29 Esophagus Flashcards
Layers of the esophagus
Mucosa (squamous epithelium)
Submucosa
Muscularis propria (longitudinal muscle layer)
NO serosa
Musculature of the esophagus
Upper 1/3 - striated muscle
Lower 1/3 - smooth muscle
Middle 1/3 - mixed
Blood supply of the esophagus
Branches off the aorta
Blood supply of the cervical esophagus
Inferior thyroid artery
Blood supply of the abdominal esophagus
Left gastric and inferior phrenic arteries
Venous drainage of the esophagus
Hemi-azygous and azygous veins
Lymphatic drainage of the esophagus
Upper 2/3 drains cephalad
Lower 1/3 drains caudad
Path of the right vagus nerve
Travels on posterior portion of the stomach as it exits the chest - becomes the celiac plexus
Criminal nerve of Grassi
Branch of right vagus nerve
Causes persistent high acid levels if left undivided after vagotomy
Path of left vagus nerve
Travels on anterior portion of the stomach, goes to liver and biliary tree
Course of the thoracic duct
Travels from right to left at T5-4, ascends to mediastinum
Inserts into left subclavian vein
Upper esophageal sphincter
15cm from incisors
Cricopharyngeus muscle - circular muscles, prevents air swallowing
Innervated by the recurrent laryngeal nerve
Normal UES pressure at rest?
60mmHg
Normal UES pressure with food bolus?
15mmHg
What is the most common site of esophageal perforation?
Cause?
Cricopharynegeal muscle
Occurs with EGD
Cause of aspiration after brainstem stroke?
Failure of cricopharyngeus to relax
Lower esophageal sphincter
40cm from incisors
Relaxation mediated by inhibitory neurons
Normally contracted at resting state (prevents reflux)
Anatomic zone of high pressure (not technically a sphincter)
Normal LES pressure at rest?
15mmHg
Normal LES pressure with food bolus?
0mmHg
Anatomic areas of eosphageal narrowing?
Circopharyngeus muscle
Compression by the left mainstem bronchus and aortic arch
Diaphragm
What initiates swallowing?
CNS
Swallowing stages?
Primary peristalsis - occurs with food bolus and swallow initiation
Secondary peristalsis - occurs with incomplete emptying and esophageal distention; propagating waves
Tertiary peristalsis - non-propagating, non-peristalsing (dysfunctional)
State of UES/LES between meals?
Contracted
Swallowing mechanism
Soft palate occludes nasopharynx
Larynx rises and airway opening is blocked by epiglottis
Cricopharyngeus relaxes
Pharyngeal contraction moves food into esophagus
LES relaxes soon after initiation of swallow (vagus mediated)
What initiates LES relaxation? When?
Vagus mediated
Initiation of swallow
Best surgical approach for the cervical esophagus?
Left
Best surgical approach for the upper 2/3 thoracic esophagus?
Right (avoids aorta)
Best surgical approach for the lower 1/3 thoracic esophagus?
Left (left-sided course in this region)
Causes of hiccups?
Gastric distention
Temperature changes
ETOH
Tabacco
Reflex arc for hiccups
Vagus, phrenic, sympathetic chain T6-T12
Causes of primary esophageal dysfunction
Achalasia
Diffuse esophageal spasm
nutcracker esophagus
Causes of secondary esophageal dysfunction
GERD*
Scleroderma
What is the best test for heartburn?
Endoscopy
Can visualize the esophagus
What is the best test for dysphagia or odynophagia?
Barium swallow
Better at picking up masses
What is the best test for meat impaction?
Dx and tx - endoscopy
Characteristics of pharyngeosophageal disorders?
Trouble transferring food from mouth to esophagus
Commonly neruomuscular disease (myasthenia gravis, muscular dystrophy, storke)
Liquids worse than solids
Plummer-Vinson syndrome
Upper esophageal web
Iron deficient anemia
Tx: dilation, iron
Need to screen for Oral cancer
Zenker’s diverticulum
Caused by increased pressure during swallowing
- False diverticulum, located posterior
- Caused by failure of the cricopharyngeus to relax
Symptoms - upper esophageal dysphagia, choking, halitosis
Where does Zenker’s diverticulum occur?
Posterior - between the pharyngeal constrictors and cricopharyngeus (Killian’s triangle)
Diagnosis of Zenker’s diverticulum?
Barium swallow studies
Manometry
(Avoid EGD - risk for perforation)
Treatment of Zenker’s diverticulum?
Cricopharyngeal myotomy Can be resected or suspended - doesn't need to be resected Left cervical incision Leave drain in Esophagogram POD1
Traction diverticulum
True diverticulum - lies lateral
Due to inflammation, granulomatous disease, tumor
Found in mid-esophagus
Sx: regurgitation of undigested food, dysphagia
Tx: excision and primary closure if symptomatic; palliative therapy (i.e. XRT) if due to invasive CA
Asymptomatic - leave alone
Epiphrenic diverticulum
Associated with esophageal motility disorders (i.e. alchalasia)
Distal 10cm
Most are asymptomatic - can have dysphagia and regurgitation
Dx: Esophagram, esophageal manometry
Tx: Diverticulectomy and esophageal myotomy on side opposite the diverticulotomy if symptomatic
Symptoms of achalasia
Dysphagia, regurgitation, weight loss, respiratory symptoms
Causes of achalasia
Caused by lack of peristalsis and failure of LES to relax after food bolus
Secondary to neuronal degeneration in muscle wall
(Also seen with T. cruzi)
Manometry findings in achalasia
Increased LES pressure
Incomplete LES relaxation
No peristalsis
Complications of alchalasia - seen on CXR
Tortuous, dilated esophagus
Epiphrenic diverticula
Bird’s beak apperance
Treatment of achalasia
Balloon dilation of LES
Nitrates, CCB
Failed –> heller myotomy (left thoracotomy, myotomy of lower esophagus only; may need partial nissen fundoplication)
Diffuse esophageal spasm
Chest pain, dysphagia, psych history
Manometry - frequent, strong, non-peristaltic unorganized contractions; LES relaxes normally
Tx: CCB, nitrates, if fails –> Heller myotomy (upper and lower esophagus)
Nutcracker esophagus
Chest pain and dysphagia
Manometry - high-amplitude peristaltic contractions; LES relaxes normally
Tx: CCB, nitrates; Heller myotomy (upper and lower esophagus)
Scleroderma
Fibrous replacement of esophageal smooth muscle
Causes dysphagia and loss of LES tone with massive reflux and strictures
Tx: esophagectomy, if severe
What is the normal anatomic protection from GERD?
LES competence
Normal esophageal body
Normal gastric reservoir
Requirements of LES competence
Resting pressures >6mmHg
Sphincter length >2cm
Intraabdominal section >1cm
Concerns if patient has: GERD + dysphagia/odynophagia
Check for tumors
Concerns if patient has: GERD + bloating
Suggests aerophagia and delayed gastric emptying
Dx: gastric emptying study
Concerns if patient has: GERD + epigastric pain
Peptic ulcer disease
Tumor
Diagnosis of GERD
pH probe (best) Endoscopy Histology Manometry (resting LES
Surgical indication for GERD
Failure of medical treatment
Avoidance of lifetime meds (young patients)
Surgical treatment for GERD
Nissen fundoplication
- Divide short gastrics, pull esophagus into abdomen, approximate crura, 270 (partial) or 360 gastric fundus wrap
What is the phrenoesophageal memebrane?
Extension of the transversalis fascia
What is the key maneuver for Nissen fundoplication wrap?
Identification of the left crura
Complications of Nissen fundoplication?
Injury to spleen, diaphragm, esophagus
Pneumothorax
Belsey fundoplication
Approach is through the chest
Collis gastroplasty
When not enough esophagus exists to pull down into abdomen
Staple the stomach along the cardia and create a neo-esophagus
Most common cause of dysphagia following nissen?
Wrap is too tight
Fixation of the fundoplication
Sutured in place with a single U-stitch of 2-0 proline pledgeted on the outside.
A 60-french mercury-weight bougie is passed thorugh the gastroesophageal junction prior to fixation of the wrap to assure a floppy fundoplication.
Hiatal hernia - type I
Sliding hernia from dilation of hiatus - GE junction above the diaphragm
Associated with GERD
Hiatal hernia - type II
Paraesophageal hernia
Hole in the diaphragm alongside the esophagus
Normal GE junction
Sx: chest pain, dysphagia, early satiety
Tx: Nissen + diaphragm repair
Always repair - high risk of incarceration
Hiatal hernia - type III
Combined sliding hernia and paraesophageal hernia
HIatal hernia - type IV
Entire stomach is in the chest, plus another organ (i.e. spleen, colon)
Schatzki’s ring
Associated with sliding hiatal hernia
Sx: dysphagia
Tx: dilation of the ring and PPI (do not resect)
Barrett’s esophagus
Squamous metaplasia to columnar epithelium
50x increased risk of cancer (adenocarcinoma)
Dysplasia –> esophagectomy
Uncomplicated Barrett’s - PPI, Nissen
EGD follow up for lifetime, no matter treatment
Effect of surgery on Barrett’s esophagus
Decreases esophagitis and further metaplasia
Does not prevent malignancy or cause regression of the columnar lining
Esophageal cancer spreads via:
Submucosal lymphatic channels
Symptoms of esophageal cancer
Dysphagia (especially solids)
Weight loss
Risk factors for esophageal cancer
ETOH Tobacco Achalasia Caustic injury Nitrosamines
Diagnosis of esophageal cancer
Esophagram
Indications of unresectability with esophageal cancer
Hoarseness (RLN invasion) Horner's syndrome (brachial plexus invasion) Phrenic nerve invasion Malignant pleural effusion Malignant fistula Airway invasion Vertebral invasion
How do you assess resectability in esophageal cancer?
Chest and abdominal CT
Characteristics of adenocarcinoma of the esophagus
Lower 1/3 of esophagus
Liver mets most common
Characteristics of SCC of the esophagus
Upper 2/3 of esophagus
Lung mets most common
Nodal spread that would indicate unresectability
Nodal disease outside the area of resection (M1)
Supraclavicular or celiac nodes
Reason for pre-op chemo-XRT
Downstage tumor and possibly make them resectable
Primary blood supply to stomach after replacing the esophagus?
Right gastroepiploic artery (have to divide the left gastric and short gastric)
Transhiatal approach for esophagectomy
Abdominal and neck incision
Bluntly dissect intrathoracic esophagus
Decreased morality from esophageal leaks - easier to access the anastomosis in the cervical area
Ivor Lewis approach for esophagectomy
Abdominal incision and right thoracotomy
Exposes all of the intrathroacic esophagus - better able to get nodal dissection
However, anastomosis is located intrathoracially - worse prognosis with leak
3-hole esophagectomy
Abdominal, thoracic and cervical incisions
Indication for colonic interposition in esophagectomy
May be choice in young patients when you want o preserve gastric function
3 anastomoses required
Blood supply depends on colon marginal vessels
Post-op follow up after esophagectomy?
Contrast study on postop day 7 to rule out leak
Treatment of post-op strictures after esophagectomy?
Dilation
Chemotherapy for esophageal cancer
5-FU
Cisplatin
(For node-positive disease or use pre-op to shrink tumors)
Malignant fistulas (esophageal cancer)
Most die within 3 months due to aspiration
Tx: esophageal stent for palliation
Leiomyoma of the esophagus
Most common benign esophageal tumor
Located in the muscularis propria (lower 2/3 of esophagus)
Sx: dysphagia
Dx: esophagram, EUS, CT (r/o cancer)
DO NOT biopsy - scare can make resection difficult
Tx: >5cm or symptomatic –> excision (enucleation) via thoracotomy
Esophageal polyps
Sx: dysphagia, hematemesis
2nd most common benign tumor of the esophagus
Located in the cervical esophagus
Tx: endoscopy; larger lesions require cervical incisions
What to NOT do with caustic esophageal injury?
NO NG tubes
Induce vomiting
Nothing to drink
Caustic esophageal injury - Alkali
Causes deep liquefaction necrosis - especially with liquid (i.e. drano)
Worse injury than acid - more likely to cause cancer
Caustic esophageal injury - Acid
Causes coagulation necrosis
Mostly causes gastric injury
Diagnosis of Caustic esophageal injury?
Chest and abdominal CT - look for signs of perforation (free air)
Endoscopy - to assess lesion (do not go past site of severe injury, do not do if suspect perforation)
Serial exams and plain films
Caustic esophageal injury - primary burn
Hyperemia
Tx: observation and conservative therapy (IVF, spitting, abx, PO intake after 3-4 days)
May develop cervical strictures (serial dilation)
May develop shortening of esophagus (GERD)
Caustic esophageal injury - secondary burn
Ulceration, exudate, shoughing
Tx: prolonged observation and conservative therapy
Indications for esophagectomy - sepsis, peritonitis, mediastinits, free air, mediastinal or stomach wall air, crepitance, contrast extravasation, pnaumothroax, large effusion
Caustic esophageal injury - tertiary burn
Deep ulcers, charring, lumen narrowing
Tx: observation, will likely need esophagectomy
Do not repair the alimentary tract until patient recovers from the caustic injury
Most common cause of esophageal perforation?
EGD
Most common site of esophageal perforation?
Cervical esophagus near cricopharyngeus muscle
Symptoms of esophageal perforation?
Pain
Dysphagia
Tachycardia
Diagnosis of esophageal perforation?
CXR (look for free air)
Gastrografin swallow, followed by barium swallow
Criteria for nonsurgical management in esophageal perforation?
Contained perforation as per contrast study
SElf-draining
No systemic effects
Tx: IVF, NPO, spit, broad-spectrum ABx
Treatment for non-contained perforations - diagnosed within 24hrs and area has minimal contamination
Primary repair with drains
Requires longitudinal myotomy to see full extent of injury
Consider muscle flaps (i.e. intercostal) to cover repair
Treatment for non-contained perforations - diagnosed after 48hrs or area has extensive contamination
Neck - just place drains (no esophagectomy)
Chest - resection (esophagectomy, cervical esophagostomy) or exclusion and diversion (cervical esophagostomy, staple across distal esophagus, washout mediastinum, place chest tubes - late esophagectomy at time of gastric replacement)
Gastric replacement of esophagus late when patient fully recovers
Boerhaave’s syndrome
Forceful vomiting --> chest pain Full thickness perforation of esophagus Highest moretality of all perforations Dx: Gastrografin swallow Tx: as above for esophageal perforations
Most likely location of perforation in Boerhaave’s syndrome
Left lateral wall of esophagus
3-5cm above the GE junction
Hartmann’s sign
Mediastinal crunching on auscultation
