Venous outflow from the chest esophagus is carried out. Abdominal diver of esophageal

• The esophagus is a hollow muscle, lined with an inside with a mucous membrane, a tube connecting the throat with a stomach.
• It is an average length of 25-30 cm in men and 23-24 cm in women
• It begins at the lower edge of the handberry cartilage, which corresponds to C vi, and ends at the level of TH XI with the transition to the cardiac part of the stomach
• The wall of the esophagus consists of three shells: mucous (Tunica Mucosa), muscular (Tunica Muscularis), connecting shell (Tunicaadventicia)
• Abdominal The esophagus is covered outside serous sheath, which is a visceral leaflet of peritoneum.
• In its go, it is fixed to the surrounding organs with connecting hills containing muscle fibers and vessels. Has several bends in the sagital and frontal planes

1. the cervical - from the lower edge of the pisteward cartilage at the C vi level to the tier cut at the level of the TH I- II. Its length is 5- 6 cm;
2. the thoracic dilution of the jugular cutting to the place of passage of the esophagus through the feed-aqueous hole of the diaphragm at the level of the TH x xi, its length is 15-18 cm;
3. abdominal department from the esophageal hole of the diaphragm to the place of transition of the esophagus in the stomach. Length of its 1-3 cm.

According to the BROMBART classification (1956), 9 segments of the esophagus are distinguished:

1. tracheal (8-9 cm);
2. retropericardial (3 - 4 cm);
3. aortic (2.5 - 3 cm);
4. nadadiaphragmal (3 - 4 cm);
5. bronchial (1 - 1.5 cm);
6. intraphragmal (1.5 - 2 cm);
7. aortic-bronchial (1 - 1.5 cm);
8. abdominal (2 - 4 cm).
9. podbronchial (4 - 5 cm);

Anatomical esophageal narrowings:

• Pharingeal - in the field of transition of the pharynx in the esophagus at the level of VI-VII cervical vertebrae
• Bronchial - in the field of contact of the esophagus with the rear surface of the left bronchus at the level of IV-V breast vertebrae
• The diaphragmal - at the site of the passage of the esophagus through the diaphragm

Physiological esophageal narrowings:

• Aortic - in the area where the esophagus goes to the arc of the aorta at the level of TH IV
• Cardual - when moving the esophagus to the cardiac part of the stomach

The endoscopic sign of the esophageal-gastric transition is the Z-line, which is located at the rate at the level of the esophageal hole of the diaphragm. The line is the transition of the epithelium of the esophagus in the gastric epithelium. The mucule of the esophagus is covered with a multilayer flat epithelium, the stomach mucosa is covered with single-layer cylindrical epithelium.

Figure shows an endoscopic pictureZ-lines

The blood supply to the esophagus in the cervical department is carried out by branches of the lower thyroid arteries, the left upper thyroid artery, connectible arteries. Verkhnegruda Division is branched by branches of lower thyroid artery, connectible arteries, right paral-free trunk, right vertebral artery, the right intrathless artery. The average breeding department feeds bronchial arteries, esophageal branches of the chest aorta, 1 and 2 intercostal arteries. Blood supply Nizhne breast Department Provided by esophageal branches of the chest aorta, its own esophageal, departing from the aorta (TH7-TH9), branches of the right intercostal arteries. The nutrition of the abdominal diet of the esophagus is carried out by the esophageal-frame branches of the left gastric, esophageal (from the chest aorta), the left lower diaphragmal.

The esophagus has 2 venous plexuses: the central in the sublifted layer and surface parasepal phasezophageal. Blood outflow from cervical department The esophagus is carried out through the lower thyroid, bronchial, 1-2 intercostal veins in Unnamed and Upper Hollow Vienna. Blood outflow from the chest department occurs on the esophageal and intercostal branches in the unpaired and semi-head veins, then into the upper hollow vein. From the lower third of the esophagus - through the branches of the left gastric vein, the upper branches of the spleen vein in the portal vein. Part of the left lower diaphragmal veins in the lower hollow vein.

Fig. Venous system of esophageal

The lymphotok from the cervical esophageal is carried out in the paratroheal and deep cervical l / y. From the Uppergrochny Department - to the paratrahelny, deep cervical, tracheobronchial, paravertebral, bifurcational / y. The outflow of lymphs from the average moral department of the esophagus is carried out to the bifurcation, tracheobrocheial, rear media, inter-phaseortopic and paravertebral / y. From the lower third of the esophagus - to the near-cardial, upper diaphragmal, left gastric, gastrointestinal, curious and hepatic l / y.

Fig. Lymph nodes of the esophagus

Sources of the innervation of the esophagus are wandering nerves and border trunks of sympathetic nerves, the main role belongs to the parasympathetic nervous system. Preggonary neurons of efferent branches wandering nerves are in the dorsal motor nuclei of the brain stem. Efferent fibers Form the front and rear esophageal plexes and penetrate the organ of the organ, connecting with the intramurally ganglia. Between longitudinal and circular muscular layers The esophagus is formed by Auerbakhovo's plexus, and in the sublifting layer - the nervous plexus of Maissener, in the ganglia of which are peripheral (postganglyonary) neurons. They have a certain stand-alone function, and a short nervous arc can be closed at their level. The cervical and uppergrochny departments of the esophagus are innervated by the branches of returning nerves forming powerful plexuses, innervating the heart and trachea. In the average germ, the esophagus in the front and rear nerve plexuses also includes branches of the border sympathetic barrel and large ventricular nerves. In the Nizhnegrudny Department of the esophagus of plexuses, trunks are remedied - right (rear) and left (front) wandering nerves. In the nadiaphragmal segment of the esophagus, the wandering trunks are closely adjacent to the wall of the esophagus and, having a spiral stroke, branch: left - on the front, and the right - on the rear surface of the stomach. Parasympathetic nervous system carries out regulation motor function esophagus reflexively. Afferent nerve fibers From the esophagus join the spinal cord at the THV-VIII level. The role is sympathetic nervous system In the physiology of the esophagus, it is not finally clarified. The mucous membrane of the esophagus has thermal, pain and tactile sensitivity, and the most sensitive zones of the pharyngeal and esophageal and gastric transition are the most sensitive.

Fig. Innervation of the esophagus

Fig. The diagram of the internal nerves of the esophagus

Functions of the esophagus include: Motor-evacuation, secretory, locking. The cardia function is regulated by the central way (pharyngeal cardial reflex), autonomous centers laid down in the cardia itself and the distal esophagus, and also with the help of a complex gumoral mechanismwhich is involved in numerous gastrointestinal hormones (gastrin, cholecystokininin-panopozimine, somatostatin, etc.), the lower esophageal sphincter is usually in a state of constant reduction. Swallowing causes the occurrence of a peristaltic wave, which leads to short-term relaxation of the lower esophageal sphincter. Signals, initiating the peristaltics of the esophagus, are generated in the dorsal motor nuclei of the wandering nerve, are then carried out through long preggaeer neurons of the wandering nerve to short postganglyonary brake neurons located in the field of the lower esophageal sphincter. The brake neurons during stimulation are isolated a vasoactive intestinal peptide (VIP) and / or approach Nitrogen, which cause relaxation of the smooth muscles of the lower esophageal sphincter using intracellular mechanisms with the participation of cyclic adenosine monophosphate.

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The thoracic dilution of the esophagus together with the downward aorta takes the entire space of the rear media. In accordance with the floors of the rear mediastum, the esophagus is divided into three parts - a third. The top third is nadortal, the average third is behind the arc of the aorta and trachea bifurcation, the lower third is behind the pericardia. The complex topographic relations of the esophagus with the rear media authorities affect its position and determine the I AK called the bends of the esophagus. Distinguish bends in sagittal and frontal planes. In the mediastia, the esophagus is part of the midline, at the level of the 3rd and 4th breast vertebrae, to the left is deflected. In the middle third at the level of the 5th breast vertebra, the esophagus rejected again to the midline and even somewhat goes to the right, this bending is determined by the arc aorta and extends to the 8th breast vertebra. In the lower third of the 8th to the 10th breast vertebrae, the esophagus deviates the kleons from the aorta and left by 2-3 cm. The degree of bends of the esophagus is expressed individually and depends on the type of physique. In children early age The bends are poorly expressed. The bends of the esophagus determine the choice of operational) access to it on different levels. For operations in the middle I region, access is used in the 4th and 5th intercourse on the right. During operations in the lower segment, access to the 7th interchanger on the left, or thoracolaparotomy is used.

The stability of the position of the esophagus in the mediastum is ensured by the esophagus of the ligament apparatus that locks it at different levels. The following esophageal ligaments are distinguished: i) esophageal-tracheal (upper third); 2) a bunch, suspended esophagus and aortic arc to the spine, - a bunch of Rosen-I Ala - Ansersov (average third); 3) esophageal-bronchial; 4) esophageal-aortic; 5) Inter-light bundles of frost- (Avwin, fixing the esophagus in the aperture hole.

The esophagus has three narrowings: pharyngeal, aortic and diaphragmal. The narrowing of the esophagus can be an inclusion foreign languagesTraumatic damage to the esophagus occurs more often in places of narrowing, including in chemical burns. In places of narrowing, the esophageal tumors are more often localized.

The relationship between the esophagus with mediastinal pleutra has especially great importance With the operations on the esophagus. They are unequal throughout the intrabriety of the esophagus. Above easy root The right pleura directly covers the esophagus in a limited space from 0.2 to 1 cm, and the left mediastinal pleurra forms a fold, which is embedded between the left connector artery and the esophagus, which can reach the walls of the esophagus. At the level of the roots of the lungs, the esophagus is separated from the mediastinal pleura: the unpaired vein, on the left - the aorta. Most of the lung roots, the right pleura in most cases covers not only the lower side wall of the esophagus, but also its back wall, forming a pleural pocket between the spine and the esophagus. The bottom of this pocket comes to the left for the middle line of the body.

Arterial blood supply to the esophagus receives from different sources, depending on the region of its position. The cervical department and the upper third of the breast range from the bottom of the thyroid artery. Average third - from bronchial arteries. The average and lower warming of the esophagus is bustling from the aorta, it complicates the release of the esophagus when it is removed. The abdominal department of the esophagus is powered by the left gastric artery. The venous outflow from the esophagus comes from the upper 2/3 in the pool of the upper hollow vein, from the lower third and the abdominal department - to the portal vein. Thus, a natural portocular anastomosis is formed in the lower segment of the esophagus, which acquires great importance in the portal hypertension syndrome. In this case, the veins of the esophagus expand significantly and become the paths of collateral outflow from the Pool Vienna basin. In the underlying layer, varicose nodes are formed, which, with a sharp increase in portal pressure, are destroyed and become the source of hazardous bleeding.

In the rear mediastum, the esophagus arises complex relationships with wandering nerves. On the rear surface of the root of the light wandering nerves of Gaya on bronchial and esophageal branches. The latter form the esophageal plexus - another anatomical factor that makes it difficult to release the esophagus when removing it.

Topographic anatomy diaphragms. The diaphragm (partition, a blessing barrier) is a muscular-aponeurotic formation separating the breastside of the abdominal. It is a flat thin muscle having a form of the dome, convexing up and covered with a clusp-covered sheet. Bottom part Covered with an adrenched leaflet of peritoneum. Muscular fibers of the diaphragm, starting from the edges of the lower hole of the chest, are sent radially up and, connecting, form a tendon center. Muscular part of the diaphragm has a lumbar, rib and sternum departments. On the borders between the departments, steam triangular sections that do not have muscle tissue are formed: breast-roar and lumbar triangles. AT lumbar Department The diaphragms muscle bundles are divided into paired legs: lateral, medial and inner. The inner legs, crossing, form the eight and limit the holes for the ports and the esophagus, and the latter in the abdominal cavity are not wandering rs. In addition, in the lumbar part there are chest ducts, sympathetic trunks, crank nerves, unpaired and semi-park veins. Through the holes in the tendral center of the diaphragm, the bottom passes hollow Vienna. Typically, the top of the right domes is at the level of the 4th, and the left - at the level of the 5th intercostal interval. The blood supply is carried out by the upper and lower diaphragmal, muscular-diaphragmal and pericardodyiaphragmal arteries. They are accompanied by the veins of the same name. Innegrated with diaphragm diaphragmal nerves.

The main function of the diaphragm is respiratory. As a result of the movements of the diaphragm, depending along with the pectoral muscles, inhale and exhale, the bulk of the ventilation of the lungs is carried out, as well as oscillations of intrapleural pressure, contributing to the outflow of blood from organs abdominal cavity And her influx to heart.

The diaphragmal hernia is the movement of the abdominal organs into the chest through a defect or a weak diaphragm zone. Distinguish between traumatic and non-damatic hernia. Non-mass hernia can be congenital and acquired. I LO localization highlight the hernia of weak diaphragm zones and hernias of natural holes, mainly esophageal hole (hiatal hernia).

Puncture of pericardia - surgical manipulation, at which a pericoral puncture of a parietal leaf of 11 derivatives is performed.

Indications. Exudative pericarditis, hemopericardium.

Anesthesia. Local anesthesia is 1% novocaine or lidocaine solution.

Position. On the back with a raised head end.

Technique in Larrey. The patient is placed on the back. A long needle, put on the syringe, produce puncture of the skin at the point located on the left at the junction of the mild-shaped process with the rib arc. Advances the needle inside at 1-2 cm (depending on the development of the subcutaneous fat layer), it is rotated upstairs and knutrice, promoting further by 3-4 cm. The puncture of the cardiac shirt is felt by overcoming the elastic resistance from the pericardium. A 10- 12 ml of painted liquid is introduced into the pericardia cavity. When repetition, this exercise produces suction of the injected fluid (Fig. 106). Technique by Marphine. Punch under mesia-shaped process In the midline, the space up to a depth of 4 cm, then the needle turns a few kice and penetrate the pericardia cavity.

Test tasks (choose the correct answer)

1. Specify the direction of the fibers of the outdoor intercostal muscles:

2. Specify the direction of the fiber of the internal intercostal muscles:

1) from top to bottom, back in advance;

2) from top to bottom, front back;

3) from the bottom up, in the back in advance;

4) Bottom up, front back.

The esophageal tube is a link between the sip of a person and the stomach, that is, delivers the digestive masses to the beginning of the gastrointestinal department where the process of digestion is beginning. Its length is quite individual, determined by the growth of man, fluctuates from 26 to 42 centimeters.

The clinical symptoms of diseases of the digestive tube is largely determined by the zone of damage. For example, in the pathology of the upper esophageal department, a person notes difficulty in swallowing in the early stages of the disease, and if the proximal separation department is damaged (that is, the closest to the stomach), such a sign is noted in the later stages of the disease.

In clinical practice, not only the structure of the escaped tube actually is important, but its location relative to other organs. The topographic anatomy of any esophagus department is important if necessary surgical intervention. For example, oncological diseases The top separation department and the average part of it is removed completely very complex due to the intensive blood supply to this zone, as well as the close fit of the main vessels, heart, lungs and bronchial trees.

The esophageal tube has a number of physiological narrowings (normal for each person):

• on the phase of the transition of the pharynx to the esophageal tube,
• in the zone where the breathing throat (trachea) branches his right and left major bronchi and naturally narrows the clearance of the esophageal tube, pressing it outside;
• on the section of passing through the main respiratory muscle (diaphragm), almost this is the entire very short abdominal department of the esophagus.

These features must be taken into account when preparing for esophagoduodenoscopy, at the stage of the tube selection.

The wall of the esophageal tube is formed by the following layers:

• external connective tissue;
• the average esophageal department, which is formed by muscle tissue and actually provides peristaltic cuts and promotion of the food lump;
• internal submucous base and mucous membrane from epithelial tissue.

These features have a greater extent to have a diagnostic value for gastrophurgeons and oncologists, since the prevalence of malignant tumor is made to be judged by its germination within one or more layers of the esophagus tube.

In order to correctly understand the structure and features of various departments of the esophageal tube, consider the detailed structure of each of them. The entire digestive tube can be divided into 3 departments: upper, middle and lower. Many clinicians allocate the abdominal or distal diversity of the esophagus, located inside the abdominal cavity. Clear topography will make it clear to understand that this is the abdominal department of the esophagus.

Upper (cervical) esophageal department

The top or cervical esophagus, respectively, is located in the thicker of the tissues of the human body. Originates from the 6th cervical vertebra, has a length in the range of 5-6 centimeters, ends at the entrance level in chest, that is, up to the 1st thoracic rib.

Before the esophageal tube there is a breathing throat (trachea). In a small gap between them, respectively, the right and left return gangny nerves, whose damage in the process of surgical intervention can deprive a person's voice. The side zone of the esophageal tube comes into contact with the lower edge thyroid glandwhich is located somewhat higher. Immediately behind the esophagus tube there is a possession of the space filled with loose fatty tissue, this space passes into the cavity of the rear mediastinum.

The blood supply to the cervical esophageal tube is carried out by branches of esophageal arteries, venous outflow - according to the corresponding venous vessels. The innervation of the cervical department is represented by returning nerves and a sympathetic barrel.

Breastway of the esophagus

This is the longest esophageal department (about 16-18 centimeters), the actual esophageal tube. For this zone of the esophageal tube, a very complex topography is characteristic.

Before the breast, the esophageal tube (inside the mediastinum) is located:

• bifurcation (discrepancy) of trachea and left master armor;
• nervous plexus (esophageal);
• total left carotid artery;
• left minor nerve and wandering branches.

Lefte are located:

• left wandering nerve;
• aorta (and her arc, and actually the breast);
• left plug-in artery.

The right to the threshold of the esophageal tube (inside the mediastinum) are located:

• unpaired vein;
• branch of the wandering nerve.

Behind are located:

• vertex pillar;
• aorta and its branches.

The blood supply to the thoracic esophageal tube is carried out directly from the chest aorta and the branches of the intercostal arteries. The outflow of venous blood takes place in the main venous trunks -par and unpaired veins.

Cardial diversity of the esophagus

It is the distal or bottom department of the esophagus located inside the main respiratory muscle to the immediate entrance to the stomach. It is the shortest part of it - only 2-4 centimeters. The bottom department of the esophagus is covered only by the leaflets of the peritoneum, the liver is right to it (her left share), and, accordingly, to the left - spleen. Sometimes it is called the cardiac department of the esophagus, but it is not entirely correct, since the cardiac part is the department of the stomach, and the part of the esophageal tube flowing into it is called the abdominal.

It is this section that the transformation in the hernia is most often exposed, shifts from the abdomen of the abdomen into the chest.

The blood supply to the abdominal part of the esophagus is carried out from the branches of the diaphragmal and gastric artery (left). Venous outflow - in porto-cavalny anastomoses.

A more detailed structure of the esophagus is required only to the doctor, mainly when conducting surgical intervention. Histological (cell) structure is important when diagnosing malignant and benign tumors, as well as prerollan pathology.

(thoracic)

Blood supply The thoracic part of the esophagus is carried out from many sources, subject to individual variability and depends on the department of the body. Thus, the top department of the thoracic part is dominant mainly due to the esophageal branches of the lower thyroid artery, which starts from the palate barrel (Truncus Thyrocervicalis), as well as the branches of the connective arteries. The average third of the breast of the esophagus always gets blood from the bronchial branches of the chest of aorta and relatively often from the I-II of the right intercostal arteries. The arteries for the lower third of the esophagus arise from the thoracic part of the aorta, II-VI of the right intercostal arteries, but mainly from III, although in general intercostal arteries are involved in the blood supply to the esophagus only in 1/3 of cases.

The main sources of blood supply to the esophagus are branches departing directly from the thoracic part of the aorta. The largest and permanent are esophageal branches (RR. Esophagei), whose feature is that they usually pass along the esophagus, and then divided into ascending and downstream branches. The arteries of all departments of the esophagus are well anatomized among themselves. The most pronounced anastomoses are available in the lower body of the authority. They form arterial plexuses, located mainly in the muscle shell and the submalism of the esophagus.

Venous outflow.The venous esophagus system is distinguished by uneven development and differences in the structure of venous plexuses and networks inside the organ. The outflow of venous blood from the pectoral part of the esophagus is carried out into the system of the unpaired and semi-regional veins, according to the anastomoses with veins of the diaphragm - into the system of the lower hollow vein, and through the veins of the stomach - to the portal vein system. Due to the fact that the outflow of venous blood from the top of the esophagus occurs in the system of the upper vein vein, the venous vessels of the esophagus are a link between the three main vein systems (upper and lower hollow and portal veins).

Lymphotok From the thoracic part of the esophagus occurs in various groups lymph nodes. From the upper third of the lymph esophagus, the right and left paratroheal nodes are sent to the right and left paratrohekal nodes, and the portion of the vessels carries it to the supplementary, lateral jugular and tracheobronchial nodes. Sometimes there is a luminosity of the lymphatic vessels of this esophageal department in the chest duct. From the middle third of the lymph esophagus, it is primarily sent to bifurcation, then into tracheobronchial nodes and further to the nodes that are between the esophagus and aorta. Less often 1-2 lymphatic vessels from this departure of the esophagus fall directly in the chest duct. From the lower part of the esophagus of the lymphotok goes to the regional stomach and the mediastinum organs, in particular, in the obstacious nodes, less often - in gastric and pancreatic, which has practical importance when metastasis malignant tumors esophagus.

Innervationthe esophagus is carried out at the expense of wandering nerves and sympathetic stems. The upper third of the breast of the esophagus is innervated by the branches of the return Gundy nerve (paragraph Laryngeus Recurrens Dexter), as well as esophageal branches that are directly from the wandering nerve. Thanks to the abundance of connections, these branches form a plexus on the front and rear walls of the esophagus, which is by nature is a vagosympoathetic.

Medium department The esophagus in the chest is innervated by the branches of the wandering nerve, the number of which behind the roots of the lungs (at the site of passing the wandering nerves) ranges from 2-5 to 10. Another significant part of the branches, heading for the middle third of the esophagus, departs from pulmonary nerve plexuses. Esophageal nerves just like in upper Department Form a large number of connections, especially on the front wall of the body, which creates the semblance of plexuses.

In the lower section of the chest, the esophagus is also innervated by the branches of the right and left wandering nerves. The left wandering nerve forms the front-winding, and the right - posterior plexus, which, as it approaches the diaphragm, form the front and rear wandering trunks. In the same department, it is often possible to detect the branches of the wandering nerves, separating from the esophageal plexus and heading directly to the curled plexus through the aortic hole of the diaphragm.

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