ESOHPHAGUS Flashcards
Dx of esophageal cancer
esophageal ultrasound
For distant met PET/CT
Early stage esophageal cancer
treatment of stage I and II esophageal cancer
Rx surgery This is stages I and II
It includes up to T3 if N0, but is mostly T1-2, N0-1
Role of adjuvant therapy is “controversial”
Neoadjuvant can be chemo or chemo/rad
If no neoadjuvant Rx then should get adjuvant chemo post op.
All the rest also “Controversial” But can do neoadjuvant and if good response go on to resection
Transhiatal, Ivor Lewis, or McKeown—no difference in outcome
If endoscopic perf above cancer and no mets—do acute resection
If endoscopic perf above cancer and mets—do stent, chest drainage, and Chemo/RT
Maximum resectable esophageal cancer
> 5cm from cricopharyngeus,
T1-3N+
or
T4aN0,
Need 15 LNs
neoadj for
T1bN+
T1b submucosa
or
> =T2
T2 Muscularis
(can forego if non-cervical, low-risk,
Not resectable
“Invading the linings is ok: pericardium, pleura, diaphragm”
T4 BBBBBB NO!
b. aorta!, vertebae, trachea
T4 a YES!
STILL GO FOR CURE
a: pleura, pericardium, diaphragm -
NO
supraclavicular node
multistation nodes:
extraregional lymph node spread:
paraaortic
or
mesenteric
PREVIOUSLY thought that celiac area remote from the primary tumor (eg, for a SCC in the upper or middle thoracic esophagus) was previously thought to be a sign of unresectability and considered metastatic disease [4].
However, celiac nodal metastases are scored as regional nodal disease in the new 2010 edition of the TNM staging system, regardless of the primary tumor location or histology, and they no longer carry the connotation of distant metastatic disease [1].
Nevertheless, prognosis is poor in such cases, even if the primary tumor is located in the distal esophagus or EGJ [11,12]. In one series, the two-year survival rate of patients with celiac node involvement who underwent surgery as a component of therapy was approximately 10 percent [12].
-ivor-lewis
laparotomy
R thoracotomy
Anastamosis at or above azygos
- inadequate proximal margin for mid-esophageal tumors
McKeown
3-hole with cervical anastamosis
nodal staging
N0 No regional lymph node metastasis
N1 Metastasis in 1-2 regional lymph nodes
N2 Metastasis in 3-6 regional lymph nodes
N3 Metastasis in seven or more regional lymph nodes
Medical therapy for esophageal varices
Antibiotics! ( for portal hypertension and bacterial peritonitis risk)
Octreotide
Proton pump inhibitor (of course, not if hypotension)
Minnesota tube
Replaced Blakemore tube because another pork to clear saliva
Passing to stomach instill 40 – 50 mL and confirm on x-ray that you’re in the stomach
Then instill 250 mL total gastric balloon
Put on traction with 2 L fluid bag
Is still bleeding:
Men inflate the esophageal balloon to 30 mmHg
(can stay inflated overnight?)
Mesocaval shunt
Nonselective
Eight – 10 mm graft
Between the superior mesenteric vein (this is portal blood) and IVC
So the SMB side first because it is more interior
So the vena cava second because it tolerates a Satinsky side biting clamp
Good for emergency
Bad for transplant
VEIN directly responsible for esophageal varices
Coronary vein
Anastomosis of left and right gastric names
Near lesser curves of the stomach
Medication used for esophageal varices bleeding
Octreotide
Do not use vasopressin
Vasopressin can worsen heart failure
PPI
Beta blocker if pressure can tolerated
Ceftriaxone
What is the basic moved to expose the esophagus to evaluate perforation
Take down the left inferior pulmonary ligament
Watch out for the inferior pulmonary vein
(this is the same move for clamping the aorta from left thoracotomy for trauma)
Management of late esophageal perforation
Spit fistula
You’re not going to salvage the esophagus
Nutcracker esophagus
Findings on manometry
Management strategies
Progressive
Try these first :
(surgery does not do great for this)
Calcium channel blocker
Nitroglycerin
Only one reflux can trigger
So, may need fundoplication
Findings on manometry to suggest diffuse esophageal spasm
Simultaneous waves of contraction
What is new adjuvant chemotherapy for esophageal cancer
5-FU
Cis-platinum
XRT
we suggest the low-dose weekly carboplatin plus paclitaxel regimen (table 4) as was used in the Dutch CROSS trial rather than two courses of cisplatin plus 5-fluorouracil (5-FU) as was used in CALGB 9781 (uptodate)
How is the gastric conduit anastomosis constructed in the neck
Side to side anterior to the stomach
Basic three points to consider anastomosis new chest for esophageal cancer
Double lumen intubation
Take down the inferior pulmonary ligament
Divided azygous vein
Make anastomosis above the pulmonary hilum (to do this the Azygous had to be divided)
Treatment of bleeding varices unstable patient, scoping times two is not worked, replace after deflating Minnesota tube
GA across the esophagus - this includes the vasculature that is bleeding
(from coronary vein - anast btw right and left gastrics veins at the lesser curve)
Mesocaval shunt:
Superior mesenteric vein to portal vein 12 mm graphs?
Management if small amount of kerosene around the esophagus but no extravasation is seen on swallow including send barium
Can do non-operative management
NPO
Antibiotics
Supportive management
Repeat study
Perforated esophagus with known esophagus cancer
Stent
Cancer operation
resection and
Cervical esophagsostomy
Feeding J
Management of perforated esophagus 24 hours Post injury septic
Left chest tube
right thoracotomy
Perforation with achalasia
LEFT seven Pentecostal space thoracotomy
myotomy performed opposite of the perforation
Perforation is closed and buttressed with omentum
NG tube is left proximal to injury
Treatment of cervical esophageal perforation
Left neck exploration
Repair defect if found
Just drain if not found!
(These will usually heal if no distal obstruction)
Leak of anastomosis after a soft objective me
Stent!
If conduit is viable check this with the scope
If conduit is Nick chronic then reduce stomach back into the abdomen and cervical esophagostomy
Dysphasia pattern with achalasia
Liquids before solids!
(this is the opposite of cancer)
This may be caused by Cold liquids an Increasing spasm
