Esophagus Flashcards
70 year old patient presents with progressive dysphagia and weight loss over the past 3 months. What is the initial workup?
- Thorough H&P
- Esophagram
- Esophagoscopy/EGD
Once the diagnosis of esophageal carcinoma is made, what workup is needed for staging?
- CBC & CMP
- CT A/P w/ PO & IV contrast (M stage)
- PET scan (M stage)
- EUS +/- FNA (T & N stage)
- +/- Bronchoscopy (If tumor at or above carina level)
What lymph node has shown to be associated with esophageal cancer?
Virchow’s node (left supraclavicular)
- If palpable on workup of cancer –> FNA
What is the Siewert classification?
Siewert should be assessed in ALL ADENOCARCINOMA PATIENTS involving GEJ.
How does Siewert Classification Type affect treatment?
- Type 1 & 2 are treated as esophageal carcinoma
- Type 3 is treated as gastric carcinoma
What is the T staging for esophageal carcinoma?
T1a - Invades the lamina propria or muscularis mucosae
T1b - Invades the submucosa
T2 - Invades the muscularis propria
T3 - Invades the adventitia
T4a - Invades pleura, pericardium, azygous vein, diaphragm, or peritoneum
T4b - Invades aorta, vertebral body, airway
What is the N staging for esophageal carcinoma?
N1 - 1-2 nodes
N2 - 3-6 nodes
N3 - 7+ nodes
What would be considered unresectable esophageal cancer?
- T4b (invasion to aorta, great vessels, airway, vetebral body, liver, pancreas, spleen), OR
- N3, OR
- M1, OR
- EGJ cancer and virchow’s node positive, OR
- Locally recurrent
What treatment options are available for unresectable esophageal cancer?
Squamous cell carcinoma OR Adenocarcinoma
- Systemic therapy, AND/OR
- Palliative support
What treatment options are available for resectable esophageal cancer in non-surgical candidates?
T1(a or b) - Can try endoscopic resection +/- ablation
All others - Definitive chemorads OR palliative RT
What treatment options are available for resectable esophageal cancer in surgical candidates?
Safe answers
Tis or T1a - ER or Esophagectomy
T1b+ - Neo-adjuvent chemorads for non-cervical esophagus (definitive chemorads for cervical esophagus)
What is considered a low risk lesion in esophageal carcinoma?
- No lymphovascular invasion
- <3 cm in size
- Well differentiated
What is treatment plan after neo-adjuvent CRT in esophageal carcinoma?
Assess therapy with PET and EGD (6 weeks post tx)
- Esophagectomy for persistent local disease and no evidence of disease.
What is post esophagectomy tx in patients that underwent neoadjuvent? What about those who didn’t undergo neoadjuvent?
Neoadjuvent post esophagectmy tx:
- R0 ypT0N0 - observation
- R0 ypT+N+ - Nivolumab vs observation
- R1 - Observation vs re-resection
- R2 - Palliative management
Non-neoadjuvent post esophagectomy tx:
- Chemorads for R0 pT2+orN+, R1, R2 (can consider palliative management)
What is follow-up plan for esophageal carcinoma?
- Clinic q6month x2 years, followed by annually
- CT C/A annually x3 years
- EGD PRN
What are the 3 main types of esophagectomy surgery?
Ivor Lewis: laparotomy/laparoscopy + right thoractomy
McKeown: right thoracotomy/oscopy + laparotomy/oscopy + cervical anastomosis
Transhiatal: laparotomy + cervical anastomosis
What conduits can be used after esophagectomy?
- Gastric (preferred)
- Colon
- Jejunum
What artery is vital for gastric conduit?
Right gastroepiploic artery (+/- right gastric)
What is the goal lymph node # for esophageal carcinoma?
15 is the goal, but can be difficult if patient received neo-adjuvent CRT
When performing esophagectomy, what vitally needs to be considered?
Nutritional access needs to be considered.
- This is often with NJ vs j tube.
- Consider UGI by POD4
- Liquid diet for 2 weeks
Esophagectomy postop complications are fairly common (40-50%). What are some early post-op complications and their treatments?
Early post-op complications s/p esophagectomy (0-2 days)
- Bleeding
- If significant and unstable, may need OR.
- RLN injury
- Only real issue if bilateral
- Pneumothorax or pleural effusion
- Treat appropriately
- Conduit necrosis
- Tx: resection of necrotic conduit, cervical esophagostomy (spit fistula)
Esophagectomy postop complications are fairly common (40-50%). What are some sub-acute (2-14 days) post-op complications and their treatments?
Intermediate post-op complications s/p esophagectomy (2-14 days)
- Anastomic leak
- Dx: Esophagram +/- esophagoscopy
- Tx limited leaks: drain & NPO
- Tx free leak to pleural cavity: OR, repair vs revision based on operative findings
- buttress with healthy vascularized tissue (diaphragm, pleura, pericardium, intercostal muscle flap)
- Stents: viable option to consider prior to OR
- Last resort: resection and cervical esophagostomy. delayed reconstruction
- Conduit necrosis
- Tx: resection and cervical esophagostomy
- Thoracic duct injury (chyle leak)
- Dx: effusion triglycerides >100 mg/dL or chylomicrons observed
- High output (>1 L)
- Tx: OR for thoracic duct ligation vs IR lymphangiography with embolization
- Give cream prior to OR to help identify area of leak.
- Tx: OR for thoracic duct ligation vs IR lymphangiography with embolization
- Moderate output (500-1000 cc) or low output (<500 cc)
- Non op for 7 days
- Medium chain PO diet vs. NPO & TPN (small- and medium-chain fatty acids)
- Octreotide
- If not successful, OR for thoracic duct ligation vs IR lymphangiography with embolization
- Non op for 7 days
Esophagectomy postop complications are fairly common (40-50%). What are late post-op complications and their treatments?
Late post-op complications s/p esophagectomy (>14 days)
- Anastomotic stricture
- Sx: dysphagia
- Etiology: techincal vs ischemic
- Tx: Esophagoscopy with dilation or stent
- Delayed gastric emptying
- Dumping syndrome
What is the most common post-op esophagectomy complication?
Respiratory complications; contribute to 50-65% of deaths.
Due to loss of protective sphincters, patients are more prone to reflux and aspiration.
- Preop optimization is critical (including smoking cessation)
- Consider epidurals for pain; intercostal nerve blocks
- Agressive post-op pulmonary toilet
Basic steps to esophagectomy (McKeown)
- Enter the abdomen (open vs lap vs robotic).
- Evaluate liver, peritoneum, and ovaries for evidence of metastasis.
- Mobilize stomach by dividing left gastric, left gastroepiploic, and short gastric arteries.
- Maintain right gastroepiploic and right gastric arteries.
- Perform Kocher maneuver for further mobilization.
- Perform pyloromyotomy.
- If placeing feeding j tube, do so now.
- Mobilize lower esophagus through hiatus.
- Mobilize thoracic esophagus through right thoracotomy/oscopy.
- Cervical esophagus mobilization with neck incision.
- Transect proximally and distally.
- Transpose gastric conduit through posterior mediastinum.
- Close hiatus and tack stomach to crus.
- Close throracic and abdominal incisions.
- Perform anastomosis at neck (side-to-side stapled); penrose drain.
- CXR prior to leaving OR.
What is Mackler’s triad?
- Subcutaneous emphysema
- Vomiting
- Chest pain
Pathognomonic for esophageal perforation.
What is the initial workup for esophageal perforation?
- H&P
- Labs (CBC, BMP, Lactate)
- Imaging
- CXR (Mediastinal widening, subQ emphysema, pneumomediastinum, pneumothorax, pleural effusion, pnuemoperitoneum
- Contrast esophagram (GOLD STANDARD)
- CT C/A/P w/ PO and IV contrast
For esophageal perforations, water-soluble esophagram can have 10% false negative findings. What can be done if suspicion is still high?
Perform thin barium esophagram.
What is tx for containues HDS esophageal perforation?
Non-operative tx:
- NPO
- IV abx & antifungals
- Repeat esophagram ~HD4
- If no leak: can try liquids and advance slowly
- If leak: continue conservative tx and consider feeding access
