ABSITE Review - Esophagus Flashcards
What are the muscle layers of the esophagus?
Squamous epithelium, circular inner muscle layer, outer longitudinal muscle layer; no serosa
What is the blood supply to the cervical, thoracic and abdominal esophagus?
Cervical - inferior thyroid artery
Thoracic - Aorta
Abdominal - Left gastric artery and inferior phrenic arteries
What is the lymphatic drainage pathway of the esophagus?
Upper 2/3 drains cephalad
Lower 1/3 drains caudad
What is the type of muscle in the upper and lower esophagus?
Upper - striated muscle
Lower - smooth muscle
Where travels the right vagus nerve as it exits the chest and what structure it forms?
Travels posterior portion of stomach and becomes celiac plexus
Where travels the left vagus nerve as it exits the chest and where it goes?
Travels anterior portion of stomach; goes to liver and biliary tree
Where is the criminal nerve of Grassi contained and was happens if it is left undivided?
Contained in the R vagus nerve; can cause persistently high acid levels postoperatively if left undivided
Where is the UES located with respect to the incisors? What are the normal pressures with food and at rest?
Located 15cm from incisors
Normal UES pressure with food bolus: 12-14 mmHg
Normal UES pressure at rest: 50-70mmHg
What is the main muscle at the UES?
Cricopharyngeus muscle (circular muscle, prevents air swallowing)
Where is the MC site of esophageal perforation during EGD?
Cricopharyngeus muscle
Where is the LES located with respect to the incisors? What are the normal pressures at rest?
Located 40cm from incisors
Normal UES pressure at rest: 10-20mmHg
What are the anatomic areas of narrowing of the esophagus?
Cricopharyngeus muscle
Compression by the left mainstem bronchus and aortic arch
Diaphragm
What is the recommended surgical approach for the cervical, upper and lower esophagus?
Cervical - Left
Upper 2/3 - Right (avoids aorta)
Lower 1/3 - Left (left-sided course in this region)
What is a Zenker’s diverticulum? What is the cause?
Is a FALSE posterior diverticulum between the cricopharyngeus and pharyngeal constrictors
Caused by increased pressure during swallowing.
What is the diagnostic study of choice for Zenker’s and what is the treatment?
Dx - Barium Swallow Studies, Manometry
Tx - Cricopharyngeal myotomy, removal of diverticulum not necessary
Left cervical incision; leave drains; esophagogram POD 1
What is a traction diverticulum? What is the cause? What is the treatment?
Is a TRUE diverticulum - usually lies lateral in midesophagus
Due to granulomatous disease, inflammation, tumor
Tx - excison and primary closure
What is the cause of an epiphrenic diverticulum? Where it is usually located? What is the treatment?
Rare; associated with esophageal motility disorders
MC in distal 10cm of the esophagus
Tx - diverticulectomy and long esophageal myotomy on the side opposite to the diverticulectomy
What is the cause of achalasia?
Caused by failure of peristalsis and lack of LES relaxation after food bolus
Secondary to neuronal degeneration in muscle wall
What is the study of choice for diagnosing achalasia?
Manometry - increase LES pressure, incomplete LES relaxation, no peristalsis
What is the treatment for achalasia?
CCBs, LES dilation –> effective in 60%
If medical tx and dilation fails –> Heller myotomy - left thorscotomy, transect circular layer of muscle lower esopagus; also need partial Nissen fundoplication
Which agent can produce similar symptoms to achalasia?
Tympanosoma cruzi
What are the manometric findings of diffuse esophageal spasm?
Frequent strong body contractions of increase amplitude and duration, normal LES tone, strong unorganized contractions
What is the treatment of diffuse esophageal spasm?
CCBs, nitrates, antispasmodics, Heller myotomy
What are the normal anatomic protection from GERD?
Need LES competence, normal esophageal body, normal gastric reservoir
What is the usual work up for GERD?
Endoscopy, pH probe (best test), manometry (resting LES < 6mmHg), histology
What is the medical therapy for GERD?
Omeprazole for 12 weeks
What are the surgical indications for GERD?
GERD on pH monitoring, failue of medical tx, complications of GERD (stricture, Barret’s esophagus, cancer)
The phrenoesophageal membrane is an extension of ____ fascia.
Transversalis
What is Collis gastroplasty?
When not enough esophagus exists to pull down into abdomen, can staple along stomach and create a new esophagus.
What is the MCC of dysphagia following a Nissen?
Wrap is too tight
What are the 4 types of hiatal hernia?
Type I - sliding hernia from dilation of hiatus (MC)
Type II - paraesophageal; hole in the diaphragm alongside the esophagus, normal GE junction
Type III - combined
Type IV - entire stomach in the chest plus another organ
Which type of hiatal hernia, you should always repair and why?
Type II due to risk of incarceration
What is treatment for a Schatzki’s ring?
Dilatation of the ring usually sufficient; may need antireflux procedure
What is Barret’s esophagus? What is the cause?
Squamous metaplasia to columnar epithelium
Occurs with long standing exposure to gastric reflux
What is the cancer risk of Barret’s esophagus?
Increases by 50 times
What is the treatment of uncomplicated and severe Barret’s?
Uncomplicated Barret’s can be treated like GERD - surgery will decrease esophagitis and further metaplasia but will not prevent cancer or cause regression - need carefull follow up with EGD for lifetime
Severe Barret’s - indication for esophagectomy
How the esophageal cancer spreads quickly?
Along the submucosal lymphatic channels
What are signs of unresectable esophageal cancer?
Hoarseness (RLN), Horner’s syndrome, phrenic nerve involvement, malignant pleural effusion, malignant fistula, airway invasion, vertebral invasion
What is the #1 type of esophageal cancer?
Adenocarcinoma
Which cancer most likely occurs in upper and lower esophagus?
Upper 2/3 - squamous cell
Lower 1/3 - adenocarcinoma
What is the primary blood supply to stomach after replacing esophagus?
Right gastroepiploic artery
What is the Ivor-Lewis esophagectomy?
Abdominal incision and right thoracotomy; intrathoracic anastomosis
How many anastomosis are present in a colonic interposition?
Three
What is the MC benign tumor of the esophagus? Which layer it is located?
Leiomyoma; submucosal
What is the treatment for a leiomyoma?
Do not biopsy bc can form scar and make subsequent resection difficult
Tx - > 5cm or symptomatic –> excision (enucleation) via thoracotomy
What is the 2nd MC benign tumor of the esophagus?
Esophageal polyps; usually in the cervical esophagus
What are the degree of injury and specific treatment in caustic esophageal injury?
No NGT with caustic injuries
Primary burn - hyperemia - observation, IVFs, spitting, Abx
Secondary burn - ulcerations, exudates, and sloughing - prolonged observation, esophagogram in HOD 2-3
Tertiary burn - deep ulcers, charring, and lumen narrowing - esophagectomy, esophagogram in HOD 2-3
What is the treatment of a noncontained esophageal perforation diagnosed in < 24 hours?
try primary repair with drainsand intercostal muscle pedicle flap
What is the treatment of a noncontained esophageal perforation diagnosed in a sick patient or more than 24 hours?
Cervical esophagostomy for diversion, washout of the mediastinum, place chest tubes, and later placement of a feeding G or J tube
What is Boerhaave’s syndrome?
Forceful vomiting followed by chest pain - perforation most likely to occur in the left lateral wall of esophagus at the level of T8, 3-5 cm above the GE junction
