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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
What kind of diverticuli form in the mid-thoracic esophagus? How are they treated?
- these are traction diverticuli (true diverticuli), usually associated with adjacent inflammatory conditions - treat with VATS diverticulectomy and myotomy if symptomatic
26
What is Barrett's esophagus?
an intestinal metaplasia of the lower esophagus from squamous to columnar epithelium
27
Why is Barrett's disease important?
it conveys a 30-60x increased risk of esophageal adenocarcinoma
28
What surveillance is recommended for Barrett's?
- annual EGD - space to every 3 years if no evidence of dysplasia x2 - perform 4 quadrant biopsies every 1-2cm
29
What is the recommended management of a patient who is found to have low grade dysplasia on surveillance EGD for Barrett's?
repeat in 6 months with biopsies
30
What is the recommended management of a patient found to have high grade dysplasia on surveillance EGD for Barrett's?
- repeat biopsy and confirm with expert GI pathologist - EMR if confirmed - no longer recommending esophagectomy
31
What is the most common benign tumor of the esophagus?
leiomyoma
32
How should esophageal leiomyomas be managed?
- endoscopic resection or enucleation if < 5cm - VATS or lap resection for > 5cm
33
What kind of esophageal cancer is more prevalent in the US?
adenocarcinoma > SCC
34
EtOH and smoking are risk factors for what kind of esophageal cancer?
SCC
35
What should be included in the staging workup for esophageal cancer?
- endoscopy and biopsy - bronchoscopy if above the carina - CT C/A/P - PET scan - EUS/FNA of any suspicions nodes
36
How is esophgeal cancer staged?
- essentially the same as gastric - T4a: resectable (pleural, pericardium, diaphragm) - T4b: unresectable (aorta vertebrae, trach)
37
What T4 esophgeal cancers are unresectable (T4b)?
those invading the aorta, trachea, or vertebrae
38
What is the best predictor of long-term survival in esophageal cancer?
nodal involvement
39
Which esophageal cancer patients should get chemoradiation?
T2 (invades muscularis propria) and higher
40
Which esopahgeal cancers can be managed with endoscopic mucosal resection or ablation?
- 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
Describe an Ivor Lewis esophagectomy.
- laparotomy and right thoracotomy with upper thoracic esophagogastric anastomosis - ideal for distal tumors
42
Describe a McKeown esophagectomy.
- similar to Ivor Lewis (right thoracotomy and laparotomy) with higher, cervical anastomosis - appropriate for slightly more proximal esophageal lesions
43
Descibe a transhiatal esophagectomy.
- 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
Which esophageal cancer patients should get adjuvant therapy?
- none for SCC - almost all for adenocarcinoma (except T1N0 with R0 resection and no neoadjuvant chemo)
45
How is esophageal cancer <5cm from criopharyngeus treated?
with definitive chemoradiation
46
What are the anatomic areas of esophageal narrowing?
- UES - aortic arch - left mainstem bronchus - LES
47
What is the primary blood supply to a gastric conduit after esophagectomy?
the right gastroepiploic
48
What diagnosis should be considered in a patient dysphagia and skin thickening of the palms/soles? Why is this important?
- tylosis, an autosomal dominant condition - increased risk of esophageal SCC, so need annual EGD at age 20
49
What diagnosis should be considered in a patient with SCC fo the head/neck, esophageus, and pancytopenia?
Fanconi anemia
50
How is a Schatzki's ring managed?
with dilation and PPI
51
Why shouldn't you biopsy esophageal leiomyomas?
creates mucosal scarring and makes enucleation more difficult
52

BTK Review 2024 (19 decks)

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