Mucosa (squamous epithelium), submucosa, and muscularis propria (longitudinal muscle layer); no serosa

  Upper ⅓ esophagus – striated muscle

  Middle ⅓ and lower ⅓ esophagus – smooth muscle

  Vessels directly off the aorta are the major blood supply to the thoracic esophagus

  Cervical esophagus – supplied by inferior thyroid artery

  Abdominal esophagus – supplied by left gastric and inferior phrenic arteries

  Venous drainage – hemi-azygous and azygous veins in chest

  Lymphatics – upper ⅔ drains cephalad, lower ⅓ caudad

  Right vagus nerve – travels on posterior portion of stomach as it exits chest; becomes celiac plexus; also has the criminal nerve of Grassi → can cause persistently high acid levels postoperatively if left undivided after vagotomy

  Left vagus nerve – travels on anterior portion of stomach; goes to liver and biliary tree

  Thoracic duct – travels from right to left at T4–5 as it ascends mediastinum; inserts into left subclavian vein

  Upper esophageal sphincter (UES; 15 cm from incisors) – is the cricopharyngeus muscle (circular muscle, prevents air swallowing); recurrent laryngeal nerve innervation

•  Normal UES pressure at rest: 60 mm Hg

•  Normal UES pressure with food bolus: 15 mm Hg

•  Cricopharyngeus muscle – most common site of esophageal perforation (usually occurs with EGD)

•  Aspiration with brainstem stroke – failure of cricopharyngeus to relax

  Lower esophageal sphincter (40 cm from incisors) – relaxation mediated by inhibitory neurons; normally contracted at resting state (prevents reflux); is an anatomic zone of high pressure, not an anatomic sphincter

•  Normal LES pressure at rest: 15 mm Hg

•  Normal LES pressure with food bolus: 0 mm Hg

  Anatomic areas of esophageal narrowing

•  Cricopharyngeus muscle

•  Compression by the left mainstem bronchus and aortic arch

•  Diaphragm

  Swallowing stages – CNS initiates swallow

•  Primary peristalsis – occurs with food bolus and swallow initiation

•  Secondary peristalsis – occurs with incomplete emptying and esophageal distention; propagating waves

•  Tertiary peristalsis – non-propagating, non-peristalsing (dysfunctional)

•  UES and LES are normally contracted between meals

  Swallowing mechanism – soft palate occludes nasopharynx, larynx rises and airway opening is blocked by epiglottis, cricopharyngeus relaxes, pharyngeal contraction moves food into esophagus; LES relaxes soon after initiation of swallow (vagus mediated)

  Surgical approach

•  Cervical esophagus – left

•  Upper ⅔ thoracic – right (avoids the aorta)

•  Lower ⅓ thoracic – left (left-sided course in this region)

  Hiccoughs

•  Causes – gastric distention, temperature changes, ETOH, tobacco

•  Reflex arc – vagus, phrenic, sympathetic chain T6–12

  Esophageal dysfunction

•  Primary – achalasia, diffuse esophageal spasm, nutcracker esophagus

•  Secondary – GERD (most common), scleroderma

  Endoscopy – best test for heartburn (can visualize esophagitis)

  Barium swallow – best test for dysphagia or odynophagia (better at picking up masses)

  Meat impaction – Dx and Tx: endoscopy

PHARYNGOESOPHAGEAL DISORDERS

  Trouble in transferring food from mouth to esophagus

  Most commonly neuromuscular disease – myasthenia gravis, muscular dystrophy, stroke

  Liquids worse than solids

  Plummer–Vinson syndrome – can have upper esophageal web; Fe-deficient anemia. Tx: dilation, Fe; need to screen for oral CA

DIVERTICULA

  Zenker’s diverticulum – caused by ↑ pressure during swallowing

•  Is a false diverticulum located posteriorly

•  Occurs between the pharyngeal constrictors and cricopharyngeus

•  Caused by failure of the cricopharyngeus to relax

•  Symptoms: upper esophageal dysphagia, choking, halitosis

•  Dx: barium swallow studies, manometry; risk for perforation with EGD and Zenker’s

•  Tx: cricopharyngeal myotomy (key point); Zenker’s itself can either be resected or suspended (removal of diverticula is not necessary)

•  Left cervical incision; leave drains in; esophagogram POD #1

  Traction diverticulum

•  Is a true diverticulum – usually lies lateral

•  Due to inflammation, granulomatous disease, tumor

•  Usually found in the mid-esophagus

•  Symptoms: regurgitation of undigested food, dysphagia

•  Tx: excision and primary closure if symptomatic, may need palliative therapy (ie XRT) if due to invasive CA; if asymptomatic, leave alone

  Epiphrenic diverticulum

•  Rare; associated with esophageal motility disorders (eg achalasia)

•  Most common in the distal 10 cm of the esophagus

•  Most are asymptomatic; can have dysphagia and regurgitation

•  Dx: esophagram and esophageal manometry

•  Tx: diverticulectomy and esophageal myotomy on the side opposite the diverticulectomy if symptomatic

ACHALASIA

  Dysphagia, regurgitation, weight loss, respiratory symptoms

  Caused by lack of peristalsis and failure of LES to relax after food bolus

  Secondary to neuronal degeneration in muscle wall

  Manometry – ↑ LES pressure, incomplete LES relaxation, no peristalsis

  Can get tortuous dilated esophagus and epiphrenic diverticula; bird’s beak appearance

  Tx: balloon dilatation of LES → effective in 80%; nitrates, calcium channel blocker

•  If medical Tx and dilation fail → Heller myotomy (left thoracotomy, myotomy of lower esophagus only; also need partial Nissen fundoplication)

  T. cruzi can produce similar symptoms

DIFFUSE ESOPHAGEAL SPASM

  Chest pain, may have dysphagia; may have psychiatric history

  Manometry – frequent strong non-peristaltic unorganized contractions, LES relaxes normally

  Tx: calcium channel blocker, nitrates; Heller myotomy if those fail (myotomy of upper and lower esophagus)

  Surgery usually less effective for diffuse esophageal spasm than for achalasia

NUTCRACKER ESOPHAGUS

  Chest pain and dysphagia

  Manometry – high-amplitude peristaltic contractions; LES relaxes normally

  Tx: calcium channel blocker, nitrates; Heller myotomy if those fail (myotomy of upper and lower esophagus)

  Surgery usually less effective for nutcracker than for achalasia

SCLERODERMA

  Fibrous replacement of esophageal smooth muscle

  Causes dysphagia and loss of LES tone with massive reflux and strictures

  Tx: esophagectomy usual if severe

GASTROESOPHAGEAL REFLUX DISEASE (GERD)

  Normal anatomic protection from GERD – need LES competence, normal esophageal body, normal gastric reservoir

  GERD caused by ↑ acid exposure to esophagus from loss of gastroesophageal barrier

  Get heartburn symptoms 30–60 minutes after meals; worse lying down

  Can also have asthma symptoms (cough), choking, aspiration

  Make sure patient does not have another cause for pain (check for unusual symptoms):

•  Dysphagia/odynophagia – need to worry about tumors

•  Bloating – suggests aerophagia and delayed gastric emptying (Dx: gastric emptying study)

•  Epigastric pain – suggests peptic ulcer, tumor

  Most treated empirically with PPI (omeprazole, 99% effective)

  Failure of PPI despite escalating doses (give it 3–4 weeks) → need diagnostic studies

  Dx: pH probe (best test), endoscopy, histology, manometry (resting LES < 6 mm Hg)

  Surgical indications: failure of medical Tx, avoidance lifetime meds, young patients

  Tx: Nissen fundoplication → divide short gastrics, pull esophagus into abdomen, approximate crura, 270- (partial) or 360-degree gastric fundus wrap

•  Phrenoesophageal membrane is an extension of the transversalis fascia

•  Key maneuver for wrap is identification of the left crura

•  Complications – injury to spleen, diaphragm, esophagus, or pneumothorax

•  Belsey – approach is through the chest

•  Collis gastroplasty – when not enough esophagus exists to pull down into abdomen, can staple along stomach cardia and create a “new” esophagus (neo-esophagus)

•  Most common cause of dysphagia following Nissen – wrap is too tight

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