GIT

Subtopic : Surgical anatomy of esophagus and Investigations

Compiled by
Rohan Hake
Seth GS Medical college, Mumbai
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Esophagus

Surgical Anatomy

• Length : 25 cm

Parts of Esophagus • Abdomen : Positive pressure cavity : 0-5 mmHg

• Cervical • Thorax : Negative pressure cavity
• Thoracic • Hiatal opening : Respiratory Inverse point
• Abdominal

Left side : Cervical part of Esophagus

I!¥p
Right side : Upper Thoracic esophagus

Left side : Lower Thoracic esophagus

If we have to approach esophagus

Ti¥¥i
Left sided neck incision : for exploration of esophagus in neck
Right Anterolateral Thoracotomy for Upper esophageal problem
Left Thoracotomy incision for Lower esophageal problem

Abdominal approach for Abdominal esophageal problem

Natural constrictions of esophagus

Distance Site

• 1st constriction 15 cm Cricopharyngeal sphincter

• 2nd constriction 22.5 cm Arch of Aorta

• 3rd constriction 27.5 cm Left bronchus

• 4th constriction 37.5-40cm Hiatus

Cricopharyngeal sphincter : It is narrowest entry point of GIT

MC site for foreign body impaction in esophagus

Esophagus is lined by squamous epithelium

Oral cavity is also lined by squamous epithelium

MC cause of Oral cavity malignancy Tobacco

: Alcohol

If anybody develops Oral cavity malignancy are also has risk of getting esophageal malignancy
V

This is called Field change

All those parts of GIT which are outside Peritoneum they don’t have serosa
Esophagus has 3 layers

☞ Submucosa is toughest layer of entire GIT

Because it has maximum amount of collagen in it

:
Whenever we do Intestinal anastomosis after resection

Most important approximation is submucosal approximation

(Submucosal anastomosis integrity)

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Esophagus

☞ Thickest layer of esophagus : Muscular layer

Esophagus has 2 sphincters > UES : Anatomical sphincter : Cricopharyngeal sphincter

> LES : Physiological sphincter

:
Muscles (Inner Circular ) at the lower
end 3-5 cm are in state of tonic spasm

15-25 mmHg

Blood supply of esophagus

¥¥
From inferior thyroid artery
Paratracheal LN
Direct branches from Aorta All the Lymph node in the body sitting on the vessels
Mediastinal LN these are those vessels which are supplying that organ

Short gastric arteries

. Short gastric LN
Left gastric LN
Left gastric artery

☞ Paratracheal LN
☞ Mediastinal LN Regional Lymph Nodes
☞ Left gastric LN
☞ Short gastric LN

Carcinoma esophagus Surgery Primary modality

i Chemotherapy
Chemoradiation
Radiation
Adjunct Modality

MC route of spread : Lymphatic

It is aggressive malignancy

Surgery

v v

Wide excision of primary Lymphadenectomy

v v

Limit Extent
-
v

I
v

Proximal :10 cm margin Regional Lymphadenectomy > Ivor Lewis Tanner approach
Distal : 5 cm margin
One incision in the abdomen
+
Radicle esophagectomy Right Thoracotomy incision

l
v v

Transhiatal approach Transthoracic approach

OR l McKeown approach
v

Orringer’s approach Thorax is opened > (Three hole/ three field)

One incision in the abdomen /

1
v

Thorax is not opened +

Right Thoracotomy incision
I +
Incision in neck

> Left thoraco abdominal approach

Not used now

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Esophagus

• Transhiatal Approach : Lower esophageal cancer

Sometimes Cervical esophageal cancer

• Ivor Lewis Approach : Middle esophageal cancer Which is best

Lower esophageal cancer approach considering
limit and extent of
• McKeown approach : Any part of esophagus surgery ?
Mainly used cervical esophageal cancer Ans : McKeown
approach : As
Lymphadenectomy will
MC cancer of esophagus : Middle esophageal cancer be very proper due to
Hence MC used approach for Ca esophagus : Ivor Lewis Approach 3 incisions
MC cause of death due to any of these approaches : Anostomosis leak

Radicle esophagectomy
V

Replacement / Conduits

v v v Conduit of choice /
Stomach Jejunum Left colon Replacement of
v v v choice :
Vascular pedicel Arterial Arcade Ascending branch Stomach
of left colic artery
>
Right Gastric artery

>
Gastroepiploic arc

>
Right Gastroepiploic Artery
>
Left Gastroepiploic Artery

Esophagus : Physiology

3 phases of swallowing Oral phase

÷
Pharyngeal phase
Esophageal phase

☞ Primary wave of peristalsis Initiates swallowing in esophagus — takes the food bonus down
>
It also neutralises the acid which gets refluxed to lower end of esophagus

☞ Secondary wave of peristalsis > Usually not present

> It comes into play to propel stubborn / difficult bolus
> Amplitude of secondary wave of peristalsis is more than Primary wave of peristalsis

☞ Tertiary wave of peristalsis > Non progressive, non progressive wave of unknown origin

Manomety
Record pressure in the esophagus at 3 points
Upper, middle, lower esophagus Probe
It measures

'

Amplitude of pressure
: Duration of wave
Length of segment having peristalsis
25

DLESR
15

DILESR : Deglutation Induced Lower Esophageal Sphincter Relaxation

It is Relaxation of LES on arrival of Primary wave of Peristalsis

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Esophagus

tLESR : Transient Lower Esophageal Sphincter Relaxation

It is relaxation of LES without arrival of Primary wave of peristalsis
It is physiological process to remove excess air that we swallowed for every breath

Factors preventing Ref lux

Mechanical factors Chemical factors

Main factors Contributory factors

• Intra abdominal pressure • Gastro Esophageal angle ( Angle of His)

• Abdominal length of esophagus • Right crus of Diaphragm
• Length of LES • Sling fibres of cardia
• Tone of LES • Mucosal folds

Investigations
• Contrast Esophagogram
• Upper GI endoscopy
• Endoscopic ultrasound
• CT scan
• Manometry
• 24 hr pH monitoring
• PET scan

Contrast Esophagogram

Barium swallow Water soluble contrast

v v

Gastrograffin Iohexol

Barium swallow
• IOC for Esophageal diverticulum
>

Esophageal stricture
>

Webs and rings in the esophagus

>

IOC for esophageal perforation :

CT scan with oral contrast
• Most sensitive investigation for Esophageal perforations

• 1st investigation in functional disorders > Achalasia cardia

>
Diffused esophageal spasm
>
Nut cracker esophagus (Jack hammer esophagus)
> Hypertensive LES

Bird beak appearance Rat tail appearance

Sigmoid / S shaped esophagus

DES : Cork screw appearance
Present in long standing cases

Rat tail appearance : It is present in Achalasia cardia also but more commonly present in Ca esophagus

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Esophagus

Esophageal stricture Esophageal diverticulum Esophageal webs

Upper GI endoscopy / EGD (Esophagogastroduodenoscopy)

v v

Diagnostic Therapeutic intent

☞ IOC for Upper GI bleed ☞ To control Upper GI bleed

☞ IOC for Ca esophagus ☞ To do stenting of esophagus
☞ IOC for dysphagia to solids ☞ To do esophageal dilatation
☞ IOC Corrosive injuries (within 24 hrs) ☞ To do PEG (Percutaneous Endoscopic Gastrostomy)
☞ IOC for GERD ☞ To do POEM (Per Oral Endoscopic Myotomy)
☞ IOC for Barrett’s esophagus ☞ To remove foreign Body
☞ To do Stapler diverticuloesophagostomy (Dolman’s procedure)
☞ Gold standard for Esophageal perforation ☞ Endoscopic mucosal resection

Upper GI endoscope Flexible

i Rigid Cannot be used for diagnostic purpose
: Sometimes used for foreign body removal

Chromoendoscopy
Naked eyes may not pick early changes in esophagus

¥
Hence to improve the yield of endoscopy

We use Chrmoendoscopy/ Stained endoscopy

We first spray the dye inside esophagus

The dyes we select has property of

getting absorbed by preferential cells

When this dyes gets preferentially

absorbed by pathological cells

They change the colour

• Methylene Blue Barret’s esophagus

• Alcian Blue
• KI
• Cresyl Blue

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Esophagus

Endoscopic Ultrasound
"

Intensity of probe : 3-30 MHz Radial probe

'
Commonly used : 7.5-14.5 MHz
'
i
Linear Probe

:
Linear probe
:
Radial probe

Endon On side
Help use seeing in front Help us seeing perpendicular
For taking biopsy

☞ We can make out dept of penetration of any lesion

☞ It can also see 3 cm into that organ
☞ We can make out LN of size as small as 3 cm

☞ Best investigation for : depth of penetration of Ca esophagus

☞ Best investigation for T staging of Ca esophagus

☞ IOC for LN status in mediastinum

CT scan

CT scan with oral contrast : IOC esophageal perforation

IOC for Hiatus hernia

Staging of Ca esophagus

PET scan
IOC for systemic spread of Ca esophagus

MC site of distant metastasis

of all GI malignancies :
Liver
except Cholangiocarcinoma,
Anal Ca (Lung)

24 hr pH monitoring / Ambulatory pH monitoring

pH sensing probe

Placed 5 cm above upper end of LES

To check how many times in a day

pH of this point goes below 4

:
We calculate percentile score

DeMeester score

If DeMeester score is >14.7 : GERD

Gold standard investigation for GERD : 24 hr pH monitoring

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Esophagus

Dysphagia Difficulty in swallowing

÷
Structural Functional

• Difficulty in initiating swallowing Sensation of food getting stuck in esophagus

• Associated with coughing / choking (Dysphagia : seconds after

sensation / Nasal regurgitation initiation after swallowing)

Oropharyngeal cause Esophageal dysphagia

Barium swallow

:
Dysphagia starting to
i
Dysphagia to solids (to start with)

• Solids and liquids both Structural disorder of esophagus

• Liquid first then solid
• Liquids only

i
'

Non progressive Progressive

v

Functional disorder of esophagus Esophageal rings

Esophagitis
v v

Intermittent dysphagia Progressive v v

Chronic heart burn • Elderly

V V V V
V
• Weight loss
DES NC Chronic heart burn Regurgitation of food / Peptic stricture • Anemia
v
Respiratory symptoms / v

Scleroderma Weight loss Ca esophagus

v

IOC for functional Achalasia cardia

disorders of IOC for structural
esophagus : disorders of esophagus :
Barium swallow Endoscopy

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