ESOHPHAGUS

Question 1

Paraesophageal

Answer 1

Laparoscopic approach:
• 5 trocar ports similar position to Nissen
• Viscera reduced by gently grasping with babcock

dividing gastrohepatic lig into hiatus (care to avoid aberrant L hepatic artery and watch for distortion in position of L gastric)

• With hiatus exposed, peritoneal sac divided along free edge of hiatus; allows for careful stripping from thorax; care taken not to breach pleura or injure pericardium; continue in clockwise fashion
• Mobilize esophagus and make window behind, taking care not to injure posterior vagus
• Close hiatal defect with nonabsorbable suture or mesh (if big)
• May do “floppy” nissen - coach says yes

if evidence of reflux (high incidence of reflux 20-40% who’ve undergone repair)

• Gastrotomy or gastropexy may be considered but not shown to prevent recurrence….should really only consider in elderly with comorbid conditions

(g-tube also done sometimes)

• For gastric volvulus, reduce stomach in to abdomen, assess for viability and gangrene; if any areas suspicious, do segmental, sub-total, or total gastrectomy; if ok, do anterior gastropexy, or G-tube insertion to prevent recurrence

Question 2

Key moves on EGD

Answer 2

follow base of tongue to the arytinoids

Have the patients swallow to show the esophagus

If not then hover at the arytinoids

Note to the GE junction distance from the incisors

With the scope of inflection performance 60 – 90° corkscrew rotation to put me in front of the pylorus

Integrate the pylorus and insufflated

Eval you wait the duodenum with flax and right hand clockwise rotation to get to the more vertical second portion of the duodenum

Evaluating ampulla

Withdraw the stomach
He violated his stomach with retro flexion and GE junction for hiatal hernia’s

Question 3

Using transverse colon for esophageal conduit is based on what artery

Answer 3

Based on the LEFT colic artery (this is the proxiamal pedical)

Requires sacrifice of the middle colic

Cervical last closest stable and handsome just like stomach

Abdominal anastomosis is descending colon to proximal J

A sending colon to sigmoid

Question 4

key moves of hiatal hernia repair

Answer 4

Reduce hernia contents

3 cm of enter abdominal esophagus reduced

Excise hernia sac(This is a reason for recurrence)

POSTERIOR re-approximation of hiatal hernia with pledget and possibly mesh

Question 5

Surveillance for high-grade versus low grade Barrett’s esophagus

Answer 5

LGD
6 to 12 months

HGD
every 3 months for patients with HGD

who have not undergone ablative therapy.

Question 6

Treatment of high-grade Barrett’s dysplasia

Answer 6

RFA and PDT are very effective in the treatment of dysplastic BE.

Endoscopic mucosal resection (EMR) is another important modality in the treatment of HGD and intramucosal carcinomas (Figures 7 through 11). EMR is now offered as a curative treatment for HGD or early EAC, with or without conjunctive ablative therapies (i.e., RFA or PDT).