Esophagus Flashcards
MCC of dysphagia and first line treatment?
Benign strictures, serial dilations
hiatal hernia ulcer? Mechanism
Cameron ulcer, constant movement
Child drinks drain cleaner and p/w drooling/vomiting but otherwise stable…. what next?
PO challenge
Benefit of hiatal mesh? what type is preferred? What if hiatus will no close with simple repair?
short term recurrence
absorbable
bridging mesh with NA
First line for hiatal hernia evaluation/imaging?
Upper GI
GS for esophageal loco-regional staging?
PET-CT chest
Diet for Nissen post op
1-2 weeks liquid diet to avoid worsening edema
Which operation for Right mid esophagus perforation with large defect, sick patient
R PLat thoracotomy, spit fistula, esophagectomy
Size for endoscopic zenkers tx?
> 3cm
Structural cause of zenkers?
cricopharyngeus
Key step in zenker’s surgery
myotomy
Barrier to endoscopic zenkers tx?
rigid neck, small sack
treatment of peptic esoph stricture?
dilation
Triad for gastric volvulus
Borchardt triad (severe epigastric pain, inability to vomit, and inability to pass a nasogastric tube)
Tx for met esophageal ca, chemo reg? Notable receptor target?
palliative – needs med onc, FOLFOX/ cisplatin/5fu or nivolumab
PDL-1
high grad dysplasia for esoph with short segment … tx?
EMR
low grade dysplasia on EGD, what next
6 month surveillance
demeester score indicating surgery appropriateness
14.7
Percent of population with GERD
20%
4 big causes of GERD
Diet/obesity, Scleroderma, lung path, hiatal hernia
4 dg studies for GERD s/s
manometry, Egd, motility, impedence, pHstudies
3 measures of a weak LES
P<6mmHg, 2cm length, abd length 1 cm
MC esoph dysmotility disorder
Achalasia
2 usual achalasia findings on manometry
no LES relaxation and absent esoph peristalsis
GS for achalasia surg tx
myotomy
med tx for DES
nitrates, sildenafil, tricylcics
Gold standard for esophageal leaks
gastrograffin and barium if negative initially
Nutcracker med tx?
nitrates, sildenafil, tricylcics
4 landmarks for EGD path start to finish
Vocal cords/aryepiglottic folds, UES(crichopharyngeal m), Aortic Arch(skeletal to smooth muscle), Squamocolumnar junction(LES)
4 steps of GERD workup
1 - Acid Test(demeester)
2 - Manometry
3- Esophagram
4 - EGD(can be same day as surgery
GS for esoph dysmotility?
manometry
5 risk factors for GERD
Obesity, pregnancy, conn tiss disorders, hiatal hernia, DGE
GS start for GERD testing
acid test + impedence
6 PPI side effects
HypoMg, osteoporosis, hypergastrinemia, AIN, B12 deficiency, Lupus
4 surgical goals of anti-reflux procedure
1 - Reduce hernia
2- Tension free intra-abd
3 - Approx crura
4 - Fundo
Medical steps before fundo after confirmed GERD
diet, double ppi
6 GERD surgical indication
Failed BID
GERD complications
Preference
Cx of PPI
Lung Tx patients
Atypical pH proven(14.7)
Structural elements predisposing GERD? Inciting disease?
Hiatal hernia; scleroderma
4 studies for GERD preop
manometry, EGD, impedence, motility
3 objective measures of a defective LES predisposing to GERD
P<6; length<2cm; abdominal length>2cm
What is the most common esoph dysmotility disorder? 2 big dg tests and their findings
Achalasia
Manometry: poor LES relaxation with absent peristalsis
Esophogram: Bird’s Beak
Pseudoachalasia?
Tumor
MOA achalasia
dec inhib ganglion cells of LES
How is HTN LES diif than achalasia
Inc LES P but it does relax normally
DES treatment? med vs surgery
Nitrates, Tricyclics, Sildenafil
Long myotomy
Nutcracker tx?
Same as DES
Gold standard for esophageal leaks
Esophogram
3 components of the LES complex
esoph muscle
phrenoesophligament
Diaphragm
4 landmarks on the path of your EGD esoph approach
vocal cords and aryepiglottic folds
UES(cricopahryng m)
Aortic Arch(skeletal to smooth)
Squamocolumnar junction(LES)
GS test for esoph motility
manometry
5 indications for manometry
Dysphagia after EGD
Non cardiac chest pain
preop
postop
Dg motil dis
Demeester cutoff for GERD
14.72 (95%)
4 tests for GERD wu
acid(demeester)
Manometry
Esophogram
EGD
Impedence test is looking for….
bile reflux
5 alarm signs of GERD
WL
hematemesis
Dysphagia
Melena
Early satiety
starting point for classic GERD signs
PPI
6 side effects of PPI
Hypomg
Osteo
AIN
Lupus
B12 defic
Hypergastinemia
After suspicion of GERD, what do you start on
if that fails
if confirmed GERD
PPI
Workup
Double PPI
6 indication for GERD surgery
Failed medical
pt pref
Gerd med compl issues
PPI cx
Lung tx pt
If there is dysplasia but ready for anti-reflux surgery
ablation first
4 tenets to a successful anti-reflux procedure
Reduce hernia
Tension free intra abdominal esoph
Approx crura
Fundo
When to avoid full fundo
dysmotility
Post op care for fundo pts
Limit narcs
Anti emetics
Barium esoph in am
Advance diet after, soft for 6 weeks
Stop PPI
crush meds
2 common post fundo complaints post op
dysphagia
Gas bloat syndrome
path finding for barrets
columnar lined esoph, intestinal dysplasia, goblet cells
Major cause of barrets
GERD
What can we do for prevention of worsening barrets + GERD
anti reflux med v surgery
Tx for LGD Barrett’s, surveillance time
If it works
If it persists
PPI, diet 6 months
PPI
ARS
Non dysplastic barrets surveillance timing
yearly then 3 to 5
What is the relationship of HGD, T1a and T1b from a management standpoint
HGD/T1a adeno —- ablation/ER/PPI plus minus ARS
T1b submuc — esophagectomy
what type of esoph cancer can get ESD
Squamous only
1 yr risks for barrets
ND
LGD
HGD
What trial set these stats
0.2
0.7
7
AIM Dysplasia
EGD screening guidelines
> 5y GERD symptoms
2 or more of these:
-white male
-50
-central obestiy
-smoker
-1st degree relative
4 reasons for pt to get esophagectomy for HGD/
t1a
high risk for mets, young, fam hx, long lesions
Ablation success percents for HGD/t1a esoph ca
RFA
AIM dysphagia trial
81v19
90%remission at 3
low stricture rate
% nodal mets estimated for a T1b
esophagectomy 30d mortality in these patients
27%
1%
3 PEsoph types
1 - sliding
2 - true
3 - mixed
2 indications for PE hernia repair
3 investigation tools
ALL symptomatics
consider young incidentals
CT/esoph
manometry
EGD
5 principles of PE repair
- Reduce
- Excise Sac
- REduce GEJ
4.2-3cm tension free intra abdominal esoph
5.Repair defect
port placement for lap PE hernia repair
POD1 for PEH repair
Next diet progression day and what duration
UGIS, clears 72h
Soft 1 week
What mesh to use if can’t close PEH?
biologic
MC type of esoph diverticulum
What type is it
Zenker’s
False
Pathophys for zenker’s
poor UES relaxation
4 big s/s for zenkers
halitosis, regurg, cough, dysphagia
4 steps to zenkers open diverticulectomy
What size sacs are these best for
1L cervical incsion
2 - Platysma, SCM and carotid sheath lateral
3 - diverticulectomy, stapler vs pexy
4 - myotomy no matter what!!!
less than 3 cm
endo parameters for zenkers
more than 3 cm
ANVIL must fit
2 muscles that make up killians triangle
pharyngeal cx m and cricopharyngeus m
MC dymotility disorder esoph
achalasia
Theoretical MOA for achalasia
infection–> loss of post ganglion inhib cells
6 ddx for achalasia
gerd, malignancy, webs, esophagitis, strictures, systemic tissue disroders
who gets medical management for achalasia and what is its
poor surgical candidates
Nitrates — isosorbide
CCBs —-nifedipine
Sildenafil(PE5 inhibit)
Botox
3 endoscopic treatments for achalasia
botox
dilation
poem
Pneumatic dilation of achalasia gerd, relief and relapse rates
30%
60-90
33%
4 heller complications
Leak
GERD
Dysphagia
PTX
6th leading cause of cancer deaths
esoph ca
MC global esoph cancer
risk factors
SCC
Smoking, ETOH, achalasia, caustics
Where is esoph adenoCA mc?
risk factors
N america and W europe
FAT, WHITE,MALES
advanced age
TYLOSIS —thickened palms
2 Late signs of esoph ca and their pathophys
Why are they so late????
Dysphagia —2/3 luminal blockage mass effect
Hoarseness/hiccups —- R laryngeal n and phrenic n
What is the Seattle Protocol
4 quad bx every 1 cm for esoph
how is esoph cancer caught early
GERD/barretts surveillance
4 parts of a full work up for esoph cancer
BX during egd
PET CT
EUS
Barium
Where do the paths split on t staging and tx in esoph cancer
T1a to T1b
mucosal to submucosal
EMR to surgery
Diff between T4a and b for esoph
a is take outable organs
pleura, pericardium, diaphragm
treatment of HGD for esoph
EMR
What is the next move for T2-T4a esoph cancer
what trial supports this
results?
Chemo plus surgery
CROSS
49 vs 24 m
inc R 0 resection
regimen for CROSS trial
carpiplatin and paclitaxel + rads 5 weeks
3 esophagectomies and their incision sites
McKeown all
Ivor - chest and abd
Trans Hiatal - neck and abdomen
what anatomical branching point does rouviers sulcus indicate
The entrance of what structure into the liver forms this sulcus?
bifurcation of the of main hepatic bile duct
right hepatic duct
muscle layers of esoph
outer - long
inner - circular
Upper GI tumors are 2nd only to ___
lung cancer
Combination of these two invest tools give the best sensitivity for esoph cance staging
EUS PET CT
What is the timing for esoph cancer surgery after preadjuvant chemo? why? data?
6 weeks
less inflam, inctumor regression
no good data
3 oncogenes for esoph ca
NOTCH1
HER2
VEGF
2 main indications for esoph stents
what type
Malignancy and fistulas
SEMS
esophageal perforation success rate with stents
80%
What contrast do we use first for esoph perforation eval
GG over barium, less mediastinitis risk
Mortality rate of esoph perf
10-40%
what are the causes by percent breakdown
60%
30%
5%
Endoscop
Borrhav
Malign/trauma/FB
What is a normal LES pressure. What is high
15-20; 45
Unknown ingestions should be assessed urgently with ….
EGD
What is the strongest prognostic factor for esophageal CA
Number of regional nodes involved
5y met esoph adenoca survival rate
almost 0
magnetic sphincter augmentation:
comparison to nissen
how often does erosion occur and what is management
Important post operative tenet
nearly equivalent
RARE, removal
eat solid food to prevent capsule formation
first line for scleroderma ind atonic esophagus
ppi
then toupet NOT nissen
What stations are important in esoph ca LN harvest
celiac, IPL, lower esoph, crural
most important artery for esophagectomy conduit
right gastro epiploic
What medication can be given for symptomatic improvement in patients undergoing serial dilations for benign stricure
Mitomycin C
what is the choice for bridging mesh repair for large hiatal defects
permanent
What percent of distal pancs become T1DM
10%