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Gullet

Oesophagus



Where is the gullet located?

The gullet (oesophagus) is a 25 cm long muscular pipe linking the throat with the stomach. The upper part of the gullet begins at the larynx and is equipped with an important sphincter as an upward reflux of the chyme has to be prevented due to its close neighbourhood with the entrance to the windpipe (trachea). On the one hand, the sections of the constrictors of the oesophagus have a protective capacity and, on the other hand, they cause a narrow passage due to the muscular pressure that increases intermittently. Further down, the gullet is located behind the windpipe, the latter again being well-protected behind the breastbone. After about 9 cm down, the windpipe bifurcates into the two main bronchial branches, which flank the heart in front to the right and left. At this place, the aorta from the heart also crosses the left bronchial tube. This is a challenging area for surgery as the gullet also passes behind it, straight and downwards. After about 20 - 24 cm, it enters the abdominal cavity through a special opening in the diaphragm (hiatus). Shortly before the gullet passes into the stomach, there is another sphincter in its wall, which is meant to prevent the gastric acid from rising into the lower part of the gullet. Therefore, this region is a critical area of transition, and for this reason, the structure of the oesophageal wall must be explained.

The mucous membrane consists of an uncornified squamus epithelium, which by and by turns into the cylindrical epithelium of the stomach lower down. If gastric juice permanently flows back into the lower gullet, the mucous membrane of that section develops a disease (gastro-oesophageal reflux disease). Sometimes, the disease is so serious that the squamus epithelium turns into a cylindrical epithelium, thus becoming a kind of preliminary stage of a carcinoma. The next layer of the oesophageal wall consists of striated and rectous muscles, which take care of a quick onward transportation of the chyme. A very tight and smooth enveloping membrane (serosa), as found in the stomach and the bowel, is missing in the gullet. This accounts for the high demands on any kind of suture in this area as a further stabilizing layer of the wall is missing.




How does the gullet function?

The act of swallowing, in which the gullet has its role, is subject to a very complicated neurogenic regulation. During the act of swallowing, a peristaltic wave is triggered, causing the upper and lower sphincters to slacken at certain intervals to let the chyme pass through. If there are no swallowing acts, the regions of the sphincters belong to an area of high pressure making sure that neither food enters the windpipe nor gastric acid flows back into the lower oesophagus. The latter phenomenon is the most common "locking defect" of the lower sphincter and is due to a relaxation of the muscles in this region. It causes the gastro-oesophageal reflux disease, which however can be treated in most cases with acid-blocking medicaments.




Important diseases of the gullet

Among the benign diseases of the gullet are sacculations in the oesophageal wall, so-called diverticula (outpouchings), which are different depending on their place of origin. They typically develop before the upper or lower sphincter when functional disturbances result in abnormal high pressure in the gullet during swallowing. Most frequently (70%), the sacculations are found before the upper sphincter, which is called Zenker's diverticulum or cervical pulsion diverticulum. The upper sphincter closes too early during the act of swallowing and causes an acute excess pressure, which in the course of time leads to protrusions of the mucous membrane sticking out through the gaps in the muscle.

With nine new cases in 100'000 inhabitants per year, the carcinoma of the gullet is the most frequent surgical disease of the oesophagus. However, men are affected five times more often than women. Normally, these tumours originate in the cells of the squamus epithelium of the mucous membrane of the gullet and develop in 50% of the cases around the middle of the oesophagus. The main risk factor to develop such a tumour is most probably chronic abuse of alcohol and nicotine. There are also tumours, which develop in mucigenous cells (adenocarcinomas). Most of them are found in the transition area between the gullet and the stomach as they are caused by a continuous lesion of the mucous membrane through the reflux of acid from the stomach.




How do I recognize diseases of the gullet?

Patients with a Zenker diverticulum, but also patients with an oesophageal tumour, will at the beginning observe mainly disorders or complaints during the act of swallowing. These may occur in the form of a sensation of pressure behind the breastbone as if the food had got stuck in one place. Sometimes, food that has already been swallowed down is pushed up into the oral cavity again. Off and on, patients mention also complaints like a pungent burn when swallowing. Especially the Zenker diverticulum may also cause coughs, hoarsenes, and strong bad breath. The diverticulum can possibly be palpated as a small bulging and elastic tumour at the larynx, mostly on the left side.




Necessary clarifications and diagnostic possibilities

As soon as a patient notices problems while swallowing something, he should consult a specialist because these complaints may be caused by various diseases of the gullet. Therefore, the anamnesis by the doctor has special importance as in three quarters of the cases a diagnosis can already be made by exact questioning: Do the problems of swallowing depend on the consistency of the food? What is the time-related course of these problems after eating - intermittent, slowly increasing? What is the time-related connection between eating and the reflux of food? Are there previous diseases like reflux disease or stroke? Did the patient notice a strong loss of weight? After this, an exact inspection of the mouth and throat of the patient should be made, and the throat should be palpated for enlarged lymphatic nodes or changes in the soft tissue. Depending on the suspected diagnosis, an endoscopy of the gullet is carried out as well as a biopsy of suspicious places of the mucous membrane. Additionally, especially in the case of diverticula, an X-ray examination of the gullet with liquid contrast medium is made, which may show movement disorders of the oesophageal wall. If the disease is caused by a tumour, it might be necessary still to carry out a CT or MRI examination to be able to assess its extension and its location within the thorax. Possibly, an examination by an ENT-specialist could become necessary; he has to check the functional ability of an important nerve in the region of the larynx. Depending on the previous diseases and the age of the patient, ultrasound examinations of the heart and a pulmonary function test are also carried out.




How can a Zenker diverticulum and a carcinoma of the oesophagus be treated?

In case of a Zenker diverticulum, surgery is indicated, independent of the intensity of the patient's pains as the rate of complications is small. For the operation, the patient lies on his back and is covered in such a way that the left side of the throat is well accessible. A skin incision of 6 cm is made lengthwise at the side and to the left of the larynx. After careful preparation, the left thyroid lobe is mobilized, so that it can be folded up, making a very important nerve clearly visible which runs here. Now, the diverticulum is dissected, exposed, and removed. Then, this place of the gullet is closed again. At the end, a special muscle transection is carried out at the upper sphincter of the gullet, exactly at the place where the acute excess pressure during swallowing is found. This causes the resistance against swallowing in this area to decrease and aims at avoiding the reoccurrence of a diverticulum.

The surgical indication in the case of a carcinoma of the gullet depends on the stadium of the tumour and on its localisation: As 50% of the tumours develop in the middle third of the gullet, it has to be carefully clarified what local relation to the bronchial system it has, as the latter is very close. Therefore, a division into two groups is made here for therapeutic reasons, namely whether the tumour is found above or below the bifurcation of the pulmonary branches:

  1. If the carcinoma is found above it and is still very small, immediate surgery is indicated. If it is bigger, the tumour is first pre-treated with radiochemotherapy and then operated.
  2. Below the bifurcation of the big pulmonary branches, even a big tumour can be operated directly and without additional therapy. This operation is called subtotal oesophagectomy and involves the partial removal of the gullet and of the cardia including important lymphatic nodes. This is always a two cavity intervention, i.e. both abdominal cavity and thorax have to be opened.

For the operation, the patient lies on his back. The incision of the skin is made from the lower end of the breastbone down to the navel. Then, the abdominal wall is severed layer by layer and the opened abdominal cavity is carefully palpated by the surgeon's hand. Doing this, he pays special attention to enlarged lymphatic nodes around the aorta, to the surface of the liver and, if possible, to the extension of the tumour. Now follows the dissection and the extensive mobilization of the stomach, of the lower region of the gullet, and of the duodenum. In a second step, the thorax is opened in front to the right, at about three finger's breadth from the nipple area. Then, the pleura is severed to expose the tumour in the region of the gullet. After some further preparation, the tumour is removed along with the lymphatic nodes and the surrounding fatty tissue. Also part of the gullet is removed above the tumour to secure a sufficiently safe distance from it. The tissue is examined by a pathologist still during the operation to make sure that the gullet was severed in a healthy area. Now follows the formation of the gastric tube, which is later pulled up into the thorax to bridge the defect of the gullet. For this reason, the junction between oesophagus and stomach is first removed at a length of about 8 cm at the area of the cardia, so that a narrow pipe is formed here. The outlet of the stomach (pylorus) is surgically widened as it otherwise would become a too narrow passage due to the unavoidable dissection of an important nerve. The cardia is put into a plastic bag and later pulled up into the thorax. To make the new suture between the stump of the gullet and the gastric tube possible, another skin incision at the left side of the gullet is necessary to safeguard the best possible view to the surgeon. In this phase, the patient receives a thick gastric tube, which is inserted through the nose and the throat to secure a better support of the gastric stump. The stump of the gullet is marked with two strong supporting retention stitches. They are then fixed to the prepared gastric tube in the plastic bag, which is given manual support while being pulled up into the thorax. There, the plastic bag is removed, and the new gastric tube receives an opening in the area of the back wall, so that the new connecting suture (anastomosis) to the gullet can be made there. This is done by hand or with the help of a modern stapling device. Finally, a drain is laid in the area of the anastomosis, and all incisions are closed layer by layer. It may also become necessary to lay a drain of the thorax as the lung may have possibly been injured at one side. The most important postoperative complication is a leakage in the area of the anastomosis between gullet and new gastric tube. This is why the patients unfortunately have to go without food and drink for several days after the operation.




What happens after the treatment?

In some rare cases, the patient has to be artificially ventilated at the intensive care unit for several hours after the operation. As a rule, a differentiated infusion and analgesic therapy is carried out at the intensive care unit. Laboratory values are regularly controlled. At the beginning, the patient is not allowed to eat or drink for several days, so that the new connecting suture is not put into danger. If necessary, the impermeability of the suture is tested by a contrast medium examination after about four days. Then, the patient is allowed to drink tea and bouillon in small sips. On the 5th day, the skin clips at the neck are removed. This is followed by a cautious development of the diet, beginning with purees and ending with a light full diet. Assisted by a nutritional counsellor, every patient learns already in hospital that he has first to take many small meals during the day until the act of swallowing through the "new" gullet passage starts to function well. The drainage is removed relatively late, namely only when the surgeon can be quite sure that the new suture is absolutely impermeable. Finally, the skin clips of the abdomen are removed on the 10th day.

All patients can take part in an intensive aftercare programme in the time to come. Its main objective is to recognize a recurrence of the tumour in good time by taking regular tissue samples. As a long-term consequence of an excision of the oesophagus, a stricture at the place of the new suture may develop, causing a disturbance of the passage of the food. To dilate this stricture, a gradual widening of the tissue with the help of conical rubber catheters is carried out (under sedation or narcosis) until a good passage of the food is again achieved.




History

In the middle of the 18th century, the then world-famous surgeon Herman Boerhaave from Leiden received an emergency call to attend the admiral of the Dutch fleet, who suffered from extreme pain in the chest and apparently was about to die without any previous illness. First, Boerhaave found out that the admiral had attended a gigantic guzzling the previous day. To alleviate himself after such a huge meal, he had taken some ipecac as it was usual at that time. When this was not successful, he drank several cups of olive oil and beer. When he tried to vomit, the admiral suddenly felt a raging pain in his chest and died a short while later, without the famous surgeon having been able to help him. Already at that time, Boerhaave, who was a vigorous champion of autopsy as he always tried to prove the connection between a clinical symptom and the injury of an organ, was surprised by the findings: He found a gullet with a hole in the lower third, through which food had been discharged into the thorax. He called it "Boerhaave syndrome", a clinical term still used today. In spite of antibiotics and intensive care, the disease is still so grave that, without surgical intervention, up to 50% of the affected patients soon die from the complications.

The gullet, which connects throat and stomach and serves as the transport route for the food, passes the thorax in its complete length, which is actually the operative field of heart, vascular, or thoracic surgeons. However, because of its anatomical structure and because of its surgical techniques, it belongs to the digestive system and therefore into the hands of an abdominal surgeon. In spite of it, the thoracic surgeons were really the first ones to develop new techniques for oesophageal surgery. Franz Torek is regarded as the pioneer in the field, who succeeded in removing a tumour from the second third of the gullet for the first time - under primitive conditions when looking at it from today. He successfully bridged the resulting gap with a rubber tube: In the upper section, he joined the gullet and the tube, conducting it to the outside through the skin. The end of the tube was then again passed through the abdominal wall and sutured to the stomach. Apart from the stopgap measure with a rubber tube, the essential principles of the old surgical technique have been preserved until today. The only difference is that the defect is today bridged by pulling up the stomach or by a special connecting piece made from the small or large bowel. Almost every operation of the gullet is an "intervention in two cavities", which means that the patient's abdominal cavity and the thorax have to be opened in order to be able to reach the important structures. Many technical details were enormously improved, especially the suture material, the use of linear stapling devices, but also a sophisticated support by ultra-modern anaesthesia and intensive care. Without them, good results in this field could not be achieved even today.