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Esophagus Flashcards

1
Q

Anatomy

A

Upper 1/3 esophagus – striated muscle. Middle 1/3 is mixed. Lower 1/3 smooth m

-Esophagus layers
-Mucosa
-Submucosa
-Muscularis propia
-No SEROSA

-Approaches to esophagus by level:
-Cervical – Left neck
-Mid thoracic – Right chest
-Distal – Left chest

-Anatomic areas of esophageal narrowing: cricopharyngeus muscle, aortic arch, left mainstem bronchus, LES

Esophagus is 30 cm long;
Incisor to cricopharyngeus 15 cm, to aortic arch indent 25, to diaphragmatic hiatus/LES 40 cm

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2
Q

Esophageal blood supply

A

-Cervical: inferior thyroid artery
-Thoracic: vessels directly off aorta; aortic branches and bronchial arteries
-Abdominal: left gastric & left inferior phrenic arteries

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3
Q

Primary blood supply to gastric conduit after esophagectomy:

A

Right gastroepiploic

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4
Q

Manometry

A

Pharyngeal contraction with food bolus: 70-120 mmHg
UES (cricopharyngeus): at rest 60-80, with food bolus 15. No pressure drop with food indicates lack of cricopharyngeus relaxation
LES: at rest 15 mmHg, with food bolus 0. With GERD resting is <6
Esophageal contraction with food bolus: 30-120. Ineffective if <10 mmHg throughout (ie burned out esophagus)

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5
Q

Manometry associated with GERD (Having one of these is diagnostic of defective LES):

A
  • Resting pressure < 6 mmHg
  • Total LES length < 2 cm
  • LES abdominal length < 2 cm
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6
Q

Cricopharyngeus

A

Cricopharyngeus = UES. prevents air swallowing. Innervated by recurrent laryngeal nerve and external branch of superior laryngeal nerve
MC site of esophageal perf. MCC is EGD
MC site for foreign body

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7
Q

Swallowing

A
  1. soft palate occludes nasopharynx
  2. larynx rises and airway opening is blocked by epiglottis
    3, cricopharyngeus relaxes
  3. pharyngeal contraction moves food into esophagus, 5. LES relaxes soon after initiation of swallow (vagus mediated)
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8
Q

Primary motility disorders

A

achalasia, diffuse esophageal spasm, nutcracker esophagus

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9
Q

Secondary motility disorders

A

Secondary – GERD (MC), scleroderma

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10
Q

Plummer Vinson Syndrome

A

Glossitis, iron deficient anemia, spoon shaped fingernails UPPER esophageal web!! Associated with oral CA Tx: dilation of web, Iron, and screen for oral CA

-Plummer-Vinson syndrome: iron deficiency anemia, esophageal webs, dysphagia, spoon-shaped fingernails (koilonychia)
-(A) Upper GI contrast study demonstrating esophageal web stenosis on a barium swallow examination in lateral view. (B) Upper GI endoscopy in a patient with an esophageal web.

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11
Q

Zenker’s

A

– Best test to dx = barium swallow. Manometry shows failure of relaxation of UES
- This is a Pulsion Diverticulum = false- located MC posterior midline, above cricopharyngeus muscle. Avoid EGD (perforation).
- Tx: Cricopharyngeal myotomy (left cervical incision) diverticulum can be resected or suspended

-Killian’s Triangle: triangular area in wall of pharynx located superior to cricopharyngeus muscle & inferior constrictor muscles
-Zenker’s diverticulum= more likely to occur in Killian’s triangle

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12
Q

Achalasia

A
  • RF for squamous CA of esophagus
  • Can have epiphrenic diverticulum
  • Definitive treatment options: endoscopic dilation, PEOM or Heller Myotomy
  • CCB and nitroglycerin short lived, lots of side effects, only think about using if not candidate for dilation, POEM or surgery
  • Botox – best medical therapy but needs repeat dosing q 6 month. Never offer if you can do dilation or surgery
  • Surgery Tx: Heller’s myotomy with PARTIAL fundoplication wrap, no nissen, Left thoracotomy if open
  • Heller’s Myotomy: Myotomy through longitudinal and circular muscle exposing the submucosa/mucosa
  • Incision extends 5-6 cm on proximal esophagus to 2 cm distal to GE junction
  • Muscle should be separated from esophagus 40% circumference to avoid re-healing
  • Perforation following balloon dilation for achalasia: left thoracotomy, repair perf, opposite side perform a longitudinal esophagomyotomy
  • Peroral endoscopic Myotomy (POEM) – Divides circular muscle layer but not outer longitudinal layer.
  • Equivalent to Heller’s with regards to symptom relief, post op GERD, and complication rate

-Achalasia: Incomplete relaxation of the LES (hypertonic) WITH aperistalsis or hypotonic esophageal contractions.
-Manometry findings, 3 Types:
-High, or normal, LES basal pressure
-Incomplete LES relaxation
-Hypotonic or absent peristalsis o Imaging
-Bird’s beak sign on barium swallow with esophageal dilation
-Caused by degenerative loss of nitric oxide producing inhibitory neurons within the LES, mixed etiology autoimmune, genetic, infectious
-Secondary to Chagas’ disease (Trypanosoma Cruzi)
-Pseudoachalasia = achalasia caused by malignancy
-Tx: Minimally invasive Heller myotomy with partial fundoplication (6 cm on esophagus, 2 cm onto stomach)
-Endoscopic therapies (Pneumatic dilation, Botulinum toxin injection): less effective, inc later surgical complication
-If perforate during dilation, myotomy after repairing esophagus

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13
Q

Diffuse esophageal spasm

A

Diffuse esophageal spasm – Chest pain and dysphagia. Simultaneous!! Frequent contractions, >20% non-peristaltic contraction. LES relaxes normally. Corkscrew esophagus
- Medical treatment 1st  CCB, trazadone
- Surgery not likely to improve symptoms, only if incapacitating dysphagia  Right thoracotomy Heller of UES and LES and partial fundoplication

Diffuse esophageal spasm
-Manometry findings:
-Normal LES pressure and relaxation
-High amplitude, uncoordinated esophageal contractions (>30mmHg simultaneous contractions is >10% of swallows)
-Tx: Ca channel blockers, nitrates. Surgery less effective. Long segment myotomy extreme cases.

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14
Q

Nutcracker esophagus

A

Nutcracker esophagus – MC primary esophageal dysmotility disorder. Chest pain and odynophagia. High amplitude and peristaltic contractions >180. LES relaxes normally

-Manometry findings: Normal LES pressure and relaxation; high amplitude, coordinated esophageal contractions
-Tx: Ca channel blockers, nitrates. Surgery less effective. Long segment myotomy extreme cases.

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15
Q

Esophageal Scleroderma

A

– Best test to make diagnosis is MANOMETRY low LES pressure, aperistalsis. High risk of esophageal adenocarcinoma.
Tx: PPI and Reglan. Indications for surgery: refractory GERD or complications of GERD (strictures, ulcers)  Esophagectomy

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16
Q

Surgical indications for GERD

A

Surgical indications for GERD – refractory (4 weeks of PPI), bleeding, esophagitis, stricture, asthma, cough, hoarseness, PNA, unable to take ant reflux meds or prefers not to take lifelong meds, Barret’s esophagus
Nissen
- Need to mobilize at least 2 cm of intrathoracic esophagus into the abdomen
A Demeester score > 14.72 indicates reflux.
MCC of dysphagia after fundoplication wrap too tight

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17
Q

-Esophageal diverticula:

A

-Zenker’s (Cervical) Diverticulum — due to dysfunction of superior esophageal sphincter muscles causing increased intraesophageal pressure; false pulsion diverticulum
-Division of upper esophageal sphincter is key to preventing continued symptoms, recurrence, and post operative fistula
-Diverticulum >3cm: Endoscopic division of upper esophageal sphincter, creating a common lumen between diverticulum and esophagus
-Diverticulum <3cm — need open myotomy (via left neck incision) with or without diverticulectomy (resection or suspension of diverticula)

-Epiphrenic esophageal diverticula= Pulsion diverticulum
-Associated with esophageal motility disorders
-Tx= Diverticulectomy + tx underlying motility disorder (generally Heller myotomy)
-Thoracic, mid-esophageal, diverticula
-TRACTION diverticula (True diverticula), associated with adjacent inflammatory conditions (e.g. tuberculosis, malignancy), can also be pulsion caused by mobility disorder
-If symptomatic: VATS diverticulectomy and myotomy

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18
Q

Peptic stricture

A

Peptic stricture JUST ABOVE EGJ! MCC of esophageal stricture  GERD
Tx: Biopsy all of these to rule out CA, start PPI, and endoscopic dilation. Will need repeated dilations, usually 1-3. Esophagectomy is last resort, consider this after 5 dilations.

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19
Q

Failed Nissen:

A

Failed Nissen:
- Complete Wrap disruption - with recurrence of hiatal hernia
- “slipped” wrap – Part of the stomach is above the wrap, but the wrap is still below the diaphragm – severe reflux
* If hiatal hernia also recurred  hourglass appearance causes severe reflux
- Herniated wrap – herniation of entire wrap above the diaphragm

Dysphagia following Nissen Clears for 1 week then dilate after a week
Post-Nissen and patient cannot swallow liquids or foamy saliva Re-operate
Recurrent reflux after nissen  Get barium
Gas bloating or delayed gastric emptying after Nissen  Tx: Reglan. If BL vagus injured  pyloroplasty

Perforation after Nissen  take down wrap, primary repair, redo wrap

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20
Q

Symptoms of GERD

A

Typical symptoms of GERD: Heartburn, DYSPHAGIA, water brash, epigastric pain, and regurgitation  these have the best chance to improve after Nissen 90%
Atypical symptoms of GERD: Cough, laryngitis, and aspiration have less of a chance to improve after Nissen 60-70%  indications for nissen

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21
Q

Dor vs Toupet vs Belsey Mark IV fundoplication

A

Dor fundoplication – Anterior 180-degree wrap
Toupet fundoplication – Posterior 270-degree wrap

Belsey Mark IV fundoplication – Transthoracic (left thoracotomy) 270 plication of the fundus buttressed by diaphragmatic crura

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22
Q

Hill esophagogastropexy

A

Used in patients who have undergone gastric surgery and don’t have enough fundus to wrap. Take lesser curvature around right side of esophagus and perform esophagogastropexy to median arcuate ligament

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23
Q

Paraesophageal hernia (hiatal)

A

Paraesophageal hernia (hiatal) Type II Type III and type IV
- Get esophagogram/UGI or CT with oral contrast.
- Must do EGD
- +/- manometry – do this if they have any dysphagia
- Treatment:
- Symptomatic  hiatal hernia repair with fundoplication
- Asymptomatic  DO NOT need repair. Risk of incarceration/strangulation is extremely low
Type 1 (sliding) hiatal hernia does not have a hernia sac. Type II-IV do. Distinguishing feature

24
Q

Hiatal hernia repair steps

A

First step of hiatal hernia repair is to reduce the hernia – with downward traction circumferentially incise hernia
Take down short gastrics
Penrose around GEJ
Excise hernia sac en block – landmark is esophageal fat pad
Mediastinal dissection – esophagus needs to be visualized up to the level of inferior pulmonary vein
Must ensure 2 cm of intra-abdominal esophagus, below diaphragm
Place bougie down to stomach
Primary closure of crura with non-absorbable suture

25
Q

Schatzki’s ring

A
  • Almost all have hiatal hernia
  • Submucosal fibrosis
  • MC symptom is dysphagia.
  • Ring lies at squamo-columnar junction.
  • Dx: Barium, can’t see it with EGD
  • If asymptomatic  leave alone. If symptomatic  dilation and PPI. Do not resect the ring.

-Patient with longstanding GERD and now with dysphagia. EGD demonstrates a narrowed ring of mucosal just above the GE junction

26
Q

Barret’s esophagus

A

Barret’s esophagus – Squamous to columnar metaplasia = Intestinal type metaplasia.
- These have goblet cells that secrete mucus  only type to cause cancer
Barret’s is an indication for anti-reflux surgery
Management:
- Non-dysplastic Barret’s – EGD q 3-5 years  treated like GERD  PPI
- LGD – #1 treatment: Start PPI, RADIOFREQUENCY ABLATION, NOT EMR
* Can also do EGD every 12 months with 4 quadrant biopsies at 1 cm interval for entire length
- HGD  Need 2 pathologists. Tx: Start PPI, endoscopic mucosal resection followed by Radiofrequency ablation is MC tx, can also do photodynamic therapy (using photofrin)
* Esophagectomy indicated in HGD if: end stage esophageal dysfunction, adenocarcinoma T1b (into submucosa), failed endoscopy treatment

-Barrett’s Esophagus
-Intestinal metaplasia of lower esophagus (Squamous Columnar)
-Mucosal reaction to lower esophageal injury due to reflux of gastric acid
-30-60x increased risk of esophageal adenocarcinoma
-Surveillance?
-EGD annually w bx; 2 consecutive years negative for dysplasia, q3 years
-4 quadrant biopsies every 1-2cm of involved segment
-Low-grade dysplasia on bx: repeat endoscopy w bx in 6 months
-High-grade dysplasia (HGD) on bx: repeat biopsy; endoscopic mucosal resection (EMR) if HGD confirmed

-Short segment < 3 cm= surveillance every 3-5 years
-Long segment > 3 cm= surveillance every 2-3 years

27
Q

Eosinophilic Esophagitis

A

Leading cause of dysphagia and food impaction in children and young adults
Symptoms: Dysphagia and GERD
Immune mediated
Classic endoscopic findings: Decreased vascular mucosal markings, longitudinal furrowing, Concentric rings (trachealization), white plaques
Treatment: 1st line: PPI, 2nd: topical steroids (inhalers or suspension)
No role for surgery

28
Q

Leiomyoma

A

Leiomyoma – MC esophageal tumor
Small risk of CA degeneration
Has smooth muscle cells
Lower 2/3 of esophagus  in the submucosa.
Symptoms: Dysphagia
Dx: Barium = best or EUS  “crescent shaped filling defect” smooth, hypoechoic, homogenous overlying mucosa is intact
NO BIOPSY
Tx: > 5 cm or symptomatic  enucleation via video assisted thorascopic enucleation

  • “Dysphagia with well circumscribed, ovoid 6cm mass on barium swallow in wall of mid esophagus”
    -Tx: For symptomatic tumors or tumors >5cm= Enucleation via VATS or thoracotomy (Right sided approach for mid esophageal lesions, Left sided approach for distal lesions)
    -DO NOT Bx= mucosal scarring and makes enucleation more dangerous/difficult
29
Q

Epiphrenic Diverticulum

A

Epiphrenic Diverticulum
These are false diverticulum = pulsion diverticulum
Zenkers = pulsion diverticulum
Distal 1/3 esophagus, near EGJ = epiphrenic
MCC = esophageal dysmotility disorders, MC = achalasia
Tx: Fix the underlying motility problem if present FIRST  balloon dilation for achalasia first
- If due to achalasia and refractory to treatment then do Diverticulectomy and esophageal Heller myotomy on opposite side of diverticulum

Traction diverticula = true diverticula
Caused by inflammatory processes (lymph nodes) pulling
Usually lies middle portion of esophagus
Leave alone unless causing sx

30
Q

Esophagitis Grade C and D

A

Esophagitis Grade C and D are pathognomonic for GERD
If diagnosed with esophagitis, need a repeat EGD in 3 months

31
Q

Caustic esophageal injury

A

Caustic esophageal injury
Risk of squamous cell CA later in life
Surgery = right thoracotomy
DO NOT PLACE NGT
Alkali- liquefactive necrosis. Worse injury in esophagus. More likely to cause cancer
Acid – coagulation necrosis; mostly gastric injury
CXR 1st to check for free air, if free air straight to OR.
IF there is no free air then do EGD best for diagnosis
EGD grading:
Grade 0 – Normal,
Grade 1 – Mucosal edema and hyperemia,
Grade 2A – Superficial ulcers, bleeding, exudates,
Grade 2B – Deep focal or circumferential ulcers,
Grade 3A – Focal necrosis
Grade 3B – Extensive necrosis
Grade 4 – Perforation
Degree of injury
- 1st degree burn shows, Hyperemia (key) → observe. Abx, IVF NPO for 3-4 days
- Second degree burn shows ulceration (key), exudate, sloughing → Prolonged therapy of above, unless there is perforation, then below
- Indications for esophagectomy: sepsis, peritonitis, mediastinitis, free air, mediastinal or stomach wall air, crepitence, contrast extravasation, pneumothorax, large effusion
- Third degree burn shows deep ulcer, NECROSIS (key), charring, lumen narrowing → esophagectomy through RIGHT thoracotomy

Surgery if perforated or necrosis
All require an exploratory laparotomy and cervicotomy with esophagogastrectomy (remove necrotic tissue), cervical esophagostomy and feeding jejunostomy.
Alimentary tract not restored until after patient recovers from caustic injury in 6 months.
High risk of strictures  no primary anastomosis of anything on initial surgery

32
Q

-Tylosis (Howel-Evans syndrome)

A

-AD, linked to chromosome 17q25; oral leukoplakia, thickened, yellowish skin on soles of feet & hands (palmoplantar keratoma)
-40-90% risk of SCC of esophagus by age 70 — annual Upper GI starting at age 20

33
Q

Fanconi anemia (not syndrome)

A

-Fanconi anemia (not syndrome): AR, DNA crosslink repair defect resulting in bone marrow failure
-SCC of head, neck, esophagus; pancytopenia

34
Q

Patient with esophageal cancer has severe dysphagia

A

-Patient with locally advanced esophageal cancer is undergoing neoadjuvant chemoradiation, has severe dysphagia and is malnourished: Jejunal feeding tube — NO G-TUBE OR PEG — Preserve gastric conduit

35
Q

Boerhaave’s syndrome

A

Boerhaave’s syndrome (spontaneous perforation)
Almost never contained perforations
Usually, present delayed and thus require an operation
Higher mortality when compared to iatrogenic perforations
MC left wall 3-5 cm above GEJ
Dx: Gastrograffin swallow = best
Left sided pleural effusion
Tx: Left thoracotomy  usually primary repair
- Usually reinforced with a wrap

36
Q

Esophageal perforations

A

Dx: gastrograffin esophogram. Followed by barium if there is no leak found on initial esophogram
- Only do EGD if above two is non-diagnostic – check for CA
- X-ray that shows evidence of perf (pneumomediastinum, pleural effusion, PTX, etc) should be followed up by contrast study to evaluate extent of injury (see if it’s contained)

Esophageal perforation: trauma (EGD, dilations, TE echo), inc luminal P (retching/ Boerhaave), malignancy, chemical ingestion
Dx:
-CXR: pleural effusion, pneumomediastinum, subcutaneous emphysema, pneumothorax, sub diaphragmatic air; may be normal
-Contrast esophagography (some may say oral contrast CT). Use water soluble first (Gastrografin) followed by dilute barium if no perforation seen w gastrografin. If aspiration risk, only dilute barium.
-MC site= distal esophagus in left posterolateral aspect 2-3cm above GE junction; Iatrogenic location= cricopharyngeus
-Tx: resuscitate, antibiotic for empiric coverage of Gram - rods, oral flora, anaerobes, fungus (e.g. ampicillin, ceftriaxone, metronidazole, fluconazole)
-Non-operative management for contained leaks, drainage alone, T-tube drainage, esophageal exclusion and diversion, esophageal stents/clips, primary repair with buttress, esophagectomy with either immediate or delayed reconstruction
-Isolated cervical esophageal injury: open neck and place drains
-Thoracic perforation: 1ary repair preferred if patient can tolerate — Left thoracotomy, debride devitalized tissue, myotomy to visualize full extent of mucosal injury, repair in 2 layers (inner absorbable, outer permanent), cover with well vascularized tissue (intercostal, omental, or latissimus flap), leak test, place NG past repair, drain chest, close. Also, consider placing enteral access.
-Consider esophagectomy for malignancy, caustic perforation, or burned out megaesophagus from achalasia
-If perforation from achalasia and esophagus normal, perform contralateral myotomy
-If severely devitalized esophagus and patient unstable — exclusion and diversion
-Closure of perforation, drainage, and cervical esophagostomy for proximal diversion
-Placing T-tube into defect and draining externally as controlled fistula
-J-tube enteral access for these situations

37
Q

Non-op management for esophageal perforation

A

Criteria requirements for nonoperative management of esophageal perforations:
- Mild symptoms
- Contained perforation
- Not draining into the peritoneum or pleura (must if present)
- Contained perforation into the mediastinum draining back into the esophagus (can do medical management)
- Not associated with cancer, obstruction or achalasia
NO evidence of sepsis
Medical Treatment = NPO, IV abx, and PPI
- Usually more applicable to iatrogenic perforations
- Spontaneous perforations (Borehaave’s) usually have to operate and can’t do non-op
- Repeat contrast imaging in 3-4 days. If negative, start liquid diet

38
Q

Surgical management for esophageal perforation

A

Non-contained perforations or septic patients
- Primary repair (Timing of presentation doesn’t matter anymore)
- 1st do longitudinal myotomy to see extent of injry, then primary repair, place drains
- Cervical– Primary repair. if you can’t find perf. Just wash out and place drain. Also, can use strap muscles to buttress primary repair
Thoracic upper 2/3 – RIGHT 5th ICS, use intercostal muscle to buttress.
- Thoracic lower 1/3: LEFT Posterolateral thoracotomy, through 7th ICS, use intercostal mm or diaphragm mm to buttress
- If perforated into the abdomen  will need ex lap
- All need repeat gastrograffin study POD 5
- Exceptions to primary repair (try to do primary repair, best treatment)
- Cervical esophagostomy (diversion) – highly morbid. Never do this just because patient presents delayed. Only time you would consider this is if:
 The patient is severely unstable
 Widespread necrosis of esophagus not amenable to primary repair
 Perforation too large for primary repair
- Esophageal stent placement
 Ideal for iatrogenic perforations from EGD and malignant perforations in patients who are stable
 For patients who are NOT septic!!
 If malignant perforation and unstable or massive contamination  diversion
 If stent placement not available then malignant perforations need an esophagectomy
 If stent is used, must be combined with drainage procedure: VATS wash out or percutaneous drain,

Intra-abdominal perforation  laparotomy, primary repair, then perform a fundoplication, and feeding J

Esophageal perforation after dilation for achalasia
- Usually distal perf  Left posterolateral thoracotomy in 7th ICS
- Treatment: Primary repair with flap AND esophageal myotomy on the other side

39
Q

Overall indications for esophageal stent placement

A
  • Luminal patency for intrinsic/extrinsic malignant compression
  • Malignant esophageal fistula
  • Contained esophageal perforations
  • anastomotic leak in patients who are NOT septic
    Most common complication is stent migration
    Must perform esophogram 2-3 days out to ensure seal of stent
    Stent must be removed in 14 days  prevents migration, tracheo-esophageal fistula, aortoesophageal fistula
    Should never use stent if: Injury > 6 cm, crosses the GEJ, near cervical esophagus or if leak associated with gastric conduit after esophagectomy
40
Q

Esophagectomy indications in perforated esophagus:

A
  • Achalasia (must be severely dilated, tortuous, burnt out esophagus otherwise primary repair then myotomy on other side),
  • Stricture
  • Malignancy

Esophagectomy for perforations is contraindicated in SEPTIC OR SICK patient  need deversion

41
Q

Esophageal cancer

A

MC esophageal CA is adenocarcinoma in US. SCC MC in the world

Usually diagnosed at end stage and metastatic

Spreads along submucosal lymphatics

Risk factors: ETOH, smoking, caustic injury, acid reflux

Adenocarcinoma = lower 1/3, Liver MC site of mets. MC Caucasians

Squamous cell = upper 2/3. Lung MC mets. MC African American
Most important prognostic factor is nodal disease

-Esophageal and Esophagogastric Junction Cancer
-M>W
-SCC: MC in Asia and Eastern Europe; risk factors= tobacco, ETOH, diet low in fruits & vegetables
-Adenocarcinoma MC in N. American and W. Europe; risk= obesity, GERD, Barretts
-WU: endoscopy w bx (+bronch if tumor above carina), CT chest/abdomen; EUS with FNA of suspicious nodes and PET/CT also recommended for staging

42
Q

Esophageal cancer unresectability

A

Unresectability: Nodes outside of resection, hoarseness (RLN invasion), Horner’s syndrome (brachial plexus), phrenic nerve invasion, malignant pleural effusion, malignant fistula¸T4b  aortic/vertebral/tracheal involvement
- These are treated with definitive chemo-radiation, especially for SCC

Resectable T4a  pleural/pericardium/diaphragmatic invasion

43
Q

Isolated hypertensive LES

A

-Manometry findings:
-High basal LES pressure
-Complete LES relaxation
-Normal peristalsis
-Tx: Ca channel blockers, nitrates, Heller

44
Q

Staging

A
  • 1st get EGD
  • EUS – Best for T status and see local lymph nodes
  • EMR is actually best if there is a nodular lesion
  • Ch/Abd CT is best test for resectability – check for mets
  • PET-CT
45
Q

neo/post chemo

A

Neoadjuvant chemo and radiation  improves overall survival
Preop chemo-XRT can downstage tumor - indicated in positive nodes T2 or greater (Through submucosa into muscularis propria) or greater
Post op chemo – indicated in T2 or node positive disease
Carboplatin and paclitaxel or 5FU and cisplatin

46
Q

T1a

A

T1a (lamina propria or muscularis mucosa)
- Most do EMR
- Radiofrequency ablation is used if there is residual disease after EMR or if lesion is not visible

47
Q

T1b

A

T1b into submucosa: can go straight to surgery (esophagectomy) with neoadjuvant therapy

48
Q

Patients who are UNFIT for surgery, especially with Squamous cell cancer

A

Patients who are UNFIT for surgery, especially with Squamous cell cancer can be treated with definitive chemo-radiation

49
Q

Esophagectomy for esophageal CA

A
  • Need 6-8 cm margins
  • Right gastroepiploic - primary blood supply after esophagectomy (have to divide left gastric and short gastric)
  • Neck anastomosis has higher leak rate but decreased mortality from leak vs thoracic anastomosis
  • Trans-hiatal approach - neck and abdominal incisions. Has cervical anastomosis
  • Ivor-Lewis- abdominal and R thoracotomy incisions. Exposes the entire intra-thoracic esophagus. Intrathoracic anastomosis
  • 3-hole thoracotomy (Mckeown)- abdominal, thoracic and cervical incisions – cervical anastomosis
  • Newest studies showing no difference in mortality or morbidity between trans-hiatal and transthoracic
  • Except trans-hiatal has a lower hospital LOS
  • Perform an esophagogastrostomy for anastomosis. Can also do esophagojejunostomy if no stomach available.
  • In pediatrics if no stomach  Colonic interposition (take left colon) – Best to use in pediatric/young patients
  • Need pyloroplasty/pyloromyotomy or botox to pylorus for these procedures
  • Need feeding J tube for all
  • Malignant fistula  esophageal covered stent
50
Q

During esophagectomy: anesthesia says there is an air leak

A

MC tear in distal trachea or left mainstem  Bronch to Dx  Right thoracotomy

51
Q

Bleeding intra-op during esophagectomy (with trans-hiatal)

A
  • High and dark blood  right thoracotomy  look for tear in azygous vein
  • Low and bright  left thoracotomy  look for aortic branch tear
  • Intra-abdominal – MC spleen
52
Q

After esophagectomy, leak: (early)

A
  • Any leak after esophageal anastomosis is ALL about the gastric conduit viability!!! Must visualize it diagnostic thoracoscopy vs EGD
  • Leak after Ivor lewis (thoracic anastomosis):
  • If gastric conduit viable  drainage procedure using the thoracoscopy or chest tube
  • If gastric conduit not viable (necrotic, gangrenous) 
     resect via right thoracotomy
     bring stomach down to abdomen
     Cervical esophagostomy and feeding J. Late reconstruction with colon (3 months)
  • Cervical anastomosis LEAK – you find a large leak or has wound infection  go to OR, open wound
  • if stomach (conduit) is viable  wash out, place drains, loosely lose neck incisions, keep NPO
  • If stomach is necrotic  resect necrotic portion and return stomach to abdomen, cervical esophagostomy, late reconstruction with colon (3 months)
53
Q

Ivor Lewis esophagectomy

A
  • Divide gastrocolic ligament, preserve right gastroepiploic. Divide left gastroepiploic and short gastric
  • Divide the gastrohepatic ligament and preserve the right gastric artery.
  • Divide the left gastric vessels.
  • Dissect hiatus and mobilize distal esophagus circumferentially within mediastinum.
  • Gastric drainage procedure: pyloromyotomy, pyloroplasty, or Botox injection to prevent delayed gastric emptying.
  • Initiate staple line to create the 4–5 cm-wide gastric conduit (optional).
  • Create feeding jejunostomy.
  • Reposition patient in the left lateral decubitus position.
  • Right posterolateral thoracotomy through the fifth intercostal space.
  • Divide the azygos vein.
  • Dissect the esophagus from the hiatus up toward the thoracic outlet. Include paraesophageal and subcarinal lymph nodes in the specimen.
  • Pull stomach into the chest and create a 4–5 cm-wide gastric conduit.
  • Divide the esophagus proximally and remove the specimen.
54
Q

Endoscopic mucosal resection (EMR)

A

Endoscopic mucosal resection (EMR) is particularly useful for low-stage esophageal cancers as they can be managed without need for esophagectomy. This is the preferred method of resection for Tis (limited to the epithelium) and T1a (has not penetrated through the muscularis mucosa into the submucosa) esophageal cancers as the risk of nodal metastasis is negligible (< 2%). The operative mortality is 2% after an esophagectomy; therefore, the risk-benefit analysis is favorable for EMR in stage T1a tumors.

Stage T1b tumors (infiltrates into submucosa but does not penetrate muscularis propria), as in the above patient, have a widely varying range of nodal involvement (from a few percent to up to 60%). Therefore, in order to decide on esophagectomy vs EMR for these patients, the tumor characteristics have to be examined.

Good candidates for EMR for T1b tumors are those with tumors < 2 cm, well to moderately differentiated tumors, lack of lymphovascular invasion around the tumor, tumor limited to SM1 level of submucosa, and no enlarged lymph nodes seen on staging imaging. Involvement of SM3 submucosa level would increase the likelihood of lymph node involvement, which would make esophagectomy in an otherwise fit surgical candidate the superior method of resection. T1b lesions that are larger, moderately to poorly differentiated, have lymphovascular invasion, or have enlarged lymph nodes on staging workup should undergo esophagectomy if otherwise fit for surgery.

55
Q

Esophageal CA Management:

A

-Preoperative chemoradiation (CROSS study) and perioperative chemotherapy (MAGIC Trial) improves survival in resectable esophageal and esophagogastric CA

-Thoracic esophageal CA >5cm from cricopharyngeus, abdominal esophageal CA, and EGJ CA: esophagectomy for resectable lesions

-Cervical or cervicothroacic esophageal CA <5cm from cricopharyngeus: chemoradiation, no esophagectomy

-Fluorouracil or Taxane based therapy for perioperative and definitive chemo

-NCCN Recommendations

-HGD, Tis or select T1a tumors (<2cm and well to moderate differentiation with no e/o lymph node metastasis): endoscopic resection +/- ablation
-T1b, N0 tumors: Esophagectomy
-Young patients, and those with high grade T1 lesions: neoadjuvant chemoradiation
-T2 or greater or any N+: Neoadjuvant chemoradiation followed by esophagectomy if resectable
-Unresectable (T4b or M1): definitive chemoradiation
-Surgical approaches:
-Transthoracic Esophagectomy
-Ivor-Lewis esophagectomy — Laparotomy and right thoracotomy with upper thoracic esophagogastric anastomosis — good for distal tumors
-Stomach mobilized and used as conduit, preservation of right gastric and right gastroepiploic artery
-McKeown esophagectomy is similar except anastomosis made higher (cervical anastomosis) — better for more proximal lesions
-Transhiatal Esophagectomy: Laparotomy and left cervical incision with cervical anastomosis
-Advantages: Avoid thoracotomy, leak with cervical anastomosis better tolerated than thoracic leak
-Disadvantages: Potentially smaller lymph node harvest, Large mid thoracic level tumors may be difficult to mobilize
-Equal long term survival as Transthoracic approach
-Patient had previous gastric resection: Colon interposition conduit
-Adjuvant therapy IN GENERAL
-SCC does not need adjuvant therapy if R0 resection (regardless of nodal status)
-Adenocarcinoma generally get adjuvant chemo, except when: T1, NO and R0 resection and did NOT receive neoadjuvant therapy

56
Q

Esophageal varices

A

-2 large-bore IVs, intubated, tranfusion target 25-30% hematocrit leves (over transfusion may worsen portal HTN), correct coagulopathy, octreotide to lower portal pressure & increase splanchnic vasoconstriction; PPI

EGD using sclerotherapy and banding

If bleeding recurs: TIPs considered

If bleeding not stopped, baloon tamponade with Sengstaken-Blakemore tube or Minesota tube

57
Q

Nissen fundoplication

A

-Crural disection
-Preservation of vagi
-Circumferential dissection of esophagus
-Crural closure
-Fundic mobilization by division of short gastric vesels
-Loose fundoplication by enveloping anterior and posterior wall of fundus aound lower esophagus

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