Chapter 29 - Esophagus++ Flashcards
Anatomy of the esophagus includes what type of epithelium? What layers?
Squamous epithelium; circular inner muscle layer, outer longitudinal muscle layer, no serosa
What blood vessel supplies the cervical esophagus? Abdominal esophagus?
Cervical esophagus - inferior thyroid artery; abdominal esophagus - left gastric artery and inferior phrenic arteries; main supply of blood from vessels directly off the aorta
Upper esophagus made up of what kind of muscle? Lower esophagus?
Upper – striated muscle, lower – smooth
What is the lymphatic drainage of the esophagus?
Upper 2/3 drains cephalad, lower 1/3 caudad
Course after exiting the chest and branches of the right vagus nerve?
Travels on posterior portion of stomach as it exits chest; becomes celiac plexus, also has the criminal nerve of Grassi which can cause persistently high acid levels if left undivided
Course of the left vagus nerve as it exits chest and branches?
Travels on anterior portion of stomach; go to liver and biliary tree
Course of the thoracic duct?
Travels from right to left in chest at upper 1/3 of mediastinum, inserts into left subclavian vein
What is the upper esophageal sphincter? How far is it from incisors? What is it’s innervation?
Cricopharyngeus muscle, 15 cm from incisors, circular muscle, prevents air swallowing, has recurrent laryngeal nerve innervation
What is the normal UES pressure with food bolus? At rest?
Food bolus – 12 to 14 mmHg, at rest - 50 to 70 mmHg
What is the most common site of esophageal perforation? usually occurs with EGD?
Left posterior distal esophagus. Iatrogenic at cricopharyngeus muscle.
What is the cause of aspiration with brainstem stroke?
Failure of UES to relax
How far from the incisors is the lower esophageal sphincter?
40 cm
What mediates relaxation of the LES?
Inhibitory neurons; muscle normally contracted at resting state, prevents reflux
What is the normal LES pressure at rest?
10 to 20 mmHg
What are the four anatomic areas of narrowing of the esophagus?
Cricopharyngeus, compression by the left mainstem bronchus and aortic arch, diaphragm
What is the normal esophageal pressures with food bolus?
70 - 120 mmHg
What are the three stages of swallowing?
Primary peristalsis – occurs with food bolus and swallow initiation by CNS, secondary peristalsis – occurs with incomplete emptying and esophageal distention propagating waves, tertiary peristalsis – non-propagating, non-peristasing
What is the surgical approach to the cervical esophagus? Upper 2/3 thoracic? Lower 1/3 thoracic?
Cervical – left, upper – right, lower – left
What causes hiccups?
Gastric distention, temperature changes, EtOH, tobacco
What is the reflex arc of hiccups?
Vagus, phrenic, sympathetic chain T6 - 12
What is the most common cause of esophageal dysfunction?
GERD
What is the procedure of choice for heartburn?
Endoscopy
What is the procedure of choice for dysphasia and Odynophasia?
Barium swallow, better at picking up masses
What is the diagnosis and treatment for meat impaction?
Endoscopy
What is the definition of pharyngoesophageal disorders? Causes?
Trouble in transferring food from mouth to esophagus; neuromuscular disease – MG, Parkinson’s disease, polymyositis, MD, Zenker’s diverticulum, lye ingestion, stroke; liquid worse than solid
What causes cervical esophageal dysphasia?
Plumber – Vinson syndrome, usually due to web
What is the treatment for Plumber – Vinson syndrome?
Dilation, iron, need to screen for oral cancer
What causes Zenker’s diverticulum? Where?
Increased pressure during swallowing (pulsion), posterior, occurs between the cricopharyngeus and pharyngeal constrictors
Symptoms of Zenker’s diverticulum? Diagnosis?
Upper esophageal dysphasia, choking, halitosis; barium swallow studies, manometry, risk for perforation with EGD
Treatment for Zenker’s diverticulum?
Cricopharyngeal myotomy, Zenker’s itself can either be resected or suspended; via left cervical incision, leave drains in, esophagram postop day 1.
Endoscopy can be used to form a common channel between the diverticulum and the esophagus - best used for diverticula b/w 2 and 5 cm.
What is a traction diverticulum? Causes?
True diverticulum, usually lies lateral in midesophagus; due to inflammation, granulomatous disease, tumor
What are the symptoms of traction diverticulum? Treatment?
Regurgitation of undigested food, dysphagia; excision and primary closure, may need palliative therapy if due to invasive cancer
What is an epiphrenic diverticulum? Where is it found?
Associated with esophageal motility disorders, most commonly in the distal 10 cm of the esophagus
Diagnosis of epiphrenic diverticulum? Treatment?
Esophagram and esophageal manometry; diverticulectomy and long esophageal myotomy on the side opposite the diverticulectomy
What causes achalasia? Symptoms?
Caused by failure of peristalsis and lack of LES relaxation after food bolus, secondary to neuronal degeneration in muscle wall; dysphasia, regurgitation, weight loss, respiratory symptoms
Diagnosis of achalasia?
Manometry – high LES pressure, incomplete LES relaxation, no peristalsis; bird beak appearance
Treatment for achalasia?
Calcium channel blocker, LES dilation (effective in 60%), nitrates; if medical treatment fails – Heller myotomy and partial Nissen fundoplication
What bacteria can produce similar symptoms to achalasia?
T. cruzi
Symptoms of diffuse esophageal spasm? Associated with?
Chest pain, other symptoms similar to achalasia; psychiatric history
Diagnosis of diffuse esophageal spasm?
Manometry – frequent strong body contractions of high amplitude and duration, normal LES tone, strong and disorganized contractions
Treatment for diffuse esophageal spasm?
Calcium channel blocker, nitrates, anti-spasmodics, Heller myotomy; treatment usually less effective for diffuse esophageal spasm than for achalasia
What are the symptoms of scleroderma of the esophagus? Treatment?
Dysphasia, loss of LES tone, most have strictures, fibrous replacement of smooth muscle; esophagectomy
What is the normal anatomic protection from Gerd?
LES competence, normal esophageal body, normal gastric reservoir
Symptoms of GERD?
Heartburn 30-60m after meals, asthma (cough), choking, PNA; worse symptoms when lying down
Dx of GERD?
Endoscopy, pH probe (best test), manomentry, histology
Tx for GERD?
Medical tx 1st: omeprazole for 12 weeks; surgical tx 2nd.
Indications for surgery for GERD?
GERD on pH monitoring, failure of medical tx, complications (stricture, Barrett’s, cancer)
Surgical treatment for GERD?
Nissen: open the pars flaccida (gastrohepatic ligament, replaced L hepatic from L gastric can reside here), open the phrenoesophageal ligament, preserve hepatic branch of right (anterior) vagus, dissect both crura, transhiatal dissection to allow 3 cm of esophagus into abdomen, divide short gastrics (for tension free wrap), pull esophagus into abdomen, repair defect in phrenoesophageal membrane (permanent suture), 2 cm fundal wrap
Complications from Nissen?
Injury to spleen, diaphragm, esophagus or pneumothorax
What maneuver necessary if there is not enough esophagus to pull down into the abdomen? (Stricture 2/2 severe GERD)
Collis gastroplasty; staple along stomach and create a “new” esophagus
Most common cause of dysphagia following Nissen?
Wrap is too tight
What is a type I hiatal hernia?
Sliding hernia from dilation of hiatus (most common); often associated with GERD
What is a type II hiatal hernia?
Paraesophageal; hole in the diaphragm alongside the esophagus with herniation of fundus, normal GE junction
What is a type III hiatal hernia?
Combined, GE junction in chest, herniation of stomach
What is a type IV hiatal hernia?
Entire stomach + another organ in chest
Timing of repair of paraesophageal hernias?
Type II-IV; all need repair, high risk of incarceration
What condition is associated with Schatzki’s ring?
Sliding hiatal hernia
Symptoms of Schatzki’s ring?
Short episodes of dysphagia following rapid swallowing
Treatment of Schatzki’s ring?
Dilation of the ring usually sufficient; may need antireflux procedure
What is Barrett’s esophagus?
Squamous metaplasia to columnar epithelium
What is the risk of cancer with Barrett’s?
Risk of adenocarcinoma increased 50x
Treatment for Barrett’s?
Uncomplicated: like GERD (PPI, Nissen), surveillance, surgery will dec. esophagitis but will not prevent malignancy; Complicated: indication for esophagectomy
What is the route of spread of esophageal ca?
Spreads quickly along submucosal lymphatic channels
Symptoms of esophageal ca?
Difficulty swallowing solids, dysphagia, weight loss
Risk factors for esophageal ca?
Achalasia, caustic injury, ETOH, tobacco, nitrosamides
Diagnosis of esophageal ca?
Esophagram (for pts with dysphagia, odynophagia, suspected mass lesions)
What makes esophageal ca unresectable?
Hoarseness (RLN), Horner’s syndrome, phrenic nerve involvement, malignant pleural effusion, malignant fistula, airway invasion, vertebral invasion (CT chest for diagnosis of unresectability)
What is the #1 cancer of the esophagus?
Adenocarcinoma; occurs in lower 1/3
Where do distant mets from esophageal cancer go?
Lung or liver; contraindication to esophagectomy
What nodal groups indicate unresectable disease?
Supraclavicular, nodal disease outside the area of resection; preoperative XRT and chemo may downstage tumors and make them resectable
What is the mortality of esophagectomy? What is the cure rate?
Mortality: 5%, cure rate: 20%
What is the primary blood supply to the stomach after replacing the esophagus?
Right gastroepiploic artery
What are the incisions with transhiatal approach? Benefit?
Abdominal and neck incisions, bluntly dissect intrathoracic esophagus; decreased mortality from esophageal leaks with cervical anastamosis
Incisions with Ivor Lewis?
Abdominal incision and right thoracotomy; exposes all of the esophagus; intrathoracic anastomosis
What additional procedure is necessary with esophagectomy?
Pyloromyotomy
What patients are candidates for colonic interposition?
Younger patients with benign disease where you want to preserve gastric function
Treatment for postop stricture?
Dilation
Chemo for esophageal cancer?
5FU and cisplatin
Role of XRT with esophageal cancer?
Proven to be effective both pre and postop
What is the cause of death with malignant fistulas?
Most die within 3 months due to aspiration
What is the most common benign tumor of the esophagus? Where is it located?
Leiomyoma; submucosal
Diagnosis of leiomyoma?
Esophagram, endoscopy to r/o cancer
Symptoms of leiomyoma?
Dysphagia, pain usually in lower 2/3 of esophagus
Are biopsies necessary with leiomyoma?
No, can form scar and make subsequent resection difficult
Treatment for leiomyoma?
> 5cm or symptomatic: excision (enucleation) via thoracotomy
Symptoms of esophageal polyps?
Dysphagia, hematemesis
What is the 2nd most common benign tumor of the esophagus? Location?
Esophageal polyp; cervical esophagus
Treatment for esophageal polyp?
Small lesions can be resected with endoscopy; larger lesions require cervical incision
General principles of treatment for caustic esophageal injuries?
No NGT, do NOT induce vomiting, nothing to drink
Effects of alkali on the esophagus?
Deep liquefaction necrosis (Drano); causes worse injury than acid, also more likely to cause cancer
Acid effects on the esophagus?
Coagulation necrosis; mostly causes gastric injury
Imaging following caustic esophageal injury?
CXR and AXR to look for free air; endoscopy to assess lesion, do not go past site of injury
Definition of primary burn of esophagus? Treatment?
Hyperemia; observation and conservative therapy (IVF, spitting, abx, oral intake after 3-4d, may need future serial dilation for strictures
Definition of secondary burn? Treatment?
Ulcerations, exudates, sloughing; prolonged observation and conservative therapy
Indications for surgery for secondary burn?
Sepsis, peritonitis, persistent back and chest pain, metabolic acidosis, mediastinitis, free air, mediastinal air, crepitance, contrast extravasation, pneumothorax, effusion, air in stomach wall
Definition of tertiary burn? Treatment?
Deep ulcers, charring, lumen narrowing; conservative treatment, esophagectomy usually necessary
What is the most common cause of esophageal perforation? Most common location?
EGD; near cricopharyngeus muscle
Symptoms of esophageal perforation?
Pain, dysphagia, respiratory distress, fever, tachycardia
Criteria for nonsurgical management of esophageal perforation?
Contained perforation by contrast, self-draining, no systemic effects
What is conservative management for esophageal perforations?
No NGT with caustic injury; IVF, NPO, spit, broad-spectrum abx
Treatment for noncontained perforations in the chest?
<24h from injury: primary repair with drains and intercostal muscle pedicle flap; for sick patients: cervical esophagostomy for diversiton, washout of mediastinum, chest tubes, later placement of feeding G/J tube and later esophagectomy and pull up
What procedure is necessary to see full injury of esophagus?
Longitudinal myotomy
How long do drains stay in place following repair of esophageal perforation?
Until pt taking good oral intake without increase in drainage from drains
What is Boerhaave’s syndrome? Where is the perforation?
Forceful vomiting followed by chest pain - perforation most likely to occur in left lateral wall of esophagus at level of T8, 3-5cm above GE junction
What is Hartmann’s sign?
Mediastinal crunching on auscultation
Diagnosis of Boerhaave’s? Treatment?
Gastrografin swallow; L. thoracotomy, longitudinal myotomy, primary repair, leave chest tubes
The technical aspects of the transthoracic heller myotomy are as follows:
Place the patient in the right lateral decubitus position.
Enter the pleural space in the 7th intercostal space.
Incise the inferior pulmonary ligament.
Retract the lung medially and cephalad.
Incise the mediastinal pleura.
Encircle the esophagus with a penrose drain.
Identify both vagus nerves.
Perform the esophagomyotomy.
When is a transthoracic Heller used?
Used for diffuse esophageal spasm as the length required for myotomy is longer than what can be accessed via an abdominal approach.
Pts with esophageal T1a disease should be considered for what procedure?
T1a tumors or those who are poor surgical candidates may be considered for esophageal preservation, using endoscopic mucosal resection techniques.
What is the role of neoadjuvant therapy in esophageal cancer?
Patients with nodal disease, T2 adenocarcinoma (penetrates submucosa into muscularis propria), T3 tumors, and select T4a tumors that are amenable to en bloc resection should receive neoadjuvant therapy prior to esophagectomy. (similar to rectal cancer)
Which esophageal cancer are surgically resectable?
The selection criteria for eligibility for a surgical resection include localized T1b to T3 lesions and select T4a lesions that involve the pericardium, pleura, or diaphragm.
What is the role for chemo or radiation in T1N0 esophageal cancer?
For patients with T1N0 esophageal or EGJ adenocarcinoma or SCC, we recommend surgery alone.
Is there a role for adjuvant treatment in esophageal SCC?
Yes, for positive margins only.
What is the role of adjuvant treatment in esophageal adenocarcinoma?
For patients with completely resected, node-positive or node-negative, pathologic T3 or T4 esophageal adenocarcinomas who have not received neoadjuvant therapy, we suggest some form of postoperative therapy in an attempt to improve outcomes. We also suggest some form of postoperative therapy for high-risk pathologic T2N0 adenocarcinomas (ie, those that are poorly differentiated, have lymphovascular or perineural invasion, or arise in a patient under the age of 50).
How do you do a transhiatal esophagectomy?
Starting with a laparotomy, the liver is mobilized and retracted laterally. The phrenoesophageal ligament is then taken down and the esophagus mobilized at the hiatus. The short gastric vessels are ligated. Care must be taken to preserve the right gastroepiploic artery as this will serve as the blood supply for the conduit. The pars flaccida is then taken down and the left gastric artery ligated. The vagus nerves are then ligated. The esophagus is then mobilized. The distal third of the dissection may be done under direct visualization, while the proximal two-thirds must be done bluntly. Only a limited and blind thoracic lymphadenectomy is able to be performed. A left cervical incision is made along the border of the sternocleidomastoid. The carotid sheath is retracted laterally. The cervical esophagus is then isolated. After completion of mobilization of the entire esophagus, it is ligated in the neck and brought through the laparotomy incision. The stomach is divided, usually taking a portion of the lesser curvature with it. The gastric conduit is then passed through the chest, and a cervical anastomosis is performed.
When would you do a transhiatal esophagectomy for cancer?
Transhiatal esophagectomy (THE) is best performed for patients with a high probability of advanced disease. It is best suited for distal esophageal tumors and is performed through an upper midline incision and a left cervical incision.
Manometry: low amplitude, simultaneous contractions, high LES pressure
achalasia
Manometry: low amplitude, simultaneous contractions, low LES pressure
scleroderma
Manometry: high amplitude, long duration (>6 sec) organized contractions, normal LES pressure
nutcracker esophagus
Manometry: low amplitude, non-transmitted contractions, normal LES pressure
ineffective esophageal motility
Manometry: normal amplitude, normal contractions, normal LES pressure
hypertensive LES
How do you manage esophageal perforation in a stable patient with a small contained leak?
In stable patients without known malignancy, the extent of the perforation can be evaluated with a swallow study and managed non-operatively if the leak is contained.
How do you manage esophageal perforation in a patient with free leak? They are successfully resuscitated.
Primary repair (myotomy to define extent, layered closure, flap covering closure) may be attempted in early esophageal perforations, excluding special circumstances such as cancer, severe peptic strictures, caustic injury, or refractory achalasia regardless of the degree of inflammation or time interval. These will require esophagectomy.
How do you manage esophageal perforation in a patient with free leak if they have known cancer? They are successfully resuscitated.
If patients present within 24 hours and the tissue remains viable without extensive inflammation, esophagectomy with primary anastomosis may be attempted. If the presentation is delayed or if there is too much inflammation to proceed with a primary anastomosis, resection and diversion is necessary.
How do you manage an esophageal perforation in a patient who is in shock and unable to be resuscitated?
In the setting of hemodynamic instability, damage control with wide drainage and diversion may be the only option.
Typical symptoms of GERD?
heartburn, regurgitation, epigastric pain
these are the most likely to resolve with intervention
Esophageal mucosal damage in GERD is caused by what?
acid and pepsin combination
Whenever you see Borchardt triad (severe epigastric pain, inability to vomit, and inability to pass a nasogastric tube), what is the concern?
gastric volvulus - immediate OR
Is there any long-term follow up for patients who recover from swallowing/ingesting caustic material?
Due to the high risk of esophageal squamous cell carcinoma, in individuals with caustic esophageal injury we perform upper endoscopy every two to three years beginning 10 to 20 years after ingestion.
When would mesh be used in a hiatal hernia repair?
If the crural fibers are disrupted during dissection, the hernia defect is large, or the crural closure is tenuous and/or under tension, we reinforce the crural closure with a biologic mesh.
Complications: intraluminal mesh erosion, esophageal stenosis, dense fibrosis
How do you manage esophageal food bolus impactions and foreign bodies in patients with evidence of complete esophageal obstruction?
Emergent endoscopy.
Complete obstruction is typically evidenced by an inability to handle oral secretions.
No need for swallow study or CT.
Pt presents to clinic. He feels like the food gets stuck in the back of his throat. He has been hospitalized three times in the past year for recurrent pneumonia. He often coughs after eating. What is next test?
Videofluoroscopic modified barium swallow
How do you treat peptic stricture?
Serial esophageal dilations until symptoms resolve.
A proton pump inhibitor should be started to prevent recurrence of the stricture after it is treated, but the drug itself is not a treatment for peptic stricture.
