1. Objective esophageal physiology testing is cornerstone
to making the diagnosis of benign esophageal disorders and in developing
an individualized treatment plan for patients.
2. While most esophageal procedures can be performed using either
a videoscopic or flexible endoscopic approach, the surgeon must
be familiar with the surgical anatomy and open approaches to the
esophagus along its entire length.
3. Laparoscopic cardiomyotomy is now considered the most effective
treatment for achalasia and should include division of the gastric
collar sling musculature.
4. While esophageal replacement is most commonly performed with
the tubularized stomach, the surgeon should be familiar with the
anatomy and techniques which enable the use of colon and jejunum.
5. Giant paraesophageal hernia should be repaired surgically in
patients with symptoms, anemia, or signs of strangulation.
6. The cornerstone to esophageal cancer clinical staging includes
the use of endoscopy, CT, PET, and endoscopic ultrasound.
7. In surgical candidates with esophageal cancer confined to the
posterior mediastinum, esophagectomy represents the best possible
chance for cure.
The esophagus is a muscular tube that starts as the continuation
of the pharynx and ends as the cardia of the stomach. When the head
is in a normal anatomic position, the transition from pharynx to esophagus
occurs at the lower border of the sixth cervical vertebra. Topographically
this corresponds to the cricoid cartilage anteriorly and the palpable
transverse process of the sixth cervical vertebra laterally (Fig. 25-1). The esophagus is firmly attached
at its upper end to the cricoid cartilage and at its lower end to
the diaphragm; during swallowing, the proximal points of fixation
move craniad the distance of one cervical vertebral body.
A. Topographic relationships of
the cervical esophagus: (a) hyoid bone, (b)
thyroid cartilage, (c) cricoid cartilage, (d)
thyroid gland, (e) sternoclavicular. B. Lateral
radiographic appearance with landmarks identified as labeled in A.
The location of C6 is also included (f).
[Reproduced with permission from Rothberg
M, DeMeester TR: Surgical anatomy of the esophagus, in Shields TW
(ed): General Thoracic Surgery, 3rd ed. Philadelphia:
Lea & Febiger, 1989, p 77.]
The esophagus lies in the midline, with a deviation to the left
in the lower portion of the neck and upper portion of the thorax,
and returns to the midline in the midportion of the thorax near
the bifurcation of the trachea (Fig. 25-2).
In the lower portion of the thorax, the esophagus again deviates
to the left and anteriorly to pass through the diaphragmatic hiatus.