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btk review 2024 > Esophagus > Flashcards

Esophagus Flashcards

1
Q
A
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2
Q

Describe the arterial blood supply to the esophagus.

A
  • cervical: inferior thyroid artery
  • thoracic: branches off aorta
  • abdominal: left gastic and inferior phrenics
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3
Q

What muscle comprises the upper esophageal sphincter? What is its innervation?

A
  • the cricopharyngeus muscle
  • the recurrent laryngeal
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4
Q

What is Killian’s triangle?

A
  • a triangular area in the anaterior wall of the pharynx between the cricopharyngeus muscles inferiorly and the inferior constrictor muscles superiorly
  • the area of a Zenker’s diverticulum
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5
Q

What is the most common site of non-iatrogenic versus iatrogenic esophageal perforation?

A
  • non-iatrogenic: distal esophagus, left posterolateral, 2-3 cm above GEJ
  • iatrogenic: cricopharyngeus
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6
Q

What stitches should be used to repair an esophageal injury?

A

inner absorbable layer and outer permanent layer

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7
Q

What incision should be used to access the esophagus?

A
  • upper: left anterior SCM incision
  • middle: right posterolateral thoracotomy
  • lower: left postterolateral thoracotomy
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8
Q

For which causes of esophageal perforation would you consider esophagectomy?

A
  • perforated malignancy
  • caustic ingestion
  • burned-out megaesophagus
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9
Q

What surgical approach would you take for an unstable patient with severely devitalized esophageal tissue?

A

exclusion and diversion

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10
Q

What defines achalasia?

A

incomplete relaxation of the LES with apersistalsis or hypotonic esophgeal contractions

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11
Q

What causes achalasia?

A

a degenerative loss of NO-producing inhibitory neurons within the LES

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12
Q

Bird’s beak esophagram is suggestive of what diagnosis?

A

achalasia

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13
Q

What is pseudoachalasia?

A

that which occurs in the context of malignancy

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14
Q

How long should a myotomy be for achalasia?

A

6cm onto esophagus and 2cm onto stomach

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15
Q

What alternatives to myotomy exist for the treatment of achalasia? What are the downsides?

A
  • botox injection
  • pneumatic dilation
  • but these are less effective and increase the likelihood of later surgical complications
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16
Q

How should you proceed in a patient with achalasia who sustains a perforation while performing a Heller?

A

repair the perforation and perform a contralateral myotomy

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17
Q

What are the options for managing hypertensive LES?

A
  • CCB and nitrates
  • Heller
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18
Q

Describe the manometry findings for those with diffuse esophageal spasm.

A
  • normal LES tone and relaxation
  • high amplitude, uncoordinated esophgeal contractions (>30mmHg simultaneous contractions for > 10% of swallows)
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19
Q

What are the management options for patients with diffuse esophageal spasm?

A
  • CCB and nitrates
  • long segment myotomy if severe/refractory but less effective
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20
Q

How does nutcracker esoaphgeus differ from diffuse esophagela spasm?

A

nutcracker patients have high, amplitude but coordinated esophageal contractions while diffuse spasm patients have uncoordinated contractions

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21
Q

What are the managment options for patients with nutcracker esophagus?

A
  • CCB and nitrates
  • long segment myotomy if severe/refractory but less effective
22
Q

How is a Zenker’s diverticulum managed?

A
  • if < 3cm need open myotomy with or without diverticulectomy
  • if > 3cm can do an endoscopic division of upper esophgeal sphincter
23
Q

What kind of diverticulum is a Zenkers?

A

a false pulsion diverticulum

24
Q

What kind of diverticulum is an epiphrenic esophageal divertic? How is it treated?

A
  • pulsion diverticulum associated with motility disorders
  • treat with diverticulectomy and treatment of underlying motility issue
25
Q

What kind of diverticuli form in the mid-thoracic esophagus? How are they treated?

A
  • these are traction diverticuli (true diverticuli), usually associated with adjacent inflammatory conditions
  • treat with VATS diverticulectomy and myotomy if symptomatic
26
Q

What is Barrett’s esophagus?

A

an intestinal metaplasia of the lower esophagus from squamous to columnar epithelium

27
Q

Why is Barrett’s disease important?

A

it conveys a 30-60x increased risk of esophageal adenocarcinoma

28
Q

What surveillance is recommended for Barrett’s?

A
  • annual EGD
  • space to every 3 years if no evidence of dysplasia x2
  • perform 4 quadrant biopsies every 1-2cm
29
Q

What is the recommended management of a patient who is found to have low grade dysplasia on surveillance EGD for Barrett’s?

A

repeat in 6 months with biopsies

30
Q

What is the recommended management of a patient found to have high grade dysplasia on surveillance EGD for Barrett’s?

A
  • repeat biopsy and confirm with expert GI pathologist
  • EMR if confirmed
  • no longer recommending esophagectomy
31
Q

What is the most common benign tumor of the esophagus?

A

leiomyoma

32
Q

How should esophageal leiomyomas be managed?

A
  • endoscopic resection or enucleation if < 5cm
  • VATS or lap resection for > 5cm
33
Q

What kind of esophageal cancer is more prevalent in the US?

A

adenocarcinoma > SCC

34
Q

EtOH and smoking are risk factors for what kind of esophageal cancer?

A

SCC

35
Q

What should be included in the staging workup for esophageal cancer?

A
  • endoscopy and biopsy
  • bronchoscopy if above the carina
  • CT C/A/P
  • PET scan
  • EUS/FNA of any suspicions nodes
36
Q

How is esophgeal cancer staged?

A
  • essentially the same as gastric
  • T4a: resectable (pleural, pericardium, diaphragm)
  • T4b: unresectable (aorta vertebrae, trach)
37
Q

What T4 esophgeal cancers are unresectable (T4b)?

A

those invading the aorta, trachea, or vertebrae

38
Q

What is the best predictor of long-term survival in esophageal cancer?

A

nodal involvement

39
Q

Which esophageal cancer patients should get chemoradiation?

A

T2 (invades muscularis propria) and higher

40
Q

Which esopahgeal cancers can be managed with endoscopic mucosal resection or ablation?

A
  • those with high grade dysplasia or T1a tumors < 2cm, moderate-to-well differenated, without nodal disease
  • remember the submucosa is rich with lymphatics, so T1b are at higher risk for spread
41
Q

Describe an Ivor Lewis esophagectomy.

A
  • laparotomy and right thoracotomy with upper thoracic esophagogastric anastomosis
  • ideal for distal tumors
42
Q

Describe a McKeown esophagectomy.

A
  • similar to Ivor Lewis (right thoracotomy and laparotomy) with higher, cervical anastomosis
  • appropriate for slightly more proximal esophageal lesions
43
Q

Descibe a transhiatal esophagectomy.

A
  • laparotomy and left cervical incision with cervical anastomosis
  • no thoracotomy and cervical leaks are better tolerated
  • but has lower lymph node harvest and can be difficult to mobilize mid-thoracic tumors
44
Q

Which esophageal cancer patients should get adjuvant therapy?

A
  • none for SCC
  • almost all for adenocarcinoma (except T1N0 with R0 resection and no neoadjuvant chemo)
45
Q

How is esophageal cancer <5cm from criopharyngeus treated?

A

with definitive chemoradiation

46
Q

What are the anatomic areas of esophageal narrowing?

A
  • UES
  • aortic arch
  • left mainstem bronchus
  • LES
47
Q

What is the primary blood supply to a gastric conduit after esophagectomy?

A

the right gastroepiploic

48
Q

What diagnosis should be considered in a patient dysphagia and skin thickening of the palms/soles? Why is this important?

A
  • tylosis, an autosomal dominant condition
  • increased risk of esophageal SCC, so need annual EGD at age 20
49
Q

What diagnosis should be considered in a patient with SCC fo the head/neck, esophageus, and pancytopenia?

A

Fanconi anemia

50
Q

How is a Schatzki’s ring managed?

A

with dilation and PPI

51
Q

Why shouldn’t you biopsy esophageal leiomyomas?

A

creates mucosal scarring and makes enucleation more difficult

52
Q
A

btk review 2024 (19 decks)

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