longitudinal
Loose Adventitia
• There is no serosa
• easy invasion by Ca

6. • Upper 1/3
– skeletal muscle
• Middle 1/3
– mixed skeletal & smooth muscles
• Lower 1/3
– smooth muscle

7. Parts of oesophagus
• Cervical
• Extends from cricopharyngeus
• Killians dehiscence – gap between
cricopharyngeus and thyropharyngeus of
inferior constrictor muscle
• Pharyngeal pouch commonly occurs here
• Is related to trachea and recurrent laryngeal
nerve

8. • Thoracic
– Initially right side, deviates towards left in lower
1/3
– Related to azygous vein, thoracic duct, aorta,
pleura, pericardium
• Abdominal
– 2.5 cm long
– Grooves behind left lobe of liver

9. Anatomic narrowing
• Cervical constriction
• Level of cricopharyngeal sphincter
– Narrowest point of GIT
• Bronchoaortic constriction
– T-4 level
• Diaphragmatic constriction
– T-10 level when crossing diaphragm

10. • Constrictions from incisor teeth:
– Cricopharynx
– at 15cm
• Arch of the aorta/Bronchus
– at 25cm
• Gastroeosphageal junction
– at 40cm

11. Arterial supply
• Inferior thyroid artery
• Oesophageal branches of aorta
• Gastric arteries
• Inferior phrenic arteries

12. Venous drainage
• Veins are longitudinal
• Lie in submucosal plane in lower 1/3
• Lie in muscular plane above
• Inferior thyroid vein
• Left hemiazygos vein
• Azygos vein
• Inferior phrenic vein

13. Lymphatic drainage
• Arranged longitudinally
• Carcinoma spread to distant LNs occurs early
• LNs are
• Paraoesophageal groups
• Perioesophgeal groups
• Lateral oesophageal groups

14. Nerve supply
• Vagus
• Both sympathetic and parasympathetic
• Has only Auerbachs plexus between muscle
layers

15. physiology
• To propel food from mouth to stomach
• 3 types of contractions
• Primary – progressive, triggered by swallowing
• Secondary – progressive, generated by
distension or irritation
• Tertiary – non-progressive
• Upper oesophageal sphincter - prevents
regurgitation into the mouth

16. LOS
• High physiological zone at lower end
• Terminal 4cm with pressure of 10-25mmHg
• Prevents reflux of gastric contents
• Influenced by food, gastric distension, gastric
pathology, smoking, GI hormones, alcohol

17. LOS ctd
• Physiological reflux due to transient relaxation
• Oesophageal clearance mechanism due to
primary peristalsis occurs immediately
• GORD occurs due to decreased LOS tone,
altered relaxation time, reduced oesophageal
clearance mechanism

18. Common Clinical features
• (oesophageal dysphagia) Difficulty in swallowing
described as food or fluid sticking
• Must rule out malignancy
• (odynophagia) ■ Pain on swallowing
• Suggests inflammation and ulceration
• ■ Regurgitation or reflux (heartburn)
• Common in gastro-oesophageal reflux disease
• ■ Chest pain
• Difficult to distinguish from cardiac pain

19. Investigations
• Barium swallow
• U/S abdomen
• pH study oesophagus
• CT Scan
• Oesophageal manometry
• Oesophagoscopy
• MRI Study
• Endosonography

20. Contrast study
Barium swallow
barium sulpahte
• Motility disorders
• Mechanical causes of
dysphgia
• Diverticla
• GORD
Water soluble contrast
• Oesphageal perforation
• Leaking oesophageal
anastomosis

21. oesophagoscopy
• Diagnostic
– Visualise lesion
– Biopsy
• Therapeutic
– FB removal
– Stricture dilatation
– Placing endostents
– Injecting sclerosants

22. Endosonography
• Assesses pathology of different layers
• Determine operability
Endscopic oesophageal staining
• Identify early carcinoma
• Use labelled iodine
• Ca cells don’t take up iodine - pale

23. Ca Oesophagus
Incidence
In North America: 5 – 10/year/100,000
population
Widespread: China, Japan, Iran, France,
Southern Africa, Central & South America

24. Ca Oesophagus
• Aetiological risk factors
• Genetic & familial
• Environmental
• Pre-existing oesophageal diseases

25. Genetic & familial
• Common in elderly patients - 40 years
• M:F = 3:1 though in endemic areas it is 1:1
• Squamous cell carcinoma more common in blacks
• Adenocarcinoma is more common in whites
• Tylosis:
• Hyperkeratosis + skin thickening (Keratoderma)of
the palms & soles
• Autosomal Dominant disease
• 90% chance of developing Ca by age 65yrs

26. Environmental
• Alcohol intake - Squamous cell carcinoma
• Tobacco smoking - Adenocarcinoma
• Combination of smoking & drinking deadly
• Chewing of betel leaf & nut in India
• Eating Pica Silica – Africa ? Zambian women
• Chewing opium residue - Iran
• Chronic ingestion of hot liquids - South
America

27. Environmental factors ctd
• Poverty & malnutrition, i.e. diets low in:
– Animal protein
– Vitamins A & C
– Riboflavin
– Trace elements
• Large amounts of nitrates, nitrites &
nitrosamines

28. Pre-existing oesophageal diseases
• Plummer-Vinson syndrome
• Lye stricture
• Achalasia cardia
• Barrett’s oesophagus (due to chronic GERD -
columnar cells)

29. Pathology
(a) Cell types:
• Commonest is squamous cell carcinoma, then
adenocarcinoma
• Less than 2% = sarcomas, choriocarcinomas,
malignant melanoma, lymphomas
• Squamous cell carcinoma arises from
squamous cell epithelium
• Adenocarcinoma arises from columnar or
Barrett’s oesophagus

30. pathology
(b) Tumour location:
• Middle 1/3 – 50%
• Lower 1/3 – 33%
• Upper 1/3 – 17%
(c) Gross Types
• Annular – 15%
• Ulcerative – 20%
• Fungating – 60%

31. pathology
(d) Mode of spread:
• Intra-oesophageal - more proximally
• Direct invasion of the wall
• Lymphatic
• Haematogenous

32. Clinical features
• Dysphagia – from solids to liquids.
• ½ or more of lumen obstructed to become
symptomatic
• GIT bleeding, weight loss, haematemesis,
haemoptysis, constipation
• Hoarseness of the voice - Recurrent laryngeal
nerve
• Back pain - Prevertebral fascia
• Cough + pneumonia - airway invasion

33. P/Examination
• Cachexia
• Supraclavicular lymphadenopathy
• Hepatomegaly
• Anaemia
• Jaundice

34. Investigations
• Early diagnosis only possible on routine
screening
• Screening + biopsy for histology

35. Investigations
• Symptomatic patients
• Barium swallow - 1st
diagnostic tool
• Shouldering sign and
irregular filling defect

36. Investigations
• Oesophagoscopy +
biopsy

37. Investigations
• EUS:
– Assess tumour penetration & lymph node
involvement
• CT Scan:
– Local invasion, LN & distant spread
– Staging of disease
• MRI:
– No added advantage to CT scan

38. Investigations
• Bronchoscopy:
– Mid-oesophagus – Bulge, invasion, fistula
• Thoracoscopy:
– LN, staging – not very useful
• PET (Position Emission Tomography):
– Non-invasive technique
– Abnormal glucose uptake by malignant cells
– Computer-generated images

39. Stage the disease
• TNM staging

40. Treatment
• Depends on stage of disease
• Curative or palliative

41. Palliative
• Most patients present late - Relieve symptoms
• Goals
– Relieve pain
– Relieve dysphagia
– Prevent bleeding
– Prevent aspiration

42. Palliative
• Palliative dilatation:
– Effective for 2 – 4 weeks
– Preparatory for other palliative procedures like
stenting, brachytherapy, laser therapy
• Palliative surgery:
– Resection
– By-pass - stomach to neck (retrosternal)

43. Palliative ctd
• Radiation therapy:
– Non-invasive
– Relieves dysphagia after prolonged RT
• For adenocarcinoma - RT less sensitive
• RT may lead to:
– Perforation
– Fistula
– Stricture
– Oesophagitis

44. Palliative ctd
• Endoluminal brachytherapy
• Laser & Photodynamic therapy
• Oesophageal intubation – immediate relief of
dysphagia

45. Curative surgery
• Indications
– Early growth when patient is fit
– No involvement of LN
– No involvement of bronchus
– No involvement of liver

46. Curative sgy
• Oesophagectomy & reconstruction
• Reconstructive involves conduit replacement
– Stomach, colon, jejunum
– Posterior mediastinum
– Intrapleural
– Substernal space
– Subcutaneous space

47. Conclusion
• RT – generally poor results when used alone
• RT as adjuvant to surgery – no added benefit
• Chemotherapy- Cisplatin, 5-FU, Vindesine,
Mitomycin

48. references
• SRB's Manual of Surgery
• General surgery dpt lectures