Esophagus

Surgery Notes
Dr Shiva Bhandari
Outline
• Anatomy
• Physiology
• Esophageal Motility Disorders
• Diverticular Disorders
• Gastroesophageal Reflux Disease
• Acquired Benign Disorders of the Esophagus
• Benign and Rare Tumors of the Esophagus
• Esophageal Cancer
Anatomy
• 25-30 cms long
• Starts at base of T6
• terminates at ?T11 at esophageal
hiatus (I ate (8) 10 eggs at t12
• Esophageal hiatus at t10

• On endoscopy distance from incisors:

• upper esophageal sphincter - 15 cm
• carina - 25 cm,
• the lower esophageal sphincter at 38 to
40 cm in men and 36 to 38 cm in
women.
Esophageal inlet
• Upper esophageal sphincter –
cricopharyngeus muscle
• Three constrictors above
esophagus
• Upper
• Middle
• Lower:
• Thyropharyngeus (oblique)
• Cricopharyngeus(horizontal)
• Killians triangle – zenkers
diverticulum
• V shaped area of laimer
Esophageal layers
• Muscle layer
• Inner circular – continuation of
cricopharyngeus - form middle
ciruclar muscles of stomach
• Collar of Helvetius – transition of
circular muscles of esophagus to
oblique muscles of stomach at cardiac
notch
• Outer longitudinal –
• Auerbachs plexus in between
Anatomic narrowing
• Normal diameter 2.5 cms
• Cricopharyngeus – 14 mm – narrowest point of git
• Bronchoaortic constriction (left mainstem bronchus and aorta
abut) – 15 to 17 mm
• Diaphragmatic constriction – 16 to 19 mm
Gastroesophageal junction
• Endoscopic landmark
• Squamocolumnar epithelial
junction (Z line)
• Smooth lining to rugal fold of
stomach
• External landmark
• Collar of Helvetius (loop of
Willis)
• Gastroesophageal fat pad
Arterial supply
• Cervical
• Inferior thyroid
arteries(branch of thyrocervical
trunk on left and subclavian artery on
right )

• Thoracic
• Esophageal arteries
from aorta and branches
of bronchial arteries
• Abdominal
• Left gastric artery
• paired phrenic arteries
• Forms capillary network
before entering
musculature
Course of esophagus and
surgical approach
• The cervical esophagus shifts to the left at the base of the neck,
approach - left neck incision (e.g., during the cervical
anastomosis for a transhiatal esophagectomy or resection of a
Zenker diverticulum).
• Thoracic esophagus shifts to the right at T7 - approach for
midesophagus - right thoracotomy or thoracoscopy (for
example, during an Ivor-Lewis or minimally invasive three-hole
esophagectomy)
• Abdominal esophagus: angulates to the left after passing
through the diaphragmatic crura, and along with the location of
the liver on the right, the best approach to the distal thoracic
esophagus is from the left for a transthoracic hiatal hernia
repair or resection of an epiphrenic diverticulum, even when
the hernia or diverticulum extend into the right chest.
Venous drainage
 Lymphatics
• above the tracheal
bifurcation drains mostly
toward the neck
• below the tracheal
bifurcation drains toward
the lowermediastinum
and the celiac axis.
• tracheal bifurcation: in
either direction.
• When lymphatics become
blocked,tumor cells can
travel in the opposite
direction
Nerve supply
Relations
Thoracic duct
• begins in the abdomen as the cisterna chyli at T12
• passes through the aortic hiatus along with the aorta and the azygos and
hemiazygos veins
• lies on the anterior surface of the vertebra and is posterior to the
esophagus between the azygos on the right and the descending aorta on
the left.
• To perform a mass ligation for a chylothorax, the tissue between the
azygos vein and aorta is ligated just above the diaphragm.
• turns behind the left mainstem bronchus, at the level T5 T6 to empty into
the junction of the left subclavian and jugular veins. (>50% )
• damaged in 1% to 2% of esophagectomies, resulting in a chylothorax.
• suspicion for a thoracic duct injury postoperatively,
• high pink, clear chest tube output,
• becomes milky once fat is added to the patient’s diet,
• the thoracic duct should either be surgically ligated or embolized by IR
Esophageal Carcinoma
• Epidemiology
• Risk factors
• Presentation
• Age: 65 to 74 years with a median age at diagnosis of 67.1
• male preponderance (7 : 1)
• Cancer of the cervical esophagus is rare.
• SCC is evenly distributed within the middle and lower thoracic
esophagus,
• whereas 75% of all EAC is located in the distal esophagus
• EGJ grouped as esophageal for staging and treatment
• (siewert classification)
Risk factors specific to Adenocarcinoma
• Obesity:
• increased incidence of GERD and low-grade systemic inflammation associated
with adipose tissue
• GERD
• Barret esophagus:
• Annual risk of cancer without dysplasia 0.25%,
• With dysplasia 6%
• Risk factors: chronic GERD, presence of hiatal hernia, advanced age, male sex,
white race tobacco use, and obesity.
• with long-segment Barrett (≥3 cm) having a transition rate of 0.22%
per year compared with 0.01% in ultra-short segment Barrett (<1 cm)
• PPI increases
• LES relaxing medication increases
• H pylori decreases
Clinical features
• Early stage tumors are typically asymptomatic and physical
examination unremarkable
• over 50% of patients present with regionally advanced or
metastatic disease
• dysphagia (74%),
• weight loss (57%),
• odynophagia (17%).
• cough, dyspnea, hoarseness, and pain (abdominal, back, retrosternal)
may indicate more extensive disease
• EAC, up to two-thirds of patients have a history of reflux symptoms.

• Examination: advanced disease: hepatomegaly, pleural effusion, or

lymphadenopathy, particularly in the left supraclavicular fossa
(Virchow node)
• The most common metastatic sites are retroperitoneal or
celiac lymph nodes, liver, lungs, and adrenals.
• Metastatic disease can also manifest as malignant pleural
effusion, ascites,and bone pain of the affected site in bone
metastasis or as hypercalcemia secondary to paraneoplastic
syndrome.
• Adenocarcinomas most frequently metastasize to
intraabdominal sites, while metastases from SCCs more
commonly spread to intrathoracic or cervical locations.
Screening
• Routine screening not recommended
• Screening for Barret esophagus (ACOG)2016
• Men with chronic or frequent symptomatic GERD with two or
more risk factors for EAC (i.e., age >50, Caucasian race, central
obesity, current or past tobacco use, family history of Barrett or
esophageal cancer in a first-degree relative).
• Women: case by case basis
• Surveillance for Barret esophagus every 3 to 5 years in
theabsence of dysplasia, with more frequent intervals and/ or
therapy in the setting of dysplasia.
Diagnosis
• Barium esophagram:
• irregular narrowing or ulceration
• Apple core: symmetrical,
circumferential narrowing
Endoscopy
• Friable, ulcerated mass
• Ulcerations or nodules
• Strictures

• Multiple biopsies
• Location of tumor relative to incisor and GEJ
• Length of tumor and degree of obstruction
• Extent of Barret esophagus
Staging
• Eighth AJCC TNM
• Separate groupings for EAC and SCC
• Separate into clinical pathologic and postneoadjuvant staging
(ypTNM)

• Location (L) – Applicable to Squamous Cell Carcinoma Only

• LX: Location unknown
• Upper: Cervical esophagus to lower border of azygos
vein
• Middle: Lower border of azygos vein to lower border of
inferior pulmonary vein
• Lower: Lower border of inferior pulmonary vein to stomach,
including esophagogastric junction
Primary Tumor (T)
• TX Tumor cannot be assessed
• T0 No evidence of tumor
• Tis High-grade dysplasia
• T1a Tumor invades the lamina propria or muscularis mucosa
• T1b Tumor invades the submucosa
• T2 Tumor invades into but not beyond the muscularis propria
• T3 Tumor invades the adventitia
• T4a Tumor invades adjacent structures that are usually
resectable (diaphragm, pleura, azygos vein, peritoneum, or
pericardium)
• T4b Tumor invades structures that are usually unresectable
(aorta, vertebral body, or trachea)
Regional Lymph Nodes (N)
• NX Regional lymph nodes cannot be assessed
• N0 No regional lymph node metastasis
• N1 Metastasis in 1–2 regional lymph nodes
• N2 Metastasis in 3–6 regional lymph nodes
• N3 Metastasis in ≥ 7 regional lymph nodes

Distant Metastasis (M)

• M0 No distant metastasis
• M1 Distant metastasis
• Histologic Grade (G)
• GX Grade cannot be assessed
• G1 Well differentiated
• G2 Moderately differentiated
• G3 Poorly differentiated or undifferentiated
EMR and EUS
• Small, superficial lesions: resected by EMR.
• EMR provides accurate staging for depth of penetration (T-
status) and may provide additional information about the risk
of nodal metastasis such as finding of lymphovascular
invasion.
• EUS has less accuracy for superficial disease and will seldom
obviate the need for EMR.
• For T1a tumors resected by EMR, the risk of lymph node
metastasis is very low, and additional staging studies are not
required.
Staging
• CT
• For larger lesions contrast-enhanced CT scan of the chest and
abdomen and PET/CT to evaluate for distant metastatic disease
should be performed.
• PET/CT
• demonstrate distant metastatic disease, eliminating the need for
the patient to undergo EUS.
• identify a suspicious lymph node that can be specifically
examined and sampled during the EUS procedure
• Bronchoscopy
• Proximal middle third esophageal tumors to assess tracheal
invasion
EUS
• If no evidence of distant metastatic disease, EUS should be
done to assess T-status and regional lymph nodes.
• Coupled with FNA of any suspicious nodes
• superior to CT or PET for assessment of both T and N-status.
• highly accurate for celiac nodal status,
• slightly lower for other regional lymph nodes due to difficulty
accessing the node without traversing the tumor.
• Obstructing lesions may preclude EUS assessment.
• dilatation to perform EUS is associated with a risk of
perforation.
High grade dysplasia and
superficial cancer
• Annual risk of cancer in Barret – 0.12%
• Seattle Biopsy protocol for mapping of Barret esophagus with
high grade dysplasia
• 4 quadrants biopsies at 1 cm intercals along the entire length of
Barret esophagus in addition to targeted biopsies of all visible
lesions
Therapeutic approaches
• Ablation
• Cryotherapy
• Endoscopic mucosal resection
• Esophagectomy

• NCCN guideline
• EMR± ablation in patients with Tis and T1a tumors
• in superficial T1b (SM1) patients with adenocarcinomas and low-
risk features, endoscopic eradication is a reasonable alternative
to surgery
Ablation
• High grade dysplasia
• RFA – lower stricture rate
• Photodynamic therapy
• Cryotherapy

• ACOG:
• low-grade dysplasia:
• endoscopic eradication therapy
• OR,yearly endoscopic surveillance
• high-grade dysplasia
• Endoscopic therapy

• Long term acid suppression

• High grade: repeat endoscopy 3 months
• Low grade: 6 months
EMR
• Nodular or raised Barret esophagus or superficial invasive
cancer
• Determine pathology – depth of invasion
• Complications
• Bleeding
• Stricture
• Pain
• Perforation

• Surveillanve
• Acid suppression therapy
• Endoscopies: every three months for 1st year and regulary
Esophagectomy
• T1b tumors
• High risk T1a tumors (larger lesions, lymphovascular invasion)
• Extensive multifocal lesions and ulcerated tumors

• Transhiatal
• Transthoracic
• Minimally invasive
Locally advanced esophageal
cancer
• Most patients present with T3n1-3 stage
• EAC:
• Regional – nodal disease from celiac axis to paratracheal region
• Distanct – nodal disease outside
• SCC
• Periesophageal cervical LN – regional disease
Radiation therapy
• Neoadjuvant radiation –no significant benefits of adding to
surgery
• Adjuvant radiation
• Ability to deliver in higher dose
• Potentially beneficial
Chemotherapy
• Death due to mets
• Chemo –
• targets micromets
• Downstage marginally resectabel tumors
• Decrease locoregional recurrence
• Neoadjuvant – helps determine biologic response

• Neoadjuvant chemo plus surgery VS surgery alone

• Cistpatin and 5FU based regimes
• Survival benefit
• Improved R0 resection

• Trials : MRC trial, Magic trial

Chemoradiation and surgery
• Synergistic effect of chemoradiation combined with surgery
• Treat locoregional disease and potential undetectable mets
• Currently standard of care

• CROSS trial
• Chemoradiation and surgery VS surgery alone
• Carboplatin and paclitaxel 5 wk course
• Concurrent radiation: 41.4Gy in 23 fraction five days a week
• Esophagectomy within 4 to 6 wks

• increased in CT-RT-SX
• R0 resection
• Complete pathologic response
• And improved survival

Other trials:
Surgical approaches to remove
esophagus
• Open
• Minimally invasive
• Vagal sparing
• Robotic
• Extent of lymphadenectomy
• Substitute for esophagus
• Anastomotic complications