ESOPHAGUS Flashcards
Barrett esophagus complicated by dysplasia should be treated aggressively. Patients whose specimens are indefinite for dysplasia and Barrett esophagus should be managed how
aggressive medical regimen,
proton pump inhibitor therapy for 3 months,
then undergo a second biopsy.
Patients with low-grade dysplasia should be treated with either aggressive medical therapy or antireflux surgery.
Surveillance follow-up, however, after antireflux surgery
may be difficult because biopsies within the wrap may be difficult for the inexperienced surgeon to perform.
most common benign tumor of the esophagus
Leiomyoma
accounts for almost two-thirds of all benign tumors of the esophagus.
benign tumor derived from smooth muscle cells.
Therefore, over 90% of leiomyomas of the esophagus are isolated to the middle to distal esophagus.
Evaluation of a patient with suspected leiomyoma includes barium swallow, CT scan of the chest and abdomen, and endoscopy.
must be aware of the increased risk of esophageal perforation associated with EUS-FNA of the esophagus.
transhiatal esophagectomy is the preferred approach by many surgeons why - what are potential disadvantage is
lower morbidity Avoiding thoracotomy
view or pulmonary complications
pulmonary complications.
anastomosis in the neck, a leak, should it occur, can be treated by simple bedside cervical drainage.
may not provide an optimal cancer operation.
The successful performance of a laparoscopic fundoplication includes What steps
crural dissection
identification and preservation of both vagi,
including the hepatic branch of the anterior vagus.
a large left hepatic artery arising from the left gastric artery is present in up to 25% of patients and should also be identified and avoided.
The esophagus should be circumferentially dissected and both crura identified and closed posteriorly behind the esophagus.
The fundus is mobilized, and the short gastric vessels are divided.
short, loose fundoplication is created by enveloping the lower esophagus with the anterior and posterior walls of the fundus.
The most common error in constructing a fundoplication is
to grasp the anterior portion of the stomach and pull it behind the esophagus. This technique results in the twisting of the gastric fundus around the esophagus.
Rather, the esophagus should be enveloped by an untwisted fundus before suturing.
Most common cause of Barrett’s esophagus
gastroesophageal reflux,
The frequency, severity, and duration of reflux symptoms are correlated with an increased risk of developing esophageal adenocarcinoma. Patients with recurring symptoms of reflux have an eightfold increase in the risk of esophageal adenocarcinoma.
Barrett esophagus develops in approximately 5% of patients with gastroesophageal reflux disease.
development of Metaplasia from squamous to columnar epithelium distally continuous with gastric mucosa.
Obesity
Symptomatic Barrett’s esophagus should be managed how
medically as any other gastroesophageal reflux disease.
Antireflux procedures should be considered for symptomatic cases.
Nissen fundoplication would not be indicated or essential management in a patient with a one-month history of symptomatic reflux and no trial of medical management.
gold standard” for the diagnosis of GERD
Twenty-four-hour ambulatory pH monitoring is currently considered the
the highest sensitivity and specificity of all tests available.
Threshold pH considered positive for GERD
pH of 4 as the threshold.
Radiographic assessment of the anatomy of the esophagus and the stomach In the workup of GERD
one of the most important parts of the preoperative evaluation.
assess:
esophageal shortening,
the size reducibility of a hiatal hernia,
the propulsive function of the esophagus with both liquids and solids.
may influence the decision to perform a partial rather than a complete fundoplication
The presence of poor esophageal body function,
likelihood of relieving
regurgitation,
dysphagia,
respiratory symptoms
function of the esophageal body is best assessed with esophageal manometrics.
Patients with Barrett’s segments should be followed by regular surveillance esophagogastroduodenoscopy (EGD) With what regimen
biopsies (4-quarter biopsies every 1-2 cm),
2 negative scopes by current literature allows for Q3 year surveillance
Adenocarcinoma of the esophagus and gastric cardia affects what patient population
white men disproportionately and rarely occurs among women.
Squamous cell carcinoma What patient population and location in the esophagus
accounted for 71% of the esophageal cancers
middle third of the esophagus was the primary location for squamous cell cancers,
Adenocarcinoma of the esophagus In the United States incidence
over the past 30 years the incidence has risen faster than any other cancer in the United States.
Barrett’s Endoscopically, it is recognized by
inflamed “salmon-colored” mucosa extending from the gastroesophageal junction.
Microscopic evaluation reveals replacement of the normal stratified squamous epithelium of the esophagus with columnar epithelium more typical of other parts of the gastrointestinal tract.
Thus, these changes are often referred to as “intestinalization” of the mucosa.
Goblet cells-
With progression to dysplasia, the nuclei become “crowded” and the normal glandular architecture is lost.
Reports document the ability of laparoscopic fundoplication to relieve typical reflux symptoms (heartburn, regurgitation, and dysphagia) in what percentage
more than 90% of patients in a follow-up interval approaching 3 years in some series.
Temporary dysphagia is common after surgery and generally resolves within 3 months.
Dysphagia persistent beyond 3 months occurs usually in less than 10% of patients.
cost utility analyses of long-term medical therapy versus laparoscopic fundoplication for gastroesophageal reflux
laparoscopic surgery is the most cost-effective treatment of patients likely to require lifelong therapy.
The primary risk factor for squamous cell carcinoma of the esophagus is
chronic irritation of the esophageal mucosa.
alcohol consumption, especially in combination with tobacco
Nitrosamines
nitrosyl compounds found in smoked meats also are important factors in native populations who rely on these for their main source of nutrition.
Medical conditions including achalasia, caustic strictures, Plummer-Vinson syndrome, and tylosis also increase the risk of squamous cell carcinoma. The risk with long-standing achalasia approximates 7%
ain blood supply to the cervical portion of the esophagus
The inferior thyroid artery
The thoracic portion of the esophagus receives its blood supply from
two sources:
branches from two or three bronchial arteries provide the proximal arterial supply,
and
branches directly from the aorta supply the more distal thoracic esophagus.
the venous drainage of the esophagus
venous plexus in the submucosa
delivers it into a periesophageal venous plexus.
left gastric vein or coronary vein provides the principal collateral in portal hypertension when esophageal varices develop.
The submucosal veins become much more superficial in the most distal esophagus, 1 to 2 cm above the gastroesophageal junction, and are consequently the most common site of bleeding in portal hypertension.
The lymphatic vessels of the esophagus
submucosal network
drains into regional lymph nodes in the periesophageal connective tissue.
Lymphatic drainage from the upper two thirds of the esophagus usually is where
cephalic,
drainage from the lower one third of the esophagus is usually
in both directions.
Although lymphatic metastasis in the esophagus generally involves the regional lymph nodes in proximity, nodal involvement can occur several centimeters away from the primary lesion because of the rich intramural lymphatic anastomotic channels.
When carcinoma is limited to the mucosa, the incidence of lymphatic metastasis is low, but once the lesion enters the submucosa, the incidence increases to 60%!
neoadjuvant chemoradiotherapy for esophageal carcinoma
significantly prolongs disease-free interval
AND survival in patients with esophageal carcinoma,
BOTH for adenocarcinoma and squamous cell carcinoma.
The chemoradiotherapy consists of cisplatinum and fluorouracil (5-FU) given concomitantly with 40 to 60 cGy directed AT THE MEDIASTIUM!
NOT for Patients with T1 and T0 lesions have a survival rate of approximately 90% after operation alone and should not be offered neoadjuvant therapy.
T2 or T3 lesions or those with nodal metastasis are good candidates for neoadjuvant chemotherapy!
(1995 data SCORE refts)..
The cervical esophagus
5 cm long,
C6- T1,
curving slightly to the LEFT in its descent.
surgical approach is LEFT incision along the anterior border of the sternocleidomastoid muscle,
relationship of esophgus to aorta as it descends
Above tracheal bifurcation, the esophagus moves to the right of the descending aorta.
Below tracheal bifurcation esophagus moves to the left,
passes behind the tracheal bifurcation and the left main bronchus,
lower third, the esophagus courses anteriorly and to the left to pass through the diaphragmatic hiatus.
general, the lower part of the esophagus is most easily approached through the
left side of the chest,
but access to the supra-aortic esophagus is restricted.
Thus, left thoracotomy is most useful for performing procedures involving the lower part of the esophagus.
access to the entire thoracic esophagus can be obtained only from the
right side of the chest.
This incision, however, limits access to intra-abdominal organs by the position of the liver and therefore normally necessitates a separate upper abdominal incision.
The next step in management of a patient with a suspected esophageal rupture
confirm the location
assess if leak is contained.
. Cervical esophagus is approached through
a left oblique incision in the neck.
Upper 2/3 of thoracic esophagus is approached through
right posterolateral thoracotomy in the fourth or fifth intercostal space.
Lower 1/3 of thoracic esophagus is approached through
LEFT posterolateral thoracotomy in sixth or seventh intercostal space.
Mid-thoracic esophageal rupture is associated with a rupture on what side
right sided pleural effusion.
Abdominal esophagus is approached through
upper midline laparotomy.
esophageal rupture is suspected with left medialstinitis what is next test after cxr
Gastrografin next
to identify the extent and location of the rupture
Sabistin / master of surg 2008
success rate of healing in GERD with severe esphagitis treated with PPI
healing may occur in only three fourths of patients with severe esophagitis.
The most effective nonsurgical treatment of achalasia is
pneumatic dilation. The goal of this treatment is to “rupture” the LES.
medical treatment of achalasia
Botulinum toxin inhibits the release of acetylcholine from nerve terminals, initial efficacy rate of about 80% to 85%.
Unfortunately, symptom recurrence can be as high as 50% within 6 months.
Muscle relaxants
(calcium channel blockers or
sublingual isosorbide dinitrate)
variable and usually decreases with a prolonged use. .
Manometric measurements of lower esophageal and the relationship of the severity of esophagitis
NOT releated!
correlation of Increasing grades of esophagitis seen endoscopically correlate well with both the severity of reflux symptoms and the extent of esophageal dysmotility
excellent correlation
The most sensitive and specific method of testing for gastroesophageal reflux is
24-hour intraesophageal pH monitoring.
what percent of GERD does not have endoscopic evidence of esophagitis.
However, 30% of persons with symptomatic gastroesophageal reflux will have no endoscopic evidence of esophagitis.
most common diverticulum of the esophagus
A Zenker or pharyngoesophageal diverticulum
Zenker or pharyngoesophageal diverticulum
weakness in the posterior pharyngeal constrictor muscle just above the cricopharyngeus muscle.
pulsion-type pseudodiverticulum
underlying motility disorder manifested by incoordinated or incomplete relaxation of the upper esophageal sphincter (cricopharyngeus) during swallowing.
Symptoms are an indication for surgical intervention.
The traditional surgical approach Zenker
left cervical incision made along the border of the sternocleidomastoid muscle.
The omohyoid muscle is divided and dissection is continued down to the prevertebral fascia.
The diverticulum is located and carefully dissected from the surrounding tissues to expose its base.
management of Zenker by size
A small diverticulum (<2 cm) can be suspended (diverticulopexy) to exclude the opening from swallowed material;
larger diverticula should be excised with a gastrointestinal stapler.
A 40-French bougie is placed prior to stapled excision to avoid narrowing the esophagus.
A vertical myotomy is performed through the entire length of the cricopharyngeus.
A small drain is placed and the neck is closed.
An alternative approach is transoral stapling, which creates a common channel between the esophagus and the diverticulum while simultaneously dividing the cricopharyngeus muscle.
Dysphagia is generally manifested as the sensation of
food immobilized in the lower esophagus rather than difficulty transferring the bolus from the mouth to the esophageal inlet.
Classically, dysphagia is limited to solid food with the normal passage of liquids. The presence of dysphagia may also be the sign of a more serious underlying disease such as esophageal carcinoma. This symptom therefore should be investigated promptly and thoroughly.
Increase LES
α-adrenergic neurotransmitters
or
beta-blockers
The hormones
gastrin
motilin
antacids,
cholinergic agonists, acetocholine
metoclopramide,
Decrease LES
alpha-blockers
β stimulants
cholecystokinin, secretin somatostatin, glucagon estrogen, progesterone,
ANTIcholinergics, barbiturates, calcium channel blockers, caffeine, diazepam, theophylline
Peppermint, chocolate, coffee, ethanol, fat
The hallmark of intestinal metaplasia is the presence of
goblet cells.
Factors predisposing to the development of Barrett esophagus include
early onset of GERD,
abnormal lower esophageal sphincter and esophageal body physiology,
reflux of mixed gastric and duodenal contents into the esophagus.
The prevalence of dysplasia in patients presenting with Barrett esophagus ranges from
15% to 25%.
what percent of patients present from nondysplastic Barrett epithelium to low-grade or high-grade dysplasia
and from nondysplastic Barrett epithelium to low-grade or high-grade dysplasia to adenocarcinoma
per year
progression of nondysplastic Barrett epithelium to low-grade or high-grade dysplasia that 5% to 10% per year
and
dysplasia to adenocarcinoma 1% per year
The innervation of the cricopharyngeal sphincter and cervical portion of the esophagus is from
both the right and left recurrent laryngeal nerves.
origin for RLN
\arising from the vagus,
travel dorsally around the subclavian artery on the right and the arch of the aorta on the left.
As these nerves ascend in the tracheoesophageal grove, they branch off to both the esophagus and trachea.
Serious episodes of aspiration following recurrent nerve injury are caused by
cricopharyngeal dysfunction,
AND
inability to close the glottis during swallowing
AND
loss of the protection afforded by effective coughing.
