Inferior thyroid arteries (branch of thyrocervical trunk on left and subclavian artery on right)

What is the arterial supply to the thoracic esophagus?

Direct blood supply from 4 to 6 esophageal arteries off of the aorta; esophageal branches off of right (R) and left (L) bronchial arteries; supplemented by descending branches off the inferior thyroid arteries, intercostal arteries, and ascending branches of the paired inferior phrenic arteries

What is the arterial blood supply to the abdominal esophagus?

Left gastric artery and the paired inferior phrenic arteries

Describe the venous drainage for the cervical esophagus:

The submucosal venous plexus drains into the inferior thyroid veins (tributaries of L subclavian vein and R brachiocephalic vein)

Describe the venous drainage for the thoracic esophagus:

The submucosal venous plexus of the thoracic esophagus joins with the more superficial esophageal venous plexus and the venae comitantes that surround the esophagus at this level. This plexus then drains into the azygos veins on the right and the hemiazygous veins on the left.

FIGURE 18-2. Venous drainage of the esophagus. (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; 1989:85.)

Drains into both the systemic and portal venous systems through the L and R phrenic veins, and the L gastric (coronary) vein and short gastrics

In what direction is the lymphatic flow in the upper two-thirds of the esophagus?

Cephalad

In what direction is the lymphatic flow in the distal third of the esophagus?

Caudad

Describe the sympathetic innervation of the esophagus:

Cervical esophagus receives branches from the cervical sympathetic trunk (from superior ganglion in neck); the thoracic esophagus receives branches from the thoracic sympathetic trunk (from stellate ganglion), which form an esophageal plexus that envelops the thoracic esophagus anteriorly and posteriorly; the distal thoracic esophagus receives innervation from the greater and lesser splanchnic nerves.

The parasympathetic fibers to the esophagus arise from which cranial nerve?

Vagus nerve

The esophagus is composed of which 2 concentric muscle bundles?

Inner circular and outer longitudinal

What kind of muscle composes the upper one-third of the esophagus?

Striated muscle

What kind of muscle composes the lower two-thirds of the esophagus?

Smooth muscle

At what vertebral level does the esophagus enter the diaphragm through the esophageal hiatus?

T11

What are the areas of anatomical narrowing of the esophagus?

Cricopharyngeus muscle; compression by the left mainstem bronchus and aortic arch; diaphragm

What is the Z line?

The transition of the distal 1 to 2 cm of esophageal mucosa to cardiac mucosa/junctional columnar epithelium

Identification of gastroesophageal junction (external):

The collar of Helvetius (loop of Willis) and the gastroesophageal fat pad

Identification of gastroesophageal junction (internal):

The squamocolumnar epithelial junction (Z-line), provided the patient does not have Barrett.

The transition from the smooth esophageal lining to the rugal folds of the stomach.

PHYSIOLOGY

What are the 6 events that occur during the oropharyngeal phase of swallowing?

Elevation of the tongue, posterior movement of the tongue, elevation of the soft palate, elevation of the hyoid, elevation of the larynx, tilting of the epiglottis

Typically present on the right secondary to the overabundance of structures in the midthoracic region of the left chest.

Treatment for a midesophageal diverticula:

If asymptomatic patient with inflamed mediastinal lymph nodes from tuberculosis or histoplasmosis, treat medically with antituberculin or antifungal agents; if diverticulum <2 cm, observe; if patient symptomatic or diverticulum >2 cm, perform diverticulopexy (suspend from thoracic vertebral fascia) and a long esophagomyotomy is indicated in patients with severe chest pain or dysphagia and a documented motor abnormality.

Treatment for epiphrenic diverticulum:

If diverticula <2 cm, perform diverticulopexy; in patients with severe chest pain, dysphagia, or a documented motor abnormality, perform long esophagomyotomy: if diverticulopexy, begin long esophagomyotomy at the neck of diverticulum and extend onto LES), and if diverticulectomy, perform esophagomyotomy on opposite esophageal wall, extending from the level of the diverticulum onto the LES; if large associated hiatal hernia, perform diverticulectomy, long esophagomyotomy, and repair of hiatal hernia

Point of potential weakness at the transition between the oblique fibers of the thyropharyngeus muscle and the horizontal fibers of the cricopharyngeus muscle

The surgical treatment of a Zenker diverticulum:

If diverticulum >3 cm—cricopharyngeal myotomy with diverticulectomy with TA stapler versus invert and perform diverticulopexy to precervical fascia If <2 cm—leave alone