Behind the Knife ABSITE 2026: Comprehensive Review of Esophagus Anatomy, Pathology, and Management

Esophageal Anatomy and Physiology

• 💡 The esophagus lacks a serosa, possessing only mucosa, submucosa, and muscularis propria layers.
• 🎯 Blood supply is segmental: inferior thyroid artery for cervical, direct aortic branches and inferior phrenic arteries for thoracic, and left gastric artery for abdominal portions.
• 🔑 The upper esophageal sphincter is the cricopharyngeus muscle, innervated by the recurrent laryngeal nerve.
• 📌 Killian's triangle, located between the cricopharyngeus and inferior constrictor muscles, is a weak spot prone to Zenker's diverticulum.

Esophageal Perforation Management

• ⚠️ Perforations can result from trauma, iatrogenic injury (e.g., EGD, dilation), wretching, malignancy, or chemical ingestion.
• 🔍 Diagnosis typically starts with a chest X-ray (showing effusion, pneumomediastinum, etc.) and is confirmed with a contrast esophagogram, using water-soluble contrast first, followed by dilute barium if needed.
• 🎯 The most common perforation site is the distal esophagus (left posterolateral, 2-3 cm above GE junction), while the most common iatrogenic site is the cricopharyngeus.
• 🏥 Treatment principles include aggressive resuscitation, empiric antibiotics, and surgical options ranging from drainage for contained leaks to primary repair (thoracotomy for thoracic perforations) or esophagectomy for severe cases.
• 💡 For isolated cervical perforations, open exploration and drainage are common; for thoracic perforations, primary repair with a well-vascularized flap is preferred if the patient is stable.

Esophageal Motility Disorders

• ⚡ Achalasia involves incomplete LES relaxation with aperistalsis or hypotonic contractions, characterized by a "bird's beak" sign on barium swallow.
• 🔬 Pseudoachalasia must be excluded, as it is caused by malignancy.
• 🧩 Treatment for achalasia includes minimally invasive Heller myotomy with fundoplication or POEM (peroral endoscopic myotomy), though the latter carries a higher risk of GERD.
• 📊 Other motility disorders like isolated hypertensive LES, diffuse esophageal spasm, and nutcracker esophagus are diagnosed via manometry and treated primarily with calcium channel blockers, nitrates, or myotomy for refractory cases.

Esophageal Diverticula

• 🎯 Zenker's diverticulum (false pulsion diverticulum) occurs in the pharynx due to cricopharyngeus dysfunction; treatment involves endoscopic division of the UES for >3 cm or open myotomy for <3 cm.
• ⚠️ Epiphrenic diverticula (pulsion) are associated with dysmotility and treated with diverticulectomy and myotomy.
• 🧩 Mid-thoracic diverticula are typically traction diverticula, often linked to inflammation (like TB) or motility disorders, treated with VATS diverticulectomy and myotomy.

Barrett's Esophagus and Tumors

• 📈 Barrett's esophagus is intestinal metaplasia of the lower esophagus due to chronic GERD, increasing adenocarcinoma risk.
• 🔍 Surveillance involves EGD with biopsies every 1-3 years. Low-grade dysplasia requires repeat biopsy in 6 months; high-grade dysplasia warrants confirmation and potentially endoscopic mucosal resection (EMR).
• 💎 Esophageal leiomyomas are the most common benign esophageal tumors, typically treated with endoscopic enucleation for tumors <5 cm or VATS/laparoscopy for larger ones; biopsies are avoided to prevent scarring.
• ⚠️ Esophageal and GE junction cancers (squamous cell or adenocarcinoma) require thorough staging (endoscopy, EUS, CT, PET-CT).
• 🏥 Management depends on stage, with T1A/high-grade dysplasia often treated with EMR, T1B generally requiring esophagectomy, and locally advanced disease treated with neoadjuvant chemoradiation followed by surgery.
• 🚀 Surgical approaches include transthoracic (Ivor-Lewis, McKeown) and transhiatal esophagectomies, with the stomach as a common conduit, preserving the right gastroepiploic artery.
• 💡 Colon interposition or jejunal free flap are options if gastric conduit is not feasible.
• ⚠️ Tylosis is an autosomal condition with a high risk of esophageal squamous cell cancer, requiring annual screening.
• 🩺 Vancomycin-resistant enterococci (VRE) is associated with head/neck, esophageal, and pancreatic cancers.
• 🍽️ For patients with dysphagia and malnutrition undergoing neoadjuvant therapy, a jejunostomy tube is preferred over a PEG tube to preserve the gastric conduit.