ESOHPHAGUS

Question 1

Dx of esophageal cancer

Answer 1

esophageal ultrasound

For distant met PET/CT

Early stage esophageal cancer

Question 2

treatment of stage I and II esophageal cancer

Answer 2

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

Question 3

Maximum resectable esophageal cancer

Answer 3

> 5cm from cricopharyngeus,

T1-3N+

or

T4aN0,

Need 15 LNs

Question 4

neoadj for

Answer 4

T1bN+
T1b submucosa

or

> =T2
T2 Muscularis

(can forego if non-cervical, low-risk,

Question 5

Not resectable

Answer 5

“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].

Question 6

-ivor-lewis

Answer 6

laparotomy
R thoracotomy
Anastamosis at or above azygos

• inadequate proximal margin for mid-esophageal tumors

Question 7

McKeown

Answer 7

3-hole with cervical anastamosis

Question 8

nodal staging

Answer 8

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

Question 9

Medical therapy for esophageal varices

Answer 9

Antibiotics! ( for portal hypertension and bacterial peritonitis risk)

Octreotide

Proton pump inhibitor (of course, not if hypotension)

Question 10

Minnesota tube

Answer 10

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?)

Question 11

Mesocaval shunt

Answer 11

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

Question 12

VEIN directly responsible for esophageal varices

Answer 12

Coronary vein
Anastomosis of left and right gastric names
Near lesser curves of the stomach

Question 13

Medication used for esophageal varices bleeding

Answer 13

Octreotide

Do not use vasopressin

Vasopressin can worsen heart failure

PPI

Beta blocker if pressure can tolerated

Ceftriaxone

Question 14

What is the basic moved to expose the esophagus to evaluate perforation

Answer 14

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)

Question 15

Management of late esophageal perforation

Answer 15

Spit fistula

You’re not going to salvage the esophagus

Question 16

Nutcracker esophagus

Findings on manometry

Management strategies

Answer 16

Progressive

Try these first :
(surgery does not do great for this)

Calcium channel blocker
Nitroglycerin

Only one reflux can trigger

So, may need fundoplication

Question 17

Findings on manometry to suggest diffuse esophageal spasm

Answer 17

Simultaneous waves of contraction

Question 18

What is new adjuvant chemotherapy for esophageal cancer

Answer 18

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)

Question 19

How is the gastric conduit anastomosis constructed in the neck

Answer 19

Side to side anterior to the stomach

Question 20

Basic three points to consider anastomosis new chest for esophageal cancer

Answer 20

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)

Question 21

Treatment of bleeding varices unstable patient, scoping times two is not worked, replace after deflating Minnesota tube

Answer 21

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?

Question 22

Management if small amount of kerosene around the esophagus but no extravasation is seen on swallow including send barium

Answer 22

Can do non-operative management

NPO
Antibiotics

Supportive management

Repeat study

Question 23

Perforated esophagus with known esophagus cancer

Answer 23

Stent

Cancer operation

resection and
Cervical esophagsostomy

Feeding J

Question 24

Management of perforated esophagus 24 hours Post injury septic

Answer 24

Left chest tube

right thoracotomy

Question 25

Perforation with achalasia

Answer 25

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

Question 26

Treatment of cervical esophageal perforation

Answer 26

Left neck exploration
Repair defect if found

Just drain if not found!
(These will usually heal if no distal obstruction)

Question 27

Leak of anastomosis after a soft objective me

Answer 27

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

Question 28

Dysphasia pattern with achalasia

Answer 28

Liquids before solids!

(this is the opposite of cancer)

This may be caused by Cold liquids an Increasing spasm