SURGICAL ANATOMY & LYMPHATIC

DRAINAGE OF ESOPHAGUS
Presentation by
Dr.P.Rajashekar
PG in General Surgery

Under the guidence of

Dr.P.Mythili,MS
Dr.O.Shankar,MS
Dr.J.Yadagiri Rao,MS

OSMANIA GENERAL HOSPITAL/OSMANIA MEDICAL COLLEGE,

HYDERABAD
AUGUST 5th ,2005
ESOPHAGUS-THE PATHWAY OF
SURVIVAL

The esophagus,lean,erect and

proud,has admitted
no challenge to leaven its name
as did the
“ventriculus” to become the
stomach.
R.G.ELMSIE
Embryology of Esophagus
Embryology of Esophagus
Embryology of Esophagus
Congenital Anomalies of esophagus
Congenital Anomalies of Esophagus
Congenital Anomalies of Esophagus
Normal Anatomy of Esophagus
Relations of Cervical Esophagus
Relations of Thoracic Esophagus
 Surgical considerations of thoracic
segment

Lesions of the upper half of the thoracic esophagus
should be explored through a right thorocotomy to avoid
technical problems with the aortic arch.

Lesions of lower half--right or left thorocotomy.

Esophageal triangle -The floor is formed by the left
mediastinal pleura beneath which the esophagus is
located.

Lower end of thoracic esophagus covered by right pleura
may be found in the Triangle of Truesdale.This proximity
of the right pleura to the hiatus introduces risk of
pneumothorax during abdominal operations on the
hiatus.
Relations of Abdominal Esophagus
Structure of Esophageal wall
Structure of Esophageal wall
Anchoring structures of Esophagus
Blood supply of Esophagus

Fourth branchial arch is the

most important.

Four pathways
Inferior thyroid artery
Esophageal branches of
descending aorta,
Left gastric artery,
Splenic artery.

The segment of esophagus
between the jugular notch & the
aortic notch is the most avascular
segment is a MYTH.
Blood supply of Esophagus

Poor technique,
not poor blood supply
is responsible for the
leakage.
Blood supply of Esophagus
Venous Drainage of Esophagus
Venous Drainage of Esophagus

Lymphatic Drainage of
Upper 2/3rds of esophagus is to
Esophagus the systemic veins & that of the
lower1/3rd is to the portal
system.

No true water-shed separates.

The veins of gastroesophageal
junction & abdominal esophagus
form an important
communication between the
portal & azygous system.

In portal hypertension this is the
most common site of bleeding.
Lymphatic Drainage of Esophagus

Lympatics remain “terra incognita”.

Form plexuses in the
muucosa,submucosa,muscularis and
adventitia.

Lymphatics run longitudinally.

Collecting trunks originate in the
submucosa & empty into the nearest lymph
node.

Upper 3rd drains to the internal
jugular,cervical,& supra clavicular areas.

Upper &middle thirds,lymph drains to the
peritracheal,hilar,subcarinal &
paraesophageal,periaortic,& pericardial
regions.

The distal 3rd,lymph drains to the lesser
curvature,left gastric,& celiac axis.
Lymphatic Drainage of Esophagus

Initial lymphatics appear to
originate exclusively in the
region between the mucosa &
submucosa to form
longitudinally arranged
collecting channels in the
submucosa.

Different from the esophageal
veins ,all the channels
possess valves.
Lymphatic Ducts & Lymph nodes of
Esophagus

Interconnections between
the mucosal and submucosal
networks essentially create
one large system.

This mucosal or submucosal

network drains via lymph
channels to the adventitia
and periesophageal lymph
nodes.
Lymphatic Ducts & Lymph nodes of
Esophagus

The periesophageal
lymph nodes form
the groups-basis for
the numbered
system of
mediastinal lymph
nodes and the
Classification of the
TNM Staging.
Direction of Lymph flow

Metastases involve
paratracheal nodes on
the right more often
than those on left.

Posterior hilar nodes

are more often
involved than other
nodes at the carina.
Lymphatic Pathways in Esophageal
wall

Lymph flows in the
submucosal channels
longitudinally.

“Silent enemy below.”

For better results

esophageal resection
from 8-10cm above &
below the tumor is
mandatory.
 Esophageal cancer and Lymphatics

Neighbouring and distant nodes may be involved in
the spread of cancer.

“Skip areas“ of as many as 8cm between involved
lymphnodes may be encountered.

“Leap frog phenomenon”.

Concept of Visali & Grimes- en bloc resection.

In malignancies of GE junction ,10cm of lower
esophagus & 2/3rd of stomach should be resected-
De Meester.

Troisier sign.
 Lymphatic Drainage of Esophagus
“Leap frog phenomenon”
(Generalities of unpredictable drainage)

Cancer of upper esophagus can metastasize to the superior
gastric nodes.

Lymph from the upper esophagus drains mostly into the
cervical & paratracheal nodes.

Cancer of the lower esophagus can metastasize to the
superior mediastinal nodes.

Lymph from the lower thoracic & abdominal esophagus
drains preferentially into the retrocardiac & celiac nodes.
Thoracic duct – the principal
collecting lymphatic vessel

Lies at the level of L2
vertebra

At T5 vertebra it
crosses behind the
esophagus to left

Drain into internal
jugular vein near its
junction with the left
subclavian vein.

Chylothorax

Chylous ascites
Lymphatic Drainage of Esophagus

Lympatics remain “terra incognita”-

unpredictable and peculiar
Lymphatic Drainage of Esophagus
“Leap frog phenomenon”
(Generalities of unpredictable
drainage)

Cancer of upper esophagus can
metastasize to the superior gastric
nodes.

Lymph from the upper esophagus
drains mostly into the cervical &
paratracheal nodes.

Cancer of the lower esophagus can
metstasize to the superior
mediastinal nodes.

Lymph from the lower thoracic &
abdominal esophagus drains
preferentially into the retrocardiac &
celiac nodes.
Nerve supply of Esophagus
Intrinsic nerve supply
Meissner’s plexus in submucosa
Auerbach’s plexus in between the
circular & longitudinal
muscularis externa

Extrinsic nerve supply

THREE sources-
Cerebrospinal
Sympathetic and
Parasympathetic(Vagal)
 “Be careful,do not permit saliva and food material to
take the wrong way down to the air passages.
Be careful with your water-tight anastamosis.
Be careful with your technique.
Don’t forget to suture the strongest layers of my
wall,the mucosa and the submucosa,and consider both
as one layer.”
“Please protect my mucosa,which is easily injured by
acid,and,
If you remember all of this,
you and your patient will be happy.”