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Clinical anatomy of the esophagus
The esophagus - one of the most important organs of the digestive system, is a natural continuation of the pharynx, connecting it to the stomach. It is a smooth, stretching fibro-muscular mucous tube, oblate in the anteroposterior direction. The esophagus begins behind the cricoid cartilage at its lower edge, which corresponds to the level VI-VII of the cervical vertebrae and ends in the cardia of the stomach at the level of the XI thoracic vertebra. The length of the esophagus depends on age, gender and constitution, averaging 23 - 25 cm in an adult.
For most of its path, the esophagus is located posterior to the trachea and anterior to the spine in a deep cervical and thoracic mediastinum. Behind the esophagus between the fourth leaf of the fascia, enveloping the esophagus and the fifth leaf (prevertebral fascia), there is a retrovisceral space made of loose fiber.
This space, which allows the esophagus to expand freely during the passage of food, is clinically important, because is a natural way to rapidly spread infection with damage to the esophagus.
In its course, the esophagus deviates from a straight line, enveloping the aorta in the form of a gentle spiral. On the neck, located behind the trachea, it protrudes somewhat to the left because of it and in this place is most accessible for surgical intervention. At the border of the IV and V thoracic vertebrae, the esophagus intersects with the left bronchus, passing behind it, then deviates slightly to the right and before perforating the diaphragm again lies to the left of the median plane. At this point, the thoracic aorta is located much to the right and posterior to it.
Three sections are distinguished in the esophagus: cervical, thoracic and abdominal (Fig. 5.1). The border between the cervical and thoracic esophagus passes at the level of the jugular notch of the sternum in front and the gap between the VII cervical and I thoracic vertebrae posteriorly. The thoracic, the longest esophagus, has a lower diaphragm border, and the abdominal is located between the diaphragm and the cardia of the stomach. The length of individual parts of the esophagus in adults is: cervical - 4.5-5 cm, chest - 16-17 cm, abdominal - 1.5-4.5 cm.
Three anatomical and two physiological constrictions are distinguished in the esophagus (Tonkov V.N., 1953). However, in clinical terms, the three most pronounced constrictions are important, the origin of which is associated with a number of anatomical formations, as well as the distances to these constrictions, which are favorite places for the delay of foreign bodies, from the edge of the upper incisors (Fig. 5.2).
The first, most important for clinical practice, narrowing corresponds to the beginning of the esophagus. It is due to the presence of a powerful muscle pulp that performs the function of the sphincter. One of the first esophagoscopists, Killian, it was called the "mouth of the esophagus." The first narrowing is located at a distance of 15 cm from the edge of the upper incisors. The origin of the second narrowing is associated with pressure on the esophagus of the left main bronchus located in front and the aorta lying on the left and behind. It is at the level of bifurcation of the trachea and IV thoracic vertebra. The distance from the edge of the upper incisors to the second narrowing is 23-25 cm. The third narrowing of the esophagus is located at a distance of 38-40 cm from the edge of the incisors and is caused by the passage of the esophagus through the diaphragm and into the stomach (gastroesophageal passage).
The aforementioned narrowing of the esophagus, especially the first, making it difficult to hold the tube of the esophagoscope and other endoscopic instruments, may be the place of their instrumental damage.
In the cervical and abdominal regions, the lumen of the esophagus is in a collapsed state, and in the thoracic region yawns, due to negative pressure in the chest cavity.
Three layers are distinguished in the wall of the esophagus, having a thickness of about 4 mm. The muscle layer is formed by external longitudinal and internal circular fibers. In the upper esophagus, the muscle layer is similar to the muscle layer of the pharynx, and is a continuation of its striated muscle fibers.
In the middle section of the esophagus, the striated fibers are gradually replaced by smooth ones and in the lower section the muscle layer is represented only by smooth fibers. Morphological studies F.F. Sachs et al. (1987) showed that the inner ends of the longitudinal muscle fibers of the outer layer go deep into the walls, where they, as if wrapping the esophagus, form a circular layer. As a result of the combination of circular and longitudinal muscles in the area of transition of the esophagus into the stomach, a cardia sphincter is formed.
The submucosal layer is represented by a well-developed loose connective tissue, in which numerous mucous glands are located. The mucous membrane is covered with a multilayer (20 - 25 layers) squamous epithelium. Due to the pronounced submucosal layer, loosely connected with the muscle, the mucous membrane of the esophagus can gather in folds, giving it a star-like appearance on transverse sections.
With the passage of food and an endoscope (esophagoscope), the folds straighten out. The absence of folds in a separate section of the esophagus may indicate the presence of a pathological process (tumor) in the wall.
Outside, the esophagus is surrounded by adventitia, which consists of loose fibrous connective tissue enveloping the muscular layer of the esophagus. Some authors consider it as the fourth (adventitious) layer of the esophagus. Adventitia without clear boundaries passes into the tissue of the mediastinum.
Blood supply. Blood supply to the esophagus is carried out from several sources. Moreover, all esophageal arteries form among themselves numerous anastomoses. In the cervical region, the esophageal arteries are branches of the lower thyroid artery, in the thoracic - branches extending directly from the thoracic aorta, and in the abdominal - from the diaphragmatic and left gastric arteries. Esophageal veins divert blood: from the cervical to the lower thyroid veins, from the thoracic to the unpaired and semi-unpaired veins, from the abdominal to the coronary vein of the stomach, which communicates with the portal vein system. Compared with other parts of the gastrointestinal tract, the esophagus is characterized by a very developed venous plexus, which, in some pathological conditions (portal hypertension), is a source of massive and dangerous bleeding.
Lymphatic system. The lymphatic system of the esophagus is represented by a superficial and deep network. The surface network originates in the thickness of the muscle wall, and the deep is located in the mucous membrane and submucosal layer. The outflow of lymph in the cervical esophagus goes to the upper paratracheal and deep cervical nodes. In the thoracic and abdominal regions, lymph is sent to the lymph nodes of the cardial part of the stomach, as well as to the paratracheal and parabronchial nodes (Zhdanov D.A., 1948).
Esophagus innervation. The esophagus is innervated by the branches of the vagus and sympathetic nerves. The main motor nerves of the esophagus are considered parasympathetic branches emanating from two sides of the vagus nerves. At the level of the bifurcation of the trachea, the vagus nerves form the anterior and posterior peresophageal plexuses, which are connected by numerous branches to other plexuses of the chest organs, especially the heart and lungs.
The sympathetic innervation of the esophagus is provided by branches from the cervical and thoracic nodes of the border trunks, as well as celiac nerves. Between the branches of the sympathetic and parasympathetic nerves that innervate the esophagus, there are numerous anastomoses.
Three closely interconnected plexuses are distinguished in the nervous system of the esophagus: superficial (adventitious), intermuscular (Auerbach), located between the longitudinal and circular muscle layers and submucosal (Meissner).
The mucous membrane of the esophagus has thermal, pain and tactile sensitivity. All this indicates that the esophagus is a well-developed reflexogenic zone.
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