Esophagus

• No serosa; mucosa is strongest layer (in small bowel, submucosa is strongest)
• Central input initiates swallow which elicits primary peristalsis, distension then elicits secondary peristalsis.  Sphincters are contracted at rest. Normal LES tone = 15-25 mmHg (length 4cm)
• Swallowing order of events: soft palate closes nasopharynx, larynx up, larynx closes, UES relaxes, pharyngeal contraction
• Zencker's diverticulum: occurs in Killian's triangle, due to increase pressure (pulsion tic), need myotomy and diverticulectomy/pexy. Approach via left cervical incision.
• Paraesophageal hernia: always operate since risk of incarceration, strangulation
• Diffuse esophageal spasm: medical treatment (Ca channel blockers)
• Esophageal rupture (Boerhaave's) key to survival is early Dx (85% dead if >36hrs)
• Achalasia: decreased ganglion cells in Auerbach's plexus, absence of peristalsis, and esophageal dilation. Bird's beak on Ba swallow; manometry shows no peristalsis, high LES pressures/failure to relax. Rx: laparoscopic or thorascopic Heller myotomy
• Barrett's esophagus: metaplasia from squamous to columnar cells. 1-2% get adenocarcinoma (30-100x risk). P53 associated (tumor supressor gene)
• Achalasia and chemical ingestion also increase risk of esophageal CA
• AdenoCA now #1 esophageal cancer over squamous (also true for lung CA)
• R gastroepiploic artery is main supply to stomach when used to replace esophagus
• Leiomyoma: if symptomatic or >5cm, excise by enucleation via thoracotomy (R if middle, L if lower esophagus). Do not biopsy on EGD.

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